Clinical Aromatherapy: Essential Oils in Practice (Second Edition)

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Library of Congress Cataloging in Publication Data

Buckle, Jane, RGN, MA, BPhil, Cert Ed, MISPA, MIScB.

Clinical aromatherapy / Jane Buckle.—2nd ed.

p. ; cm.

Rev. ed. of: Clinical aromatherapy in nursing / Jane Buckle. c1997.

Includes bibliographical references and index.

ISBN 0-443-07236-1

1. Aromatherapy. 2. Nursing. I. Buckle, Jane, RGN, MA, BPhil, Cert Ed, MISPA,

MIScB. Clinical aromatherapy. II. Title.

[DNLM: 1. Aromatherapy—methods. WB 925 B924ca 2003]

RM666.A68B83 2003

615⬘.321—dc21 2003043823

Printed in the United States of America.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

CHURCHILL

LIVINGSTONE

An Imprint of Elsevier Science

This book is for all those who walk the path with me.

Thank you.

romatherapy is possibly the most simple of all complementary therapies

to integrate because when we inhale air, we inhale aroma, although we

are usually unaware of it. However, aromatherapy is rarely presented in a

cogent, scientiﬁc way; as a result, it has been difﬁcult for physicians and nurses to

take the ﬁeld seriously, or to understand how we could use it in our practice. Here

is a book from a health professional who writes about aromatherapy in a way that

we can understand and apply.

As a small boy growing up in Turkey, I had my own special paradise—my

grandfather’s walled garden—where I became aware of the power of the senses;

in particular, how the fragrance of plants made me feel good. Now, as a cardio-

vascular surgeon, I work on repairing the heart. I know the heart is perceived by

many to be more than a pump, the epicenter of emotion, and I continue to be

aware of how important our senses are to our well being, and how feeling good can

help recovery. The very smell of many hospitals is unpleasant, alien, or distressing

to our patients. Patients feel at their most vulnerable in a hospital’s high-tech sur-

roundings, so a familiar and comforting smell can do much to put them at their

ease. In common with several forward-thinking hospitals in the United States, we

now use aromatherapy at Columbia Presbyterian, and we have been working with

Jane Buckle on research since 1995.

Our sense of smell is located in the catacombs of the most primitive area of

the brain and is extremely powerful. Smell can produce all sorts of physical reac-

tions ranging from nausea to napping. The amygdala, the brain’s emotional cen-

ter, is located in the limbic system and is directly connected to the olfactory bulb.

Rage and fear are processed in the amygdala and both contribute to heart disease.

Our studies at Columbia have found that diluted essential oils rubbed on the feet

affected some volunteer’s autonomic nervous system within minutes.

Clinical Aromatherapy is presented logically, with considerable background

information given at the outset. I expect many readers will go straight to the clin-

ical section and look at their own specialty. In each specialty, a few symptoms or

problems have been explored, and the way in which aromatherapy might help

treat those symptoms or problems is clearly outlined. The information will be of

particular interest to readers working in that clinical specialty. However, I think

the book will also be of great interest to those who want to know what aro-

matherapy really is, and how it can be used in a scientiﬁc way.

Jane Buckle is well qualiﬁed to write this ground-breaking book. She brings

a wealth of knowledge and clinical experience acquired over 25 years in the ﬁeld.

Foreword

vii

With a PhD in health service management, a background in critical care nursing,

a teaching degree and a ﬁstful of degrees from the world of alternative medicine,

she writes authoritatively, and she speaks from the heart. Jane was a co-presenter

with me at The World Economic Forum in Davos, Switzerland, a few years ago.

We were invited to talk about the economics of alternative medicine and its im-

pact on globalization. I was impressed by Jane’s passion, as she also hosted four

different events that helped bridge the divide between big business, alternative

medicine, pharmaceutical organizations, and political leaders. An underlying

question permeated all her presentations: What can we do to get the caring back

into healthcare? When Jane speaks, people listen.

Jane Buckle is a pioneer and she uses writing, researching, and teaching to

get her message across. Her message is one of holism and she inspires those in

healthcare to evaluate how they use simple things like smell and touch to help

people heal. In the United States, many hospitals are beginning to integrate clin-

ical aromatherapy and use Jane’s program. She is involved in numerous hospital

research programs (apart from our own) and has been a reviewer for NIH grants.

Under her guidance, hundreds of students have carried out small pilot stud-

ies in American hospitals. She has written templates for aromatherapy policies

and protocols that are being used by hospitals. More than any other person, Jane

Buckle has labored to integrate clinical aromatherapy into hospitals, not as a pos-

sible add-on but as a legitimate part of holistic care. That achievement alone is

remarkable. But, she has another string to her bow. She has pioneered a registered

method of touch, called the “m” technique. This technique was tested in our lab-

oratory at Columbia Presbyterian on the legs of students and found to have a

pronounced parasympathetic response in some. The technique is very relaxing (I

have experienced it myself!) and eminently suitable for hospital patients (with or

without the use of essential oils), so I am delighted to see a section on the “m”

technique in this book.

Essential oils offer extraordinary potential from a purely medicinal stand-

point, and the recent studies on MRSA and human subjects show just how pow-

erful they can be. That an essential oil can be effective against resistant organisms

is medicine indeed and I think the chapter on infection will be of great interest

to pharmacists as well as those involved in infection control. When nausea is re-

lieved through the inhalation of peppermint and insomnia is alleviated through

the inhalation of lavender or rose, we are witnessing clinical results—not just the

“feel-good” factor. The studies on alopecia and topically applied essential oils, or

Candida albicans and teatree, show that aromatherapy can work at a clinically sig-

niﬁcant level. However the strength of clinical aromatherapy is that it offers care

as well as, in some instances, cure. This is of particular relevance in the ﬁeld of

chronic pain where the perception of pain can be altered using smell and touch.

The subject of clinical aromatherapy is vast and will be of interest to nurses

and physicians, chiropractors and massage therapists, pharmacists and natur-

opaths, pharmaceutical companies and herbalists. I share a goal with Jane

Buckle—to enhance patient care and give the best of what we have to offer, what-

viii Foreword

ever that may be. As a physician, I believe clinical aromatherapy has an important

role to play in integrative medicine. Jane Buckle gives us a glimpse of the future,

and it smells good!

Mehmet Oz

Mehmet Oz, MD, is a cardiac surgeon. He is the Director of the Cardiovascular Institute

and Vice Chairman of the Department of Surgery at Columbia Presbyterian

Medical Center, New York, NY.

Foreword ix

his book is intended for health professionals in the United States want-

ing to use aromatherapy in a clinical way to enhance their practice. It

draws from Clinical Aromatherapy in Nursing (London: Arnold, 1997) but

is a different book as it is no longer written from a nursing perspective and has

been substantially expanded to meet the needs of all health professionals. Things

have changed since 1997. I have gained a PhD (which helped my thinking!) and

much has improved in the aromatherapy world. Several clinical studies have ap-

peared in peer-reviewed medical journals. Aromatherapy is ﬁnding its way into

wellness clinics, hospices, and hospitals, and courses are being taught at leading

universities. Aromatherapy has become part of everyday language. Despite this,

popular misconceptions abound. This book was written to try to correct those

misconceptions and to indicate the important role that essential oils could play in

future healthcare.

The book is laid out in a similar way to the ﬁrst book but with several im-

portant differences.

1. The book is no longer written from a nursing perspective, although there

is a section on aromatherapy as part of nursing care.

2. The text has been reviewed and edited by experts in the ﬁeld (see Ac-

knowledgments).

3. The text includes many new tables to help the reader assimilate the in-

formation.

4. The chemistry section has been expanded and improved and includes

molecular drawings.

5. There are new sections on psychology, psychiatry, and aromatic medicine

(which covers internal use). There are speciﬁc sections for the physician,

massage therapist, chiropractor, and naturopath.

6. The individual clinical sections have been updated and expanded, espe-

cially the part on immunology.

7. The book is intended for U.S. residents and so OSHA and JCAHO re-

quirements are covered and education in the United States is addressed.

8. The number of references has almost doubled.

9. The reference system has been changed to make it easier to identify the

references in the text.

10. There is an extensive index.

Preface

The book is divided into two broad sections. These are Overview and Clin-

ical Use. The overview begins with a background section, which covers such top-

ics as historical use, where essential oils come from, how they are obtained, what

they consist of, how they work, and how they are absorbed into the body. Then

there is a short introduction to the psychology of smell. This is immediately fol-

lowed by contraindications, toxicology, and safety issues. After this broad intro-

duction, the book begins to become more speciﬁc, with sections on how aro-

matherapy could be used by nurses, massage therapists, and physical therapists, or

as part of prescriptive medicine used by physicians, chiropractors, and natur-

opaths. A general hospital section follows, addressing how the generic problems

of infection, pain, insomnia, nausea, and stress could be relieved by essential oils.

Finally the clinical section is divided into departments found in a medical setting,

and there is a discussion of how aromatherapy could alleviate some of the com-

mon problems found in each clinical section with reference to published research,

my own clinical experience, and that of my students.

I am greatly indebted to the many physicians, nurses, and other profession-

als who edited and reviewed these sections. At the end of the book there are ap-

pendixes covering OSHA and JCAHO requirements, training and education in

the United States, and some recommended reading, websites, and essential oil

companies.

This book has been a labor of love. I hope you enjoy reading it as much as I

enjoyed the journey. If one piece of good research is carried out because of this

book, all the hours will be have been well spent.

Jane Buckle

xii Preface

would like to acknowledge the following people who edited speciﬁc parts of

the book. Thank you for your generosity of spirit and your nurturing editor-

ship.

Ann Adams, RN, CMN

Elizabeth Barrett, RN, PhD

James Duke, PhD

Charlotte Eliopoulos, RN, PhD

Ben Evans, MSN

Claire Everson, MSN

Debbie Freund, RN, LMT

Howard Freund, PhD

Ron Guba

Diana Guthrie, RN, PhD

Sue Hageness, MSN

Bob Harris

Rhi Harris, RN

Dorothy Larkin, RN, PhD

Michael McCrary, MA

Lee McGunnigle, DC

Lori Mitchell, RN, MSN

Gayle Newsham, RN, PhD

Tom Numark

Mary Poolos, RN, PhD

Ganson Purcell, MD

Scottie Purol-Hershey, RN, PhD

Linda Scaz RN, PhD

Kurt Schaubelt, PhD

Paul Schulick

Neal Schultz, MD

Keith Shawe, PhD

Kay Soltis, MSN

Brenda Talley, RN, PhD

Mark Warner, MD

Acknowledgements

xiii

section

Overview

Chapter 1 Introduction

Chapter 2 The Nature of Aromatherapy

Chapter 3 Basic Plant Taxonomy, Chemistry, Extraction, Biosynthesis, and

Analysis

3.1 Basic Plant Taxonomy and Chemistry

3.2 Extraction, Biosynthesis, and Analysis

Chapter 4 Toxicity and Contraindications

4.1 Essential Oil Toxicity

4.2 Contraindications

Chapter 5 Psychology

Chapter 6 Evidence-Based Aromatherapy in Nursing Practice

Chapter 7 Oral and Internal Use of Aromatherapy

Chapter 8 Manual Therapies

Introduction to Section 1

Section I is an overview covering the foundations of aromatherapy. This section

opens with an examination not only of the history of aromatic medicine and the

emergence of a new, complementary therapy in the 1940s but also of the “what,

how, why, and when” aspects of essential oil production from plant to bottle. Next

is a two-part chapter on toxicity and contraindications (the “when and why not”

aspects of aromatherapy). Following this is a chapter on the psychology of smell.

The next part of Section I covers the use of aromatherapy within the context of

speciﬁc healthcare ﬁelds—nursing and manual therapies—including a discussion

of the oral and internal uses of essential oils.

The author is grateful for the input of many reviewers in this section whose

help and advice was most appreciated. The reviewers include: Tony Balazs PhD;

Elizabeth Barrett, RN, PhD; James Duke, PhD; Howard Freund, PhD; Ron

Guba; Bob Harris; Dorothy Larkin, RN, PhD; Lee McGunnigle, DCh; Gayle

Newsham, RN, PhD; Tom Numark; Mary Poolos, RN, PhD; Scottie Purol-

Hershey, RN, PhD; Brenda Talley, RN, PhD; Kurt Schaubelt, PhD; Keith

Shawe, PhD; and Neal Schultz, MD.

Introduction

The scent organ was playing a delightfully refreshing Herbal Capriccio—rippling

arpeggios of thyme and lavender, of rosemary, basil, myrtle, tarragon; a series of

daring modulations through the spice keys into ambergris; and a slow return

through sandalwood, camphor, cedar and new-mown hay.

Aldous Huxley

Brave New World

FALLthe complementary therapies, aromatherapy is perhaps the most

misunderstood. It is maligned, misrepresented, and can be very confus-

ing. Even the name aromatherapy is a misnomer. Contrary to popular be-

lief, aromatherapy is not just about smells! It is little wonder that orthodoxy

ridicules what the perfume industry guards so well.

Despite the misunderstanding, aromatherapy has become very popular in the

United States ( Jacknin 2001) and was even part of the millennium celebrations

in Times Square, New York. Two million celebrants were each given a 4

⁄

-inch

square scent strip that bore a global bouquet representing the aromatic choice of

every nation—the culmination of 10 years work by Gayil Nalls, a New York artist

who works in multimedia. Her work was endorsed by the United Nations Edu-

cational, Scientiﬁc and Cultural Organization (Kyle 2000). The United States

chose pine, England chose sweet grass, and France chose lavender.

Aromatherapy is the fastest growing of all complementary therapies (Buckle

2001). Although not mentioned in David Eisenberg’s groundbreaking 1993 study

on alternative medicine, aromatherapy was clearly in the picture just 5 years later

when it was being used by 5.6% of the study cohort (Eisenberg 1998). Aro-

matherapy is now an all-time favorite with UK nurses (Thompson 2001) and

is becoming popular among nurses in the United States. In a recent survey of

certiﬁed nurse-midwives in North Carolina, 32.9% had recommended aro-

matherapy (Allaire et al 2000).

There are currently 761,000 web sites on aromatherapy. This is hardly sur-

prising. As Larry Dossey, MD, states in his editorial on the impact of smell

(2001), “Throughout history people have responded to aromas.” Clinical aro-

matherapy has been described as the “most exciting of all complementary thera-

pies” by Andrew Weil, MD (personal communication). At the Nurse Practitioner

Associates for Continuing Education conference in 2001, Tieraona Low Dog,

MD, stated, “If you think herbal medicine is exciting, wait for clinical aro-

matherapy!” Mehmet Oz, MD, cardiothoracic surgeon at Columbia Presbyterian

Medical Center and pioneer of the ﬁrst complementary medicine center in New

York city wrote, “Aromatherapy appears to impact perceptions of pain” (Oz 1998);

chronic pain is big business.

The effect of complementary therapies in general, and aromatherapy in par-

ticular, is economic. I was one of the speakers at the World Economic Forum in

Davos, Switzerland, in January 1999. The economics of herbal medicine (in

which clinical aromatherapy has its roots) is exciting and global. Americans spend

an astonishing amount of money on health care, approximately $4000 per person

in 1997. Americans and others in the Western world are growing tired of phar-

maceuticals as the “cure all” and are yearning for a more holistic approach that

would enable them to use more natural products. “People’s perception of the

chemical industry is belching chimneys, acrid smells and toxic waste products, not

an enticing prospect” (Brooks 2001). The recent Fen-Phen debacle, involving

hundreds of thousands of people whose heart valves were damaged by the drug,

is more evidence of a pharmaceutical industry that is accused of seeing itself above

federal regulation (Mundy 2001). The 44,000 to 98,000 deaths that occur each

year because of medical error (Pear 1999) also are encouraging people to try com-

plementary therapies, or at least to be wary of hospital visits.

Despite aromatherapy’s popularity, some important questions remain. What

is aromatherapy? Does it work? Is it safe? Where is the research? Many licensed

health professionals (LHPs) have been using aromatherapy in clinical settings

without really knowing exactly what they are using on their patients (Buckle

1992). There are few specialized training courses for LHPs who want to use clin-

ical aromatherapy to enhance the care they provide. Most training programs are

intended for the lay public. Some universities have begun to bridge the void, in-

troducing a more academic voice. A discussion on the different types of training

available appears in Appendix I.

Some critics of clinical aromatherapy have cited the paucity of research

(Vickers 1996). This is a fair criticism. Until recently, research has been limited

mainly to studies of animals or in-vitro systems. However, in the last 3 years

many pilot studies have been carried out and published, as a search on the Na-

tional Library of Medicine’s journal search engine, PubMed, indicates. Many of

the studies on human subjects have been carried out by nurses, many of whom

were not trained in research and had little or no funding. Often, the patient

4 Section I Overview

population was small and the study modest. However, these studies demonstrate

that aromatherapy is being used clinically in many hospitals throughout the

world. The results of these studies also indicate that aromatherapy is safe, efﬁca-

cious, and, most importantly to managed care, less expensive than orthodox drug

therapy.

Perhaps orthodox medicine might be more open to the published research

available if they were to look hard at their own research. A Canadian study eval-

uated 4000 medical papers, applying 28 basic criteria that should be met in sci-

entiﬁc papers; the researchers concluded that only 40 of the 4000 papers met all

of the criteria. This analysis went on to state that only 15% of medical interven-

tions are supported by reliable scientiﬁc evidence, that most therapies applied

daily in doctors’ ofﬁces have never been tested by the scientiﬁc method, and that

these therapies are not supported by any evidence at all (Smith 1992). Peter

Gotzsche, a Danish statistician, chose for his thesis in 1990 the title “Bias in

Double-Blind Trials.” Gotzsche is director of the Cochrane Collaboration, which

reviews clinical studies; he made headlines in 2001 with his suggestion that mam-

mograms did not show evidence of reducing the number of deaths resulting from

cancer (McNeil 2002).

Although aromatherapy has been ridiculed by some, a growing group of

practitioners believe that aromatherapy has a valid place in integrative medicine.

Integrative medicine includes complementary and alternative medicine (CAM).

CAM has been around much longer than Western medicine (Buckle 1999a).

However, the growth in CAM’s popularity has precipitated a power struggle be-

tween the believers in Western medicine and the believers in CAM. Both appear

to be entrenched in their philosophies, but share the idea that if one is correct, the

other one is wrong.

Orthodox medicine may save lives, but it does have considerable drawbacks:

expense, serious side effects, and a considerable loss of life. Orthodox medicine

prides itself on being reductionist. It treats everyone more or less the same re-

gardless of age, sex, ethnicity, diet, stress level, or weight. Orthodox medicine talks

about the “average” patient and claims to be rigorously scientiﬁc. However,

some well-promoted procedures such as appendectomies and tonsillectomies

have, over time, proven to be of little value. Even bone-marrow transplants, the

much-lauded treatment of the 1990s, received a major setback in 1998. Results

presented at a world conference in Atlanta, Georgia, indicated that in four out of

ﬁve major trials there was no difference between the survival rate of patients re-

ceiving chemotherapy and patients receiving chemotherapy plus bone-marrow

transplantation (Kolata & Eichenwald 1999).

Some orthodox treatments are invasive and some can go badly wrong. In the

United States in 1998 there were between 44,000 and 80,000 deaths caused by

the misuse of pharmaceutical drugs. This exceeds the number of people killed in

car accidents (44,500), who died from breast cancer (42,300), or who died from

HIV/AIDS (16,500) (Pear 1999). Success in orthodox medicine is measured by

how quickly patients return to work. Few follow-up audits of orthodox treatment

Chapter 1 Introduction 5

have taken place, and if a patient “breaks down” again, it is classiﬁed as a new oc-

currence rather than as a reoccurrence.

The rationale behind CAM, including aromatherapy, is quite different.

These therapies are multidimensional and are not aimed at one specific body

system. They are not usually invasive. CAM therapists are interested in the in-

dividuality of the patients and what has led each patient to his or her particu-

lar disease process or set of symptoms (Hildebrand 1994). CAM therapists feel

that when the patient is balanced, homeostasis can return and the disease will

be unable to survive. They believe that the world is full of viruses and bacteria

but that it is mainly individuals whose immunity is compromised because

of emotional, spiritual, or physical trauma who tend to succumb to disease

(Gasgoigne 1993). Thirty years of orthodox research into cancer, with relatively

little progress toward an overall cure, support this viewpoint (Beardsley 1994).

Currently, 3% of the US population (9 million people) is living with the diag-

nosis of cancer (Okie 2001).

Success in CAM therapies is based on a long-term view. Practitioners look

at the “patterning” of the disease process: how often a patient has been ill during

his or her lifetime, and whether the incidence and severity of the disease has in-

creased. All diseases are taken into account, not just those of the same system. Pa-

tients are warned that treatment may take time. Emphasis is placed on teaching

the patient preventative medicine to avoid a relapse and on providing support

during the healing process. The patient is encouraged to rest, and not to work,

while the repairing process is in progress. The old-fashioned idea of convalescing

is stressed.

Is it possible for the two opposite positions to merge? Possibly. Certainly, the

term integrative medicine, coined by Andrew Weil, MD, conveys that vision. Per-

haps CAM is the yin of medicine and orthodoxy is the yang. Together yin and

yang make a circle, each needing the other to complete a whole. Yin is often per-

ceived as intuitive, feminine, spiritual, and artistic. Yang is often seen as mascu-

line, dominant, invasive, and scientiﬁc. Together, there could be a strong symbi-

otic partnership between orthodox medicine and CAM, each bringing out the

best in the other. Acute illnesses and trauma could be treated with Western drugs

or surgery, and chronic illnesses (e.g., arthritis, insomnia, and irritable bowel syn-

drome) could be helped with CAM.

So what is the place of clinical aromatherapy? Clinical aromatherapy can be

used to encourage healing and promote relaxation, but it can also help ﬁght in-

fection and chronic illness. Clearly it has a role to play in integrative medicine.

Angela Avis (1999), chair of the Complementary Therapies Forum of the Royal

College of Nurses (the largest union in the world with approximately 330,000

members), suggests that an aromatherapist (normally a lay person) is not “an aro-

matherapist” when essential oils are being used clinically within the parameters of

a recognized license. In other words, aromatherapy is a tool used by LHPs, and,

as such, requires more specialized training than most lay practitioners receive.

6 Section I Overview

Approaches to aromatherapy can be herbal or chemical. Aromatherapy is

rooted in herbal medicine. Many orthodox medicines also are derived from

herbs, for example, aspirin, atropine, codeine, curare, digitalis, ephedrine, er-

gometrine, ipecacuanha, morphine, papaveretum, podophyllum, quinine,

senna, theophylline, and vinblastine (Hollman 1991). Even the contraceptive

pill was originally derived from a plant, the Mexican yam (Ryman 1991).

Herbalists are vitalists; they believe in the synergy of plants (i.e., the whole is

more than the sum of its parts), and they also understand that plants are adap-

togens (i.e., that their therapeutic effects are affected by the “terrain” of the pa-

tient). Chemists believe that the chemistry of a plant indicates its therapeutic

properties. A chemist is more likely to have a reductionist viewpoint similar to

orthodox medicine: Eradicate the symptom and the patient will be cured. An

herbalist might have a broader and more holistic approach to the patient,

stressing the patient’s background and intrinsic make-up. Both approaches

have validity.

In the United Kingdom, aromatherapy has been closely associated with mas-

sage. Perhaps this confusion arose because aromatherapy emerged in England via

the beauty therapy industry. However, aromatherapy has become sufﬁciently ac-

cepted as a therapy in its own right and the massage element has become less im-

portant. Certainly, applications of essential oils in massage have their place, partic-

ularly in stress reduction, but there are many other ways essential oils can be used

in health care. It is troubling that the only systematic review of aromatherapy ex-

amined 12 studies targeting relaxation and combining essential oils with massage

(Cooke & Ernst 2000). Double-blind, randomized studies of essential oils used

topically, through inhalation, or orally, instead of in conjunction with massage,

were ignored.

In France, aromatherapy is seen in a different light. Essential oils are often

diluted in vegetable oil and given orally in a gelatin capsule by a medical or herbal

doctor. The oral use of essential oils is often called aromatic medicine; it can be

an effective treatment for gastrointestinal complaints or to combat an acute or

chronic infection. Essential oils can also be given rectally or vaginally; the essen-

tial oils are absorbed through the “internal skin” of the body. Dermatologist Neal

Schultz (2002) suggests that there is a clear difference between the modus

operandi of essential oils that are ingested and those that are absorbed through

external or internal skin. However they are used—topically, through inhalation,

or orally—the use of essential oils goes back several thousand years.

Because often only one or two drops of essential oil are used, aromatherapy

is known for its gentleness and is important in stress management (Buckle 1999).

Aromatherapy can produce tremendous relaxation in a relatively short period

(Mathers 1991). Many nurses use aromatherapy to help their patients relax.

However, aromatherapy is not just about relaxing patients, improving their com-

fort level, or reducing pain. Essential oils can also help ﬁght infection, also an ac-

ceptable nursing diagnosis (Carpenito 1993).

Chapter 1 Introduction 7

Essential oils are multitalented, and it is possible to use the same essential oil

for relaxation and for infection. This can pose a problem: Is the essential oil cure

or care? Florence Nightingale once said “the cure is in the caring” (Dossey 2000).

(Nightingale was adamant that patients should be removed from malodorous

odors.) During illness and following surgery relaxation can be a vital key to

recovery (Nightingale 1859), and the ability to relax can be greatly enhanced by

aromatherapy. By helping patients relax and feel better, they may actually get bet-

ter. Shames (1993) suggests that “we need to put more caring back into curing so

we can create a less costly, healthier system that will empower us all.”

This book is not intended to be a substitute for training. I believe strongly in

education, preferably in a hands-on class. There is a need for a clinical focus; the

“recreational” issues can be left to the perfumers and soap makers. Safety con-

cerns, as listed by the US Department of Labor Occupational Safety and Health

Administration, need to be addressed. Health professionals need to be aware of

the position on aromatherapy taken by the Joint Commission on Accreditation of

Healthcare Organizations ( JCAHO). JCAHO is in favor of complementary

therapies that have a positive effect on pain and improve patient care. Protocols

and policies need to be written. With these guidelines in place, aromatherapy can

enhance patient care and reduce costs. This last point is important in a health care

business desirous of a rapid, reliable turnover.

This book is about aromatherapy in clinical settings. It describes the use of

essential oils in health care: as part of nursing care and as an aid in massage and

physical therapy. It also covers the oral use of essential oils for physicians, nurse

practitioners, pharmacists, and chiropractors. The chapter on the psychology of

smell will be of interest to clinical psychologists, neurologists, behaviorists, and

psychiatrists.

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Allaire A, Moos M, Wells S. 2000. Complementary and alternative medicine in preg-

nancy: a survey of North Carolina certiﬁed nurse-midwives. Obstetrics and Gynecol-

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Chapter 1 Introduction 9

The Nature

of Aromatherapy

When, from a long-distant past nothing subsists, after the people are dead, after the

things are broken and scattered; taste and smell alone, more fragile but more

enduring, more insubstantial, more persistent, more faithful, remain poised a long

time, like souls, remembering, waiting, hoping, amid the ruins of all the rest; and

bear unﬂinchingly, in the tiny and almost impalpable drop of their essence, the vast

structure of recollection.

Marcel Proust

Remembrance of Things Past

The Nature of Aromatherapy

ontrary to popular opinion, aromatherapy is not just about smelling

things. The true deﬁnition of aromatherapy is much more speciﬁc: the use

of essential oils for therapeutic or medical purposes. However, the way in

which those essential oils are used is not speciﬁed. English aromatherapist Shirley

Price deﬁnes aromatherapy as “the use of essential oils, all of which are derived

from plants” (Price & Price 1999). American aromatherapist Jeanne Rose

classiﬁes aromatherapy as “the healing of essential oils through the sense of smell

by inhalation, and through other application of these therapeutic volatile sub-

stances” (Rose 1992). An aromatherapy school in the United Kingdom deﬁnes

aromatherapy as “a natural treatment which uses the concentrated essential oils

from plants in association with massage, friction, inhalation, compresses and

baths” (Kusmerik 1992). French physician Valnet (1990) writes that aromather-

apy involves essences obtained from plants that are generally given “in the form

of drops, or capsules.”

There are four different types of aromatherapy: clinical, stress management,

beauty therapy, and environmental fragrancing (Gilt 1992). British aromatherapy

pioneer Robert Tisserand classiﬁes them as psychotherapeutic, esthetic, holistic,

and nursing and medical aromatherapy (Tisserand 1993a).

Without doubt, “nice smells” added to a massage in a beauty salon are some-

thing akin to ﬂowers on the table at a restaurant; they are not speciﬁc ingredients

of the meal, but they certainly enhance it. This is a form of esthetic aromather-

apy. Beauty therapists do not usually treat disease. However, at the other end of

the aromatherapy spectrum, medical aromatherapy suggests that speciﬁc medical

conditions can be treated with essential oils. French medical aromatherapists

Franchomme, Penoel, Gattefosse, and Belaiche have each written books dedi-

cated to this subject. These two types of aromatherapy—esthetic and medical—

are very distinct. The misunderstandings that arise often concern the types of aro-

matherapy that fall in between and what they entail.

Holistic aromatherapy suggests the therapist is involved with all parts of the

patient—in other words, with mind, body, and spirit. Holistic aromatherapy in-

volves “supporting” a patient; this is consistent with Tisserand’s diagrammatic

outlines. It is a procedure often carried out by body workers who may or may not

know much about the chemistry of the essential oils or the pathologic conditions

for which they are appropriate. These therapists are not “treating” the patient so

much as supporting other treatments the patient may be receiving, which can be

either orthodox or alternative.

Esthetic aromatherapy is about pleasure. Choosing a smell because it is

pleasing is similar to studying a beautiful picture. The picture is treasured for the

pleasure it gives, not for its intrinsic molecular structure. To put it another way,

the use of perfumes, scented bath soaps, and incense sticks are the use of esthetic

aromatherapy, and the world would be a sadder place without them. When pa-

tients are nearing the end of their lives, the focus is on keeping them comfortable,

not prolonging life. At that stage, esthetic aromatherapy can give both pleasure

and comfort.

Psychoaromatherapy concerns the ways smells or odors affect our brains by

inﬂuencing the production of endorphins and noradrenaline. Whether we realize

it or not, our entire life is affected by smell. All forms of aromatherapy have been

around for hundreds of years. They are deﬁnitely not “New Age.” Despite the ex-

plosion of products on the market that include the word aromatherapy on their la-

bels, the use of essential oils in products is not new. Only the use of their synthetic

copies is a recent development.

History of Aromatherapy: An Outline

Ancient History

The use of aromatic plants (and thus aromatherapy) was originally part of herbal

medicine. Herbal medicine dates back thousands of years and is not conﬁned to

any one geographical area. Almost every part of the world has some history of the

use of aromatics in its health care system.

Chapter 2 The Nature of Aromatherapy 11

Iraq

Perhaps the earliest use of aromatics was discovered only recently. In 1975, dur-

ing investigation of an archaeologic dig in Iraq, concentrated extracts of yarrow,

knapweed, grape hyacinth, mallow, and other plants were found near a Nean-

derthal skeleton dating back 60,000 years (Erichsen-Brown 1979). Of the eight

species of herbs discovered there, seven are still being used today in medicine

(Griggs 1981). Yarrow is an aromatic herb that produces an essential oil often

used in aromatherapy.

France

One of the earliest records of plant medicine is in the form of paintings drawn on

the walls of caves in Lascaux, Dordogne, in southern France (Ryman 1991).

These drawings show the use of medicinal plants and date back to 18,000

BC.

Much later, in the thirteenth century, a medieval religious sect called the Cathars

lived in the area around Languedoc and Montaillou in southern France (Le Roy

Ladurie 1984). Vegetarian and deeply spiritual, their priests (called parfaits) were

also highly skilled in herbal and aromatic medicine. Regarded as heretics by the

Catholic Church, they were tortured and murdered during the Inquisition. One

night, more than 100 Cathar men, women, and children were tied to stakes and

burned alive (Guirdham 1990).

Mesopotamia

The Sumerians, who lived in Mesopotamia around 5500 BC, were sophisticated

herbalists. In their matriarchal society women were the healers. They were either

shamans called Ashipu or herbalists called Asu (Lawless 1994). They left as their

legacy clay tablets bearing prescriptions, names of plants, methods of preparation,

and dosages for their treatments (Erichsen-Brown 1979). Aromatic medicine ﬁg-

ured strongly in this early culture, and pots have been found that could have been

used in plant distillation. In the Epic of Gilgamesh, a Sumerian poet writes, “There

is a plant whose thorns will prick your hand like a rose. If your hands reach that

plant you will become a young man again” (Swerdlow 2000).

Egypt

One of the most famous manuscripts listing aromatic medicines is the Egyptian

Papyrus Ebers manuscript, found near Thebes in 1872. This document, written

during the reign of Khufu (around 2800

BC), was followed by another document,

written about 2000

BC, that mentions “ﬁne oils and choice perfumes.” These

manuscripts, written while the Great Pyramid was still being built, reveal that

during the time of Moses, frankincense, myrtle, galbanum, and eaglewood were

used as medicines to cure symptoms of disease. There is also mention of myrrh

being used to treat hay fever.

When Tutankhamun’s tomb was opened in 1922, the boy-king’s ﬂoral collars

were still faintly aromatic. Thirty-ﬁve alabaster jars of perfume were found in his

12 Section I Overview

burial chamber, but all of them were broken or empty. Many had contained frank-

incense and myrrh, highly valued commodities and likely the ﬁrst items to be

stolen from the tomb (Steele 1991). The ancient Egyptians also used aromatics in

their embalming process. They removed most of the internal body parts and re-

placed them with fragrant preparations such as cedar and myrrh. In the seven-

teenth century some of these mummies were sold and distilled to be used in med-

icines themselves (Levabre 1990).

China

The earliest known text containing written instructions on how to use herbs as

medicines was written by the Chinese in approximately 2800

BC. The Great

Herbal (Pen Ts’ao) is believed to have been written by Shen Nung. In it he lists

some 350 plants, many of which are still being used today. One of them is the

herb Ephedra sinica, which was among those found in the Neanderthal grave in

Iraq. The Great Herbal dates back to around 2800

BC. Another emperor, Huang

Ti, sometimes called the Yellow Emperor, wrote the Huang Ti Nei Ching Su Wen.

The English translation is called The Yellow Emperor’s Classic of Internal Medicine

(Rose 1992a). Today, a huge concrete statue of ginseng presides over the state-run

herbal market in Anguo, China (3 hours south of Beijing), indicating how im-

portant herbal medicine remains. The Chinese method of soaking a cloth in herbs

and resting it on the skin indicates how the Chinese have always accepted the ef-

ﬁcacy of transdermal delivery—something Western medicine denied for many

years. There is a great similarity between Ayurvedic and Chinese medicine, prob-

ably dating back to when India and China ﬁrst traded. As early as 1000 BC, the

Chinese were exchanging herbs with India (Swerdlow 2000).

India

Vedic medicine (the precursor to Ayurvedic medicine) has at its core the Vedas,

a series of texts that refer to plants as “supreme, a remedy for need and a bless-

ing for the heart.” The first Sanskrit medical treatises, Caraka Samhita and

Sushrata Sambita, date back to 2000

BC and describe the use of 700 plants, many

of them aromatics such as ginger, coriander, myrrh, cinnamon, and sandalwood

(Swerdlow 2000). Ayurvedic medicine was pushed underground by the Muslim

invasion of India in the eleventh and twelfth centuries and later by the British

occupation. The British prohibited the funding of Ayurvedic colleges and clin-

ics. India fought back in 1921 with a document presented to the British gov-

ernment in Madras, India, stating that no Western scientist should think of

criticizing Ayurveda until he had learned the Sanskrit language (Swerdlow

2000).

In the last few decades Ayurveda has become popular again, in part because

of the inﬂuence of Deepak Chopra, MD (Chopra 1991). Preparing an Ayurvedic

medicine can take many days of following the Sanskrit instructions. Ayurveda

has a strong spiritual base, and in northern India, Ayurvedic physicians are known

as holy men. Traditional Indian shamans were known as perfumeros and were

Chapter 2 The Nature of Aromatherapy 13

healers who used the scents of aromatic plants (Steele 1991). Today, aromatics re-

main an important part of Ayurvedic medicine.

Tibet

Tibetan medicine is thought to date back to pre-Buddhist times and is based on

the Four Tantras of Tibetan Medicine, written in the eighth century. This is a

whole medical system and is similar to Chinese medicine in that it focuses on the

person (or the society in which the person lives), rather than the disease. Tibetan

medicine has traditionally used aromatic herbs, often as inhalations. These herbs

are usually prescribed in complex remedies such as Aquilaria A, which contains

aromatics including clove, cardamom, sandalwood, and myrrh (Lawless 1992).

Greece

Theophrastus was a pupil of Aristotle and inherited the botanical garden at

Athens that Aristotle had planted (Stearn 1998). In 300

BC, Theophrastus wrote

Enquiry into Plants, in which he described speciﬁc uses for aromatics. At that

time doctors who used aromatic unctions were called latralyptes. One aromatic

formula, called Kyphi, contained 16 different ingredients. Kyphi was used as an

antiseptic and an antidote to poison; it was soothing to the skin and would also

“lull one to sleep, allay anxiety and brighten dreams.” It was Theophrastus, later

called the “father of botany” (Ryman 1991), who discovered the perfume of jas-

mine was stronger at night. Hippocrates (who lived around 460

BC) is recognized

as the father of medicine. He wrote “aromatic baths are useful in the treatment

of female disorders, and would often be useful for the other conditions too”

(Chadwick & Mann 1983). He understood the principles of psychosomatic dis-

orders, and his was possibly the ﬁrst statement on holism: “In order to cure

the human body it is necessary to have knowledge of the whole” (Lawless 1994).

Hippocrates also knew aromatics could have important antibacterial properties,

and when an epidemic of plague broke out he urged the people to use aromatic

plants to protect themselves and stop the spread of the disease. He also wrote,

“the growth of plants forms an excellent parallel to the study of medicine”

(Chadwick & Mann 1983).

Greek army doctors traveled with large supplies of herbal remedies, and, in a

manual written for the Emperor Claudius in 43

AD, detailed instructions were

given on how to recognize plants abroad and how to pick and pack them. Every-

one seemed to be using aromatic medicine in some form. Even audiences watch-

ing competitive sports in the stadium at Daphne were sprinkled with rose water

to keep up their spirits and urge on the games. Helen of Troy was famed for her

use of aromatics in mood-enhancing potions.

The legendary Greek Pedanios Dioskurides (often spelled Dioscorides) lived

around 100

AD and wrote the famous De Materia Medica. This foundation of

Western herbal medicine lists and illustrates some 700 plants that were in use at

the time (Holmes 1993). Included are aromatics such as basil, verbena, car-

damom, rose, rosemary, and garlic. Each section of De Materia Medica begins

14 Section I Overview

with a drawing and description of a plant and the contraindications are carefully

listed (Griggs 1981). Dioscorides suggests that one of them, tarragon (Artemesia

dracunculus) might be useful in four different treatments: for cancer, for gangrene,

to produce abortions, and as protection against viper bites. Tarragon was later

used by Native Americans during difﬁcult labor and to induce menstruation. Na-

tive Americans believed tarragon was such an important herb it was classiﬁed a

“chief medicine,” requiring the collector to pull it (pick it) and not dig it up out

of respect for its power.

When Claudios Galenos (known in English as Galen) was appointed per-

sonal physician to Emperor Marcus (130-200

AD) he continued the use of fra-

grant oils and referred to the fragrance of narcissus as the “food of the soul.”

Galen also introduced a system for identifying plants (Griggs 1981). In his fa-

mous work Peri, he listed not only different herbs but different grades of herbs

like cinnamon (Holmes 1993). Unfortunately, many of the 500 works he com-

piled were destroyed when his clinic in Rome burned down. However the sys-

tem introduced in his largest work (which consisted of 11 books) survived. By

describing a disease process in terms of temperature and moisture, Galen laid the

cornerstone of modern physiology (Lawless 1994). He also described a plant’s

energetic proﬁle, which is similar to both Chinese and Ayurvedic approaches.

This approach is continued today with contemporary writers (Holmes 1993;

Mojay 2000). During the immediate pre-Christian era, Jewish women spiked

wine with myrrh and frankincense, which have anesthetic effects, and gave it to

those being tortured. The early Christian era considered aromatics to be pagan

because they could heighten sensual pleasure. In 529

AD, Pope Gregory the

Great passed a law banning all Materia Medica. This was the ﬁrst hiccup in the

history of aromatherapy. The school of philosophy at Athens closed down, and

the works of Galen and Hippocrates were smuggled to Syria. There the works of

Galen, Hippocrates, and Dioscorides were translated into Arabic by Hunayn ibn

Ishaq al’Ibadi who was paid for his efforts with an amount of gold equal to his

weight.

Arabia

In the prologue to The Canterbury Tales, Chaucer describes four Arabic physi-

cians. Arabic doctors were regarded as the greatest medical authorities in the

fourteenth century. One of Chaucer’s physicians is an historical ﬁgure known as

Ibn Sina—later called Avicenna (Tschanz 1997). Arabia added a whole host of

new aromatics such as senna, camphor, tamarind, nutmeg, and cloves to the list

of medicinal plants, and began to play an important part in the development of

herbal and aromatic medicine. Arabs suggested rose and orange-blossom water to

make medicines taste more palatable, and they were familiar with the anesthetic

effect of inhaled henbane. Arabic physicians also used topical sugar to staunch

bleeding. Sugar promotes new cell growth by drying the bed of the wound and

dehydrating the bacteria there. This practice is still used today by some physicians

(Swerdlow 2000).

Chapter 2 The Nature of Aromatherapy 15

By the third century AD, the city of Alexandria had become a center for med-

icine, continuing the Greek tradition of the science of aromatics. At the start of

the ninth century, the ﬁrst private apothecary shops opened in Baghdad. Medi-

cines were manufactured and distributed commercially to physicians and phar-

macists who dispensed them to the public as pills, tinctures, suppositories, and in-

halants.

Abd Allah ibn Sina (980-1037) was born in what is now called Bukhara

(present-day Uzbekistan). His name was later westernized into Avicenna. Ibn

Sina was to the Arabic world what Aristotle was to the Greeks. He was a child

prodigy: a scholar who at the age of 10 could recite the entire Koran and who

went on to excel in medicine, poetry, math, physics, and philosophy. At the age of

20 ibn Sina was appointed court physician and during his life he wrote more than

20 medical texts including the Canon of Medicine, which remained a standard

medical textbook until the sixteenth century (Lawless 1994). The Canon lists 760

medicinal plants and the drugs that can be derived from them. Ibn Sina also laid

out the basic rules of clinical drug trials, principles that are still followed today

(Tschanz 1997).

Ibn Sina is also credited with inventing a new kind of apparatus for distill-

ing essential oils, called an alembic. During the tenth century many classic texts

were translated from Arabic to Latin, and ibn Sina’s Canon of Medicine ﬁrst ap-

peared in Europe in the twelfth century. It is interesting that Constantinus

Africus and Gerard of Cremorna, the two translators of this classical text, lived in

different towns and came from two different worlds—one Arabic and one Chris-

tian. This joint project was possible because the two scholars lived in towns close

to the border dividing the Arabic and Christian worlds at that time. Ibn Sina’s

portrait still hangs in the great hall of the School of Medicine at the University

of Paris, and Dante Alighieri held him in the same regard as Hippocrates and

Galen.

Europe

By the thirteenth century, “the perfumes of Arabia” mentioned by Shakespeare

had spread to Europe. Bad odors were thought to harbor disease (interestingly

malaria literally translated means bad air), and being surrounded by pleasant

odors was supposed to give protection against disease, especially the plague.

Physicians wore birdlike masks containing aromatics to protect themselves. They

also carried plague torches, fragrant herbs burned in a tiny brazier at the top of a

long stick, containing aromatic resins and sprinkled houses affected by disease

with aromatic waters like eau de cologne (Stoddart 1990).

Glovemakers in London became licensed to impregnate their wares with es-

sential oils, and legend has it this is why so many glovemakers and perfumers sur-

vived the Great Plague. Scent boxes and pomanders containing solid perfumes

(which originated in the East) became popular among the aristocracy. During this

time the Abbess of Bingen, St. Hildegarde, wrote four books on medicinal plants.

16 Section I Overview

By the sixteenth century, many Europeans had written their own collective

works on herbs and aromatics. With the Renaissance and subsequent world ex-

ploration, many spices were added to Europe’s knowledge of herbs. Cocoa (Theo-

broma cocao) was discovered in South America and tea tree was found in Australia.

During one expedition in the winter of 1535, French explorer Jacques Cartier dis-

covered a cure for scurvy from the Native Americans. Cartier’s ship was frozen in

the St. Lawrence River at St. Croix in Quebec, Canada. Most of the ship’s com-

pany had fallen ill and had purple blotches on their skin, swollen legs, joint pain,

and putrid gums. Several were dying. Cartier’s friend, a Native American called

Agaya, who had been very sick, suddenly appeared to be completely well. In-

trigued, Cartier investigated and discovered Agaya had drunk an extract made

from the tree Native Americans called Annedda.

Native Americans

Annedda is now thought to have been white spruce (Picea glauca), and this was

the ﬁrst documentation of successful scurvy treatment (Erichsen-Brown 1979).

Native Americans were also adept at treating wounds, often with a tree gum like

Abies balsamea. They treated dysentery with cedar leaves, and they used sweat

lodges to promote healing. Native Americans also used narcotic plants such as

water hemlock in topical applications, vigorously scratching the skin until it bled

before applying the herb. Native-American medicine has produced many plant

remedies such as Black cohosh root (Cimicifuga racemosa) for musculoskeletal

pain and as an aid for labor and hormonal imbalances (Low Dog & Riley 2001)

and May apple resin (Podophyllum peltatum), originally used for warts and today

used to treat skin cancer. Only recently has Native American medicine become

respected for its depth, history, and sophistication (Erichsen-Brown 1979). One

of its advocates, Tieraona Low Dog, MD, is an eminent physician herself.

Fourteenth Century to Present

Paracelsus was born Philippus Aureolus Theophrastus Bombast von Hohenheim

in 1493 near Zurich, Switzerland. Although his father was a physician, it is un-

clear whether Paracelsus ever completed his medical training. He wandered from

university to university and was something of a rebel. His wanderings took him

to live with the Tartars in Asia from whom he learned herbal medicine. He also

learned anatomy from executioners. While he was on his travels he took the name

Paracelsus.

Paracelsus was the subject of many legends, some suggesting he had magic

powers and could conjure a hurricane with a twirl of his hat (Swerdlow 2000). He

was a controversial ﬁgure and angered the orthodox medical community of the

day by burning volumes of Avicenna’s work at a public bonﬁre in the marketplace

in Basel, Switzerland. Paracelsus was frustrated by what he felt were old princi-

ples and wanted to experience something innovative and new. He questioned

Galen’s work and thought the plethora of herbal manuals in circulation were

Chapter 2 The Nature of Aromatherapy 17

written by “quacks” who abused sick people’s lack of knowledge and were only af-

ter quick money.

Paracelsus believed the way forward was to isolate an active ingredient from

a plant. “What the eye perceives in herbs or stone or trees is not yet a remedy; the

eye sees only the dross. The remedy must be cleansed from the dross, then it is

there. This is alchemy” (Griggs 1981). Paracelsus believed isolating the active in-

gredient would enhance the medicine’s strength and increase its safeness. He was

associated with the revolution supporting mineral preparations, and he used mer-

cury, iron, sulfur, and antimony as well as herbs. Although Paracelsus remained

fascinated by alchemy all his life (Griggs 1981), he was also a strong believer in

the doctrine of signatures: that plants indicate the organ of the body they can help

either by their shape or by the place where they grow. It is obvious from his co-

pious writings (14 large volumes) that Paracelsus used herbs knowledgeably, and

he was very successful.

Although a speciﬁc action of a plant may appear to depend on a single chem-

ical constituent, isolating it may not make the effect more active or safer. Nature

is not a fool; plants have their own synergistic action that is irreplaceable. In the

plant world, the sum of the parts really does add up to more than the total (Mills

1991). If the most active constituent is removed and applied in isolation, it may

have a different effect or negative side effects. The ability of one part of a plant to

“switch off ” negative properties of another part is sometimes called quenching

(Watt 1991). For example, isolated citral (an aldehyde found in lemongrass) pro-

duces a more severe sensitization reaction at a lower concentration than does the

complete essential oil, which contains a higher percentage of citral.

This concept is further demonstrated by extracting and separating all the ac-

tive ingredients of an essential oil, then recombining them. They will not neces-

sarily produce the same effect as the complete essential oil (or herb). However,

this is how drug companies usually approach research of herbs: they isolate and

synthesize. To this day Paracelsus is regarded as the ﬁrst medical pharmacologist,

the “patron saint” of drug companies.

When Rene Descartes (1596-1650) declared that man was a machine, the

next hiccup occurred for aromatherapy. Descartes’ philosophy, the basis of Carte-

sian thinking, is summed up in his own words, “cognito, ergo sum,” or “I think,

therefore I am” (Cook 1978). Descartes went on to say mind and body bore no

relationship to one another, and the concept of soul faded. The idea that an aro-

matic compound could have an effect on the body via the brain fell into disrepute.

Not until the eighteenth century when a physician named Gaub suggested that

“bodily diseases may often be more readily alleviated or cured by the mind, that

is by the emotions, than by corporeal remedies” did the idea of a connection be-

tween mind and body return (Lawless 1994). In 1763 Julien La Mettries wrote

an essay that said man was a machine. Gaub disagreed and wrote a response, sug-

gesting doctors should search for substances that affect the mind.Today it is grad-

ually becoming accepted that smell affects the mind. The mind is not an isolated,

18 Section I Overview

single organ, but is connected to every cell of our body. The way each cell feels in-

timately affects the way a person feels overall (Pert 1997).

United Kingdom

William Turner (1520-1568) was one of the earliest English herbalists. A

Cambridge graduate, he believed in the doctrine of signatures and gave many

plants, such as lungwort and liverwort, their common names to indicate their use.

At this time, qualifying to become a physician took up to 10 years. Interestingly,

Shakespeare’s son-in-law John Hall called himself a physician, although he had

only a Master of Arts degree. However, this did not stop him from purchasing

300 plants, “practicing” medicine, and leaving notes from 178 different cases. One

of his patients was the Earl of Compton who lived some 40 miles away, several

days’ journey by horseback (Swerdlow 2000).

During Shakespeare’s time the apothecaries, from whom physicians pur-

chased their medicines, were also prescribing. In 1512, in an attempt to control

the situation, the British Parliament introduced the ﬁrst laws controlling the pre-

scription and sale of medicines. Six years later, the Royal College of Physicians of

London was established.

However, the seventeenth century is mainly remembered as the golden era

for herbal medicine. Nicholas Culpeper, who posthumously became one of the

more famous herbalists, published his Complete Herbal in 1660. During the 1700s

essential oils were widely used in “mainstream” medicine. In William Salmon’s

The Compleat English Physician oils of cinnamon, lavender, lemon, clove, and rue

are listed with others in a recipe to “cheer and comfort all the spirits, natural, vi-

tal and animal”(Tisserand 1979). In 1770 the British Parliament passed an act to

protect men from the “guiles of perfumed women” who might trick them into

matrimony as the “witchcraft of scent could manipulate their mind” (Watson

2000). The United States followed with a paper published in the New York Med-

ical Journal on the “connections of the sexual apparatus with the ear, nose and

throat” that suggested perfume was a conscious attempt to “stimulate lecherous

thoughts” (Dabney 1913).

The ﬁrst scientiﬁc evaluation of essential oils occurred in the nineteenth cen-

tury, and many of the results were published in William Whitla’s Materia Medica

and Therapeutics in 1882. The industrial and scientiﬁc revolutions followed. Dur-

ing the next two centuries scores of essential oils were analyzed. It was thought

important to identify and isolate therapeutic components of plants (just as

Paracelsus had advocated). In the late 1890s speciﬁc components such as geran-

iol and citronellol were identiﬁed, and in 1868 William Henry Perkin announced

the synthesis of coumarin.

Modern Drug Development

Synthetic copies of perfumes and aromatics began to be appear, and the

era of modern drug development dawned—the third hiccup for aromatherapy.

Chapter 2 The Nature of Aromatherapy 19

Willow bark became aspirin, and foxglove became digitalis. Despite important re-

search on the therapeutic effects of many essential oils by Cadeac and Meunier in

France and Gatti and Cajola in Italy, essential oils and herbal medicine lost out

to the proﬁts of synthetic drugs. With the 1930 partnership of Rockefeller in the

United States and Faben in Germany, the petrochemical pharmaceutical industry

became a major economic and political force.

Following the Flexner report on the nation’s medical schools in 1910 (which

was paid for by the Carnegie Foundation), almost all homeopathic and naturo-

pathic medical schools in the United States were squeezed out. Herbal medicine,

including the use of aromatics, was excluded from medical school curricula.

Petrochemical drug companies became the major underwriters of all medical col-

leges in the United States. More importantly they also became the major funders

of the American Medical Association and therefore 90% of all medical research

(Buckle 2001).

Renaissance of Aromatherapy

The modern renaissance of aromatherapy began in France with the work of a

chemist, a physician, and a nurse: Gattefosse, Valnet, and Maury.

Rene-Maurice Gattefosse, a chemist, lived in France from 1881 to 1950. He

was interested in both the psychologic and physiologic effects of aromatics and

mainly used topical application of essential oils. It was because of an accident that

Gattefosse was ﬁrst drawn to aromatherapy. In 1910, while he was working in his

laboratory, an explosion occurred, covering him with burning substance. He rolled

on the grass to extinguish the ﬂames. A few days later the wounds became in-

fected with gas gangrene but “one rinse of essential oil of [English] lavender (La-

vandula angustifolia) stopped the gassiﬁcation of the tissue”(Tisserand 1993).

Impressed by the way his wounds had healed, Gattefosse dedicated his life to re-

searching essential oils. Many of his patients were soldiers wounded in the

trenches of World War I. Among the essential oils Gattefosse used were thyme,

chamomile, clove, and lemon. Until World War II, those essential oils were used

both as natural disinfectants for wounds, and to sterilize surgical instruments

(Ryman 1991).

Gattefosse was one of the ﬁrst people to use the word aromatherapy. He dis-

covered essential oils take between 30 minutes and 12 hours to be absorbed com-

pletely by the body after being applied topically. His work Aromatherapie: The Es-

sential Oils — Vegetable Hormones (giving detailed medical case studies performed

by various physicians) was published in France in 1937. The manuscript was dis-

covered by Jeanne Rose, translated into English, edited by Robert Tisserand, and

published in English in 1993 (Tisserand 3).

Throughout World War II, French physicians used essential oils on infected

wounds and as a treatment for gangrene. Perhaps the course of aromatic medicine

would have been different if Alexander Fleming had not discovered a piece of

moldy bread that led to the manufacture of penicillin. With the emergence of

manufactured antibiotics—full of promise, proﬁt, and easy availability—came the

20 Section I Overview

fourth hiccup in the history of aromatherapy, and its demise seemed certain.

However, during World War II, American nurses stationed at Pearl Harbor used

handkerchiefs infused with perfume to help cope with the nauseating aroma of

burned ﬂesh (Sarnecky 2001). They also offered the scented handkerchiefs to

their patients. Fessler (1996) suggests this was an early example of modern aro-

matherapy.

Jean Valnet, MD, was born in the early 1900s and died only a few years ago.

A French army physician, he spent much of his life researching aromatherapy and

was interviewed in 1993 by Christine Scott for the International Journal of Aro-

matherapy (Scott 1993-1994). His publication Aromatherapie (Valnet 1937) was

the ﬁrst “medical” publication on aromatherapy, full of case studies and citing nu-

merous references. Valnet wrote it “is not necessary to be a doctor to use aro-

matherapy. But one has to know the power of essential oils in order to avoid ac-

cidents and incidents” (Scott 1993-1994).

During his time in Indochina, when he was commander of an advanced sur-

gical unit, Valnet used essential oils with the full approval of his superiors. How-

ever, despite impressive results, when he returned to France he found the ortho-

dox medical community unhappy with his use of unconventional medicine and

they tried to strike him from the general medical list. Fortunately for aromather-

apy, some of his patients were high-ranking government ofﬁcials, including the

Minister of Health, so this did not happen (Scott 1993-1994). Valnet’s book, The

Practice of Aromatherapy, possibly the classic on aromatherapy, has been translated

into German, Italian, Spanish, and Japanese, as well as English.

Marguerite Maury’s life was initially one of tragedy. Born in Austria, she mar-

ried very early and had her ﬁrst child while still a teenager. Sadly her son died from

meningitis when he was only 2 years old. Shortly afterward, her husband was

killed in action, and his death was closely followed by her father’s suicide. Keen to

make a new start, Marguerite decided to move to France and train as a nurse.

While working in France as a surgical assistant, she met and married Dr. Maury.

He shared her love of the arts and her fascination with alternative approaches to

medicine, and together they formed a cohesive and inspirational team.

Marguerite Maury classiﬁed the use of essential oils into various clinical de-

partments: surgery, radiology, dermatology, gynecology, general medicine, psychi-

atry, spa treatment, physiotherapy, sports, and cosmetics. She won two interna-

tional prizes for her research on essential oils and the skin, and her book, Le

Capital Jeunesse, was published in 1961 and translated into English 3 years later.

She left a dedicated and now famous pupil, Daniele Ryman, to continue her

work (Maury 1964).

Gattefosse, Valnet, and Maury may have been the ﬁrst pioneers of modern aro-

matherapy, but there were plenty of now-famous names waiting in the wings.

Tisserand and Price made aromatherapy a household word in England and sparked

the interest of the medical and nursing community. Many researchers—too many

to list—followed. Of particular note are Gildemeister in Germany, Guenther and

Lawrence in the United States, Leclerc and Belaiche in France, and Dodd, Deans,

Chapter 2 The Nature of Aromatherapy 21

and Svoboda in the United Kingdom, all of whom wrote extensively about the clin-

ical use of essential oils. Today, there is a wealth of information and sufﬁcient evi-

dence to suggest the medicine of the future could be a sweet-smelling one.

How Essential Oils Work

The study of where essential oils go when they are absorbed and how they are ab-

sorbed and eliminated by the body is called pharmacokinetics. Essential oils are ab-

sorbed into the body through digestion, through the “internal skin” lining of ori-

ﬁces (mouth, vagina, and anus), by olfaction, and through the external skin ( Jager

et al 1992).

There is fairly heated debate as to how aromatherapy should be used. Some

people believe the term aromatherapy means just that: inhalation. But, in many

parts of the world, aromatherapy is often combined with touch, as the absorption

of essential oils through the skin coupled with soothing touch (or warmth) may

enhance and prolong their therapeutic effects. Some believe the sublingual, rec-

tal, and vaginal routes of absorption are the most effective. Others believe essen-

tial oils are most useful when taken orally and digested. Clearly there is a differ-

ence in metabolism between a substance that is ingested and one that is applied

topically (to internal or external skin) or inhaled. Ingestion of essential oils is

more akin to Western medicine.

There is a substantial body of knowledge about the absorption of essential

oils through the shaved skin of animals or by injection into their peritoneal cavi-

ties, but published research on the absorption of essential oils through human

skin or by ingestion is limited. There is published research to show inhaled es-

sential oils affect the human brain, but clearly the use of aromatherapy in a clin-

ical setting is in its infancy. Patients say aromatherapy works, and the whole

movement of aromatherapy in health care appears to be led by patients as much

as practitioners.

Using aromatherapy in a clinical setting is still a bit like pioneer work. Nurses

using aromatherapy say they feel a little like modern-day Florence Nightingales.

Although it is impossible to provide evidence of efﬁcacy without research, a pat-

tern of efﬁcacy is emerging. Health professionals believe there is sufﬁcient anec-

dotal evidence to show clinical aromatherapy is efﬁcacious, cost effective, and

safe, but the information is scattered. A major collaborative effort is needed to

bring together all that information so the “pattern” becomes clear. That pattern

will be the basis for future research.

Routes of Absorption of Essential Oils

Essential oils contain many different components, and these components are ab-

sorbed by the body. Thus lavender is not found in the bloodstream, but linalyl ac-

etate and linalol, two of the major components found in lavender, are found in the

bloodstream after inhalation, topical (internal or external) application, or inges-

tion of lavender essential oil.

22 Section I Overview

There are four methods by which the components within essential oils can

be absorbed.

1. Topical: using external skin via touch, compress, or bath

2. Internal: using internal skin via mouthwashes, douches, pessaries, or sup-

positories

3. Oral: via gelatin capsules or diluted in honey, alcohol, or a dispersant (pur-

chasable from most good essential-oil companies)

4. Inhaled: directly or indirectly, with or without steam

Each method of application has its own physiologic process, advantages, and

disadvantages.

Topical Application

“A good name is like a precious ointment; it ﬁlleth all around about, and will not

easily away; for the odors of ointments are more durable than those of ﬂowers.”

Francis Bacon, 1561-1626

The skin is a complex, multifaceted membrane, varying from a fraction of a mil-

limeter thick on the eyelid to approximately 3-mm thick on the back. The skin is

the largest organ in the body. For many years the skin was thought to be a bar-

rier, and it was believed drugs could not be absorbed through the skin. Women

were ridiculed for putting creams and lotions on their faces in an effort to pre-

serve their youthfulness. Now it is acknowledged that cosmetics not only pene-

trate the stratum corneum but are also absorbed into the viable epidermis (Zatz

1993). Autoradiography can be used to demonstrate the absorption of lipid-

soluble substances through the skin (Fig. 2-1) (Suzuki et al 1978).

Nicotine patches are common since the advent of patch therapy, and many

conventional drugs are now administered transdermally on a continuous basis.

Examples of such drugs are antianginals such as nitroglycerine, the female hor-

mones estradiol and progesterone, antihypertensives such as clonidine, narcotics

such as fentanyl, and antispasmodics and antiemetics such as scopolamine (Cleary

1993). Topical anesthetic lidocaine and cortisone dexamethasone have also been

introduced using a transdermal patch in combination with an electric current

(Zetzer et al 1991). Tests are currently in progress to establish how commercially

viable it will be to deliver beta-blockers timolol and bupranolol, antihistamines

tripolidine and azatadine, and testosterone via this method. Furthermore, the

New York Times reported that scientists may have found a way to avoid the sting

of vaccinations by spreading the vaccine on the skin. The vaccinations tested on

the mice were diphtheria, tetanus, and cholera (Associated Press 1998).

Not every substance is absorbed through the skin in the same amount.

Hotchkiss (1994) demonstrated that only 1% of Cypermethrin (a pesticide) was

absorbed, but 65% of benzoic acid (a fungicide) was absorbed through human

skin. Two processes are involved in topical absorption: penetration and perme-

ation (Reiger 1993). Penetration is the actual entry of a substance into and

through the skin, whereas permeation is the subsequent absorption of a substance

Chapter 2 The Nature of Aromatherapy 23

24 Section I Overview

Figure 2-1 Diagram to show drug absorption through skin. (From Zatz J. 1993. Factors affecting absorption of topically applied substances. In Zatz J

(ed.), Skin Permeation: Fundamentals and Applications. Wheaton, IL: Allured.)

into the body. Obviously the former is more important if the skin is being treated

and the latter if a systemic treatment is sought.

The process of diffusion and permeation are in part described by Fick’s laws

(Rieger 1993). These are a series of mathematical descriptions of diffusion

through membranes. More important than the actual concentration of the sub-

stance (in this case the essential oil), is its chemical activity or potency. Therefore

if an essential oil contains a small amount of a potent component (a phenol), its

chemical potential is greater than that of an essential oil containing a larger

amount of a less potent chemical (an alcohol).

If the essential oil is diluted in a substance with lower permeability, its

progress, or pharmacokinetics, are adversely inﬂuenced. In other words, essential

oils diluted in a ﬁxed oil (carrier oil) are absorbed more slowly than undiluted es-

sential oils. The actual carrier medium can also affect (and to a certain extent in-

hibit) the concentration of the active ingredients of essential oils. For example, in

one study, the germicidal effects of phenol (a common constituent of essential

oils) could not be exerted when it was applied to the skin in a fatty base (Zatz

1993a). Heat appears to enhance penetration, and hot water may speed up the ab-

sorption of essential oils into the skin. Studies have shown that penetration of the

dermis is increased 100-fold if essential oils are dispersed in a bath (Buchbauer

1993a).

Essential oils are lipid soluble, and they can be absorbed through the skin

rapidly. Fuchs et al (1997) reported that carvone, a ketone component found in

essential oils, was found in the bloodstream of a human subject within 10 min-

utes of a massage. Carvone was also found in the subject’s urine. The subject, a

25-year-old woman, wore a mask to avoid inhaling the aroma. The exact time re-

quired for absorption depends on the weight of the molecule and certain physio-

chemical properties, such as polarity and optical activity (Jager et al 1992). In

simple terms, polarity refers to polar molecules, so called because they have a neg-

ative and positive “pole” which attract opposite charges (Bowles 2000). Optical

properties refers to the ability of molecules to rotate in polarized light (Williams

1996). In the case of lavender, most of the two main constituents, linalol and lina-

lyl acetate, were absorbed within 20 minutes and eliminated within 90 minutes.

The disadvantage of applying essential oils topically is not all of the essential oil

is absorbed unless an occlusive dressing is applied. Otherwise, much of the es-

sential oil evaporates because of its high volatility. Straehli, who researched the ki-

netics of essential oils in 1940, found that all the essential oils appear in the breath

following absorption through the skin, although the time interval differs with

each essential oil (Tisserand 1985).

The greater the percentage of skin covered, the greater the penetration by an

essential oil (Balacs 1993). Friction, caused by stroking or massage, encourages di-

lation of blood vessels in the dermis, which increases absorption of the essential

oils (Pratt & Mason 1981). Because the stratum corneum (the outer layer of the

epithelium) is partly hydrophilic and partly lipophilic, some water-based and

some oil-based components can pass through it (Riviere 1993). Essential oils are

Chapter 2 The Nature of Aromatherapy 25

lipid soluble so they gain rapid access to lipid-rich areas of the body (Buchbauer

1993), such as the myelin covering of medullated nerve ﬁbers. This lipid solubil-

ity also enables the relatively small molecules of components within the essential

oils to cross the blood-brain barrier: the separation of neurons from capillary walls

by astrocytes (Anthony & Thibodeau 1983).

Although some areas of skin are more accessible, all areas of the skin are per-

meable. Clearly this indicates that it is not necessary, or sometimes even advis-

able, to give a patient a full-body treatment. Patients’ feet are usually easily acces-

sible, and they rarely have intravenous infusions attached to them. Treatment of

feet requires no removal of clothes apart from shoes and socks, and therefore the

feet are possibly the least embarrassing body part to have touched (except for the

hands). Another advantage of using the feet is they are not highly innervated ar-

eas like the face, nor are they areas of low innervation like the back (Weiss 1979).

Caution should be taken when applying essential oils to damaged skin, be-

cause damaged skin is more absorbent of outside chemicals. Moore et al (1980)

found twice as much lead was absorbed by abraded skin as undamaged skin. In a

clinical setting, damaged skin includes skin affected by systemic disease; derma-

tology problems; or dehydration caused by a cold, dry environment or the daily

use of strong detergents. Stress (either physical or emotional) results in vascular

shut-down, which produces cold hands and feet. Psychologic stress also perturbs

the epidermal permeability-barrier homeostasis (Garg et al 2001); in the case of

essential oils this means that less is absorbed. However, when a patient is sweat-

ing, the body is trying to get rid of heat and the blood vessels are dilated. But di-

lated blood vessels can increase penetration of essential oils. Older skin, because

it is thinner and its barrier function is diminished, tends to absorb essential oils

faster.

Topical absorption can be enhanced with an occlusive dressing (Fuchs et al

1997). This reduces the potential for evaporation. Fuchs et al (1997) found that

with an inclusive wrap, substantially more of the essential oil components were

absorbed. Bronaugh’s study (1990) showed that 75% of a fragrance was absorbed

when the skin was covered, and only 4% was absorbed when the skin was not cov-

ered. Covering the skin also increases its temperature and hydration and therefore

enhances penetration. Topically applying essential oils has several advantages:

they do not need to be digested, they are simple to use, and the essential oils are

excreted slowly. This is also the most direct way to treat topical issues such as skin

problems or muscle complaints. There are a few disadvantages. One disadvantage

is that the skin contains certain enzymes that can activate (or inactivate) toxic

chemicals (Tisserand & Balacs 1995). Another disadvantage of applying essential

oils topically is that some essential oils (those containing phenols) can be epider-

mal irritants and others (containing furocoumarins) may cause photosensitivity.

Epidermal absorption is still not fully understood, and pharmacokinetics is a

relatively new ﬁeld. What is safe to put on the skin and in what concentration is

an ongoing dialogue between cosmetic manufacturers. For many years the most

commonly used hospital bactericide for hand washing and consumer products

26 Section I Overview

was hexachlorophane. At the time, it was thought to be completely safe. How-

ever, hexachlorophane was later demonstrated to be a potential neurotoxin

(Sherman & Leech 1973). Because of a manufacturing error in the 1970s, a baby

powder was manufactured that contained 10 times the intended concentration of

hexachlorophane. This resulted in the deaths of several babies in France. It is

thought that because the diapers acted as an occlusive dressing, the drug’s ab-

sorption was enhanced ( Jackson 1993). The use of hexachlorophane in medical

products such as Ster-Zac and Dermalex was halted in 1973 because of the toxic

effects it might produce when absorbed into the body (McFerran 1996).

Finally, a serious disadvantage is that many essential oils plants are still grown

with pesticides. While gas chromatography might indicate this, because it ana-

lyzes the different compounds in an essential oil, pesticides are not beneﬁcial to

human skin and can also cause a reaction that has nothing to do with the essen-

tial oil. Expressed essential oils are most likely to have high levels of pesticides.

Topical application of essential oils can be used for the following:

Relieving localized trauma such as bruising, sprains, stings, or burns

Relaxing and warming speciﬁc muscles

Cooling speciﬁc areas

Relieving neuralgic conditions

As an antiinﬂammatory

As an antispasmodic

As a speciﬁc antiviral, antifungal, or antibacterial agent for skin infections

For systemic treatments including hormonal imbalance

As a general body relaxant

Topical applications can be given as follows:

In a carrier oil (cold-pressed vegetable oils)

In an ointment

In a gel

Undiluted (see Chapter 4)

In a bath (sitz, hand, foot, or full)

As a compress

In a wound irrigation

The amount of an essential oil absorbed through the skin depends (not in any speciﬁc or-

der) on the following:

Dilution used

Amount used

Amount of skin surface covered

Choice of essential oil

Choice of carrier (lotion, oil, cream, alcohol, water)

Part of the body used

Temperature of the skin

Integrity of the skin

Heat of the environment

Age of the skin

Chapter 2 The Nature of Aromatherapy 27

In an aromatherapy massage, or when the essential oil is applied using the

“m” technique, much of the essential oil evaporates into the room and is inhaled

by the patient. Therefore the beneﬁt is likely to be a synergy of the topically ap-

plied and inhaled essential oils together. Both, mixed with gentle touch, allows

the patient to relax and breathe deeply. It is difﬁcult to separate the two means of

entry, and it is suggested they could work synergistically. Currently there is no

body of comparative knowledge on the gastrointestinal and cutaneous absorption

of the same test material ( Jackson 1993).

Oral and Internal Administration

The oral route for administering essential oils is important and can be an excel-

lent way to treat gastrointestinal problems. Almost all other problems can be

helped using other methods. For those who have a license to prescribe, the oral

route (aromatic medicine) is very powerful. Aromatic medicine can produce im-

pressive results, especially with chronic or acute infections. In the United King-

dom the Aromatherapy Organization Council, the lead body for aromatherapy,

advises against the oral use of essential oils. The Royal College of Nursing accepts

all methods of aromatherapy as part of nursing care except the oral use of essen-

tial oils. However, the internal skin route (using the inner skin of the mouth, rec-

tum, and vagina) is an extension of the external skin route (Schultz 2002) and is

very relevant to nursing care.

Essential oils can be used in a mouthwash, which is excellent for mouth in-

fections, and are very important in dental care. Gargles can be very effective in

treating tracheitis. Essential oils can also be diluted in a douche or on a tampon

and are very effective for some vaginal infections. Essential oils can also be used

in both vaginal and rectal pessaries to treat infection and inﬂammation. Both rec-

tal and vaginal routes have a distinct advantage in the treatment of reproductive

or urinary conditions because the essential oils are absorbed directly into the sur-

rounding tissue. Recurrent cystitis responds well to this method of treatment.

In aromatic medicine, essential oils can be administered orally either in a

gelatin capsule, honey water, or alcohol (Valnet 1990). For more information,

please see Chapter 7. This is a highly specialized ﬁeld that requires proper train-

ing and, in the United States, probably a license to prescribe. Despite the fact that

many essential oils are used in small amounts as ﬂavoring agents in our food, pure

essential oils are concentrated and are not to be experimented with casually. Just

as a whole bottle of Tylenol can be lethal (although this drug is still sold over the

counter because the public is expected to take only one or two tablets at a time),

so a few essential oils can be lethal if several milliliters are ingested at once. Price

and Price (1999) suggest the maximum number of essential oil drops taken in-

ternally should be limited to 3 drops 3 times a day for a period of 3 weeks maxi-

mum. Brinker (2000) suggests up to 2

⁄

ml a day. (If there are 20 drops per mil-

liliter, this works out to be 50 drops a day, which does seem a little high.)

However, much depends on the essential oils and its chemical constituents.

28 Section I Overview

A safer option is to offer herbal teas. These are gentle and are sold over the

counter. Common herbal teas are chamomile, peppermint, ginger, and fennel.

Warning: Encouraging patients to take essential oils by mouth is not advised

unless the person advocating it is trained in this method.

Inhalation

“Smells are surer than sounds and sights to make your heartstrings crack.”

Rudyard Kipling (Birchall 1990)

Of all the methods for introducing essential oils into the human body, inhalation

is the simplest and fastest. It is also the oldest method, and the use of aromatics

in rituals is well documented. Perfume, as the name implies, began its existence

as a ritual source of odor spread by heat and smoke (Watson 2000). The Oxford

Dictionary deﬁnes perfume as “odorous fumes of burning substance,” and the

word is derived from the Latin fume, meaning smoke (Oxford Dictionaries 1964).

Inhalation may be the oldest method of drug use, but it is also turning out to be

one of the most current. The latest drug to be used via olfaction is insulin. In this

revolutionary method of treating diabetes, powdered or liquid insulin is inhaled

once a day (Epstein 2001). Inhalation takes the essential oils from the outside of

the body to deep inside the body in one easy step. The lungs have a huge surface

area that is intimately connected to the blood system via the alveoli. Jori et al

(1969) showed that inhaled cineole (an oxide found in eucalyptus and several

other essential oils) can have a measurable effect at very low concentrations.

Olfaction

The nose has two distinct functions: to warm and ﬁlter incoming air and to act as

the ﬁrst part of the olfactory system. If inhalation was the same as olfaction, then

olfactory stimuli would be obvious each time a breath was taken, which is not the

case; taking a normal breath is different than snifﬁng an essential oil (Alexander

2001). However, aromas can have instant effects, and sometimes just thinking

about a smell can be as powerful as actually smelling it (Betts 1996). Odors have

psychologic and physiologic effects. Until very recently smelling salts were the

standard method for reviving someone who had fainted. A person knows imme-

diately if a smell is pleasant or unpleasant and what memories it evokes. Smell is

a chemical reaction; receptors in the brain respond to chemicals within the es-

sential oil. As a person breathes in, these chemicals move up behind the bridge of

the nose, just beneath the brain, where they attach themselves to millions of hair-

like receptors connected to the olfactory bulb. These receptors are extremely sen-

sitive and can be stimulated by very subtle scents. Different odors bind to distinct

arrays of receptors. This allows people to discriminate between more than 10,000

odors, even though there are only about 1000 odor receptors.

Because olfactory receptors are so sensitive, they are easily fatigued, which ex-

plains why smells seem less obvious as the body tires or adapts to them (Anthony

Chapter 2 The Nature of Aromatherapy 29

& Thibodeau 1983). Air ﬂows through the nostrils at different rates because of

turbinate swelling. Every few hours, the nostril taking in more air switches from

left to right. In one study, odors breathed through one or the other nostril pro-

duced different effects; 17 out of 20 participants identiﬁed l-carvone differently,

depending on which nostril was dominant. However, there are no differences with

regard to the electrical changes in the brain between the left and right nostrils

(Walter et al 1964). Essential oils are highly complex and are made up of many dif-

ferent chemical components, or odor molecules. These molecules travel via the

nose to the olfactory bulb and on to the limbic system of the brain.

The limbic system (LS) is vital for normal human functioning and is the

oldest part of the human brain, supposedly having evolved ﬁrst. (In lower verte-

brates it is called the smell brain, because these animals depend on their sense of

smell for survival.) The LS is a complex inner ring of brain structures below the

cerebral cortex, arranged into 53 regions and 35 associated tracts (Watts 1975).

The main structures in the limbic system are the amygdala, septum, hippocam-

pus, anterior thalamus, and hypothalamus. These structures are connected by a

number of complicated pathways (Anthony & Thibodeau 1983). Of these re-

gions, the amygdala and hippocampus are of particular importance in processing

aromas.

The amygdala is an almond-shaped group of subcortical nuclei located un-

der the surface of the front medial portion of the temporal lobe. It is thought to

play a pivotal role in processing emotion and in the formation of emotional mem-

ory, and it governs emotional response. The amygdala is known to affect survival

behavior and is intimately responsible for the sensation of fear. It is also thought

to play an important role in controlling aggression. Autism has been linked to a

change in the cells of the amygdala (Edelson 2001). Diazepam (Valium) is

thought to reduce the effect of external emotional stimuli by increasing gamma

aminobutyric acid (GABA)-containing inhibitory neurons in the amygdala

(LeDoux 1996). True lavender (Lavandula angustifolia) is thought to have a

similar effect on the amygdala, producing a sedative effect similar to diazepam

(Tisserand 1988). This is interesting because tricyclics or benzodiazepines, which

were commonly used by orthodox medicine to treat chronic pain, also inhibit the

action of nociceptor neurotransmitters. True lavender is a common essential oil

used topically for pain relief that also appears to enhance the effect of orthodox

pain medication.

The hippocampus is where the memory of smell is triggered, so this part of

the limbic system is concerned with the formation and retrieval of explicit mem-

ories (LeDoux 1996). It is also closely involved with the three types of memory:

semantic (facts and concepts), episodic (recollection of events), and spatial (recog-

nition). The hippocampus is thought to be the storage area for new experiences

before they become permanent memories that are then believed to be stored in

the cerebral cortex. The hippocampus is particularly vulnerable to ischemia,

Alzheimer’s disease, and epilepsy (Healing Arts 2001). A stroke can affect mem-

ory, but only if it causes bilateral damage to the hippocampus.

30 Section I Overview

As well as inﬂuencing the expression of emotions, instinctive behaviors, dri-

ves, and motivations, the limbic system plays an essential role in learning and

memory (Kirk-Smith 1993). Buchbauer (1993a) states the limbic system is re-

sponsible for sexual desires and feelings of wellness and harmony. The posterior,

superior part of the cingulate gyrus is related to sexual behavior and is linked to

obsessive-compulsive behavior (Diamond et al 1985).

The limbic system also receives most sensory input and passes it on to the

voluntary and involuntary motor centers. Gatti and Cajola (1923) noted that

odors produced an immediate effect on respiration, pulse, and blood pressure, and

therefore concluded that odors had produced, by a reﬂex action, a dramatic effect

on the functioning of the central nervous system. Singewald et al (2000), nearly

80 years later, found that the locus coeruleus played a pivotal role in conditioned

fear and inescapable shock.

The effect of odors on the brain has been “mapped” using computer-

generated tomographics. These brain electrical activity maps indicate how sub-

jects linked to an electroencephalogram psychometrically rate odors presented to

them (Van Toller et al 1992). Smells can have a psychologic effect even when the

aroma is below the level of human awareness. Lorig et al (1990) reported the ef-

fects of subliminal (below consciousness) smelling of vanilla. The scent of vanilla

was found to elicit positive mood change. Aromas can also have an effect while a

person is sleeping (Bardia et al 1990).

An electrical phenomenon discovered by Grey in 1964 called contingent

negative variation (CNV) showed the sedative effects of diazepam decreased

CNV, and the stimulant effect of caffeine increased CNV. When fragrances were

tested, these also caused different effects. Lavender produced a similar reaction to

diazepam, decreasing CNV, and jasmine had the reverse effect, increasing CNV

(Torii et al 1991). Rovesti and Columbo’s research (1973) showed that olfactory

receptors are also affected by nonvolatile molecules in aerosols. This was con-

ﬁrmed with research conducted by Vellmair et al in 1998.

Anosmia Certain genetic conditions, such as Kallman’s syndrome, pro-

duce anosmia (Bartoshuk & Beauchamp 1994), the lack of a sense of smell.

Sometimes there is speciﬁc anosmia, which means a certain aroma, such as an-

drostenone, is not smelled or is perceived differently. When the olfactory nerve

has been severed by trauma, aromas are unable to connect to the limbic part of

the brain. However essential oils can still enter the body through the lungs, skin,

or ingestion. When a person has a sinus infection or a heavy cold, some aromas

may get through; they tend to be the most penetrating, such as peppermint and

eucalyptus. Temporary loss of smell can also follow a severe shock or infection.

Smell is closely aligned to the sense of taste. Taste is divided into four categories:

salty, sour, sweet, and bitter. Salty and sour tastes involve ion channels in the cells

of receptor membranes, whereas sweet and bitter tastes bind to receptor proteins

(Bartoshuk & Beauchamp 1994).

Administration Via the Olfactory System Inhalation can be targeted di-

rectly to a single patient, in which case it is called direct inhalation, or it can be

Chapter 2 The Nature of Aromatherapy 31

used in a more general way, for example in a room of people. This second method

is called indirect inhalation. Indirect inhalation can use a selection of apparatus:

electrical, heat, or battery operated.

Direct Inhalation

1. Tissue or cotton ball: Put one to ﬁve drops of essential oil(s) on a facial

tissue or cotton ball and inhale for 5 to 10 minutes. Alternately, aroma rib-

bons can be attached to the bedclothes of children or adults for an easily

applied sleeping or comfort aroma. Cut off a 1-inch piece of ribbon and

attach it to the mattress or pillow with a diaper pin. Caution: Ensure that

the pin is secure and that a child cannot put the ribbon in his or her

mouth.

2. Steam: Add one to ﬁve drops of essential oil to a bowl of steaming water.

Place a towel over the patient’s head and ask him or her to inhale for 10

minutes. Remember to ask the patient to close his or her eyes and remove

spectacles. Because soft contact lenses can absorb some of the essential oil

and cause stinging, it is a good idea to remove lenses before steam inhala-

tion. Caution: Avoid this procedure with the elderly, confused, very

young, or inﬁrm.

3. Hood: The hood is a new method of delivery, initially designed for a labo-

ratory experiments, that uses a controlled and measured supply of essential

oil and involves a stream of vaporized aroma combined with air and

pumped at a constant rate into an oxygen-therapy hood (Palmer et al 1999).

Indirect Inhalation

1. Room fresheners: Add one to ﬁve drops of essential oil to a bowl of hot

water and place in a safe space. The warmth of the water gradually allows

the essential oils to evaporate with the water. This is excellent in air-

conditioned facilities where the atmosphere may be dry.

2. Burners: Burners usually have a small candle that heats a container sus-

pended above. Float one to ﬁve drops of essential oil on top of water in

the container. The water stops the essential oil from burning and leaving

a yellow, sticky residue. Caution: Keep away from children and pets.

3. Fans: Fans can be battery or electrically operated and come with a num-

ber of small, absorbent pads. Add one to ﬁve drops to the pad, place in the

fan, and switch on. Inexpensive spare pads can be made by cutting incon-

tinence pads or pantyliners into the correct small, square size.

4. Humidiﬁers: Humidiﬁers can be purchased in most drug stores. Fill the

container with water. Place essential oils on a tissue and put the tissue in

the direct pathway of the exiting steam. Do not ﬂoat the essential oil on

top of the water inside the humidiﬁer because it will not come out with

the steam, but will remain ﬂoating on the water. This is an excellent

method for treating croup and asthma.

5. Diffusers: Diffusers can be multifaceted, with different compartments

timed for different hours, or a more simple apparatus. Gentle heat causes

the essential oil to evaporate.

32 Section I Overview

6. Nebulizers: Nebulizers are electrical units with small, glass attachments

into which drops of undiluted essential oil are placed. Microdroplets of

the essential oil are atomized into the air, often at timed intervals, ioniz-

ing the air. Most nebulizers use no heat. They can be expensive and frag-

ile, but they are most effective for large areas. Caution: Avoid overdosing

with essential oils.

7. Spritzer sprays (essential oils in water): Sprays are excellent for hot ﬂashes

or fatigue. Caution: Avoid spraying on plants or ﬂowers by mistake.

Beneﬁts of Inhalation: Inhalation is effective for both physical and psy-

chologic complaints. It is a simple method, is fast acting, and is empowering for the

patient. Inhaled essential oils can be particularly useful for treating the following:

Upper and lower respiratory tract infections

Hay fever, sinusitis, and headache

Asthma

People who cannot be touched, for physical or psychologic reasons

Prevention of cross-infection

Depression or fatigue

Insomnia

Finally, the nose, as well as governing the smell system, contains a touch sys-

tem, which is often (wrongly) thought to be part of the smell system. This touch

system is the trigeminal system and forms part of the ﬁfth cranial nerve. It can

detect aggressive odors such as acetic acid and ammonia and causes the head-

swiveling reﬂex (Van Toller & Dodd 1991).

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36 Section I Overview

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Chapter 2 The Nature of Aromatherapy 37

Basic Plant Taxonomy,

Chemistry, Extraction,

Biosynthesis, and Analysis

The problem with wonder drugs is that they breed in the public mind a sense that

medicine can and always should work miracles, even with benign problems. What

gets forgotten is the price we always pay by tampering so totally with Mother

Nature

McTaggart (1996)

earning how and why a plant manufactures an essential oil is relevant to

understanding aromatherapy. The way plants make essential oils gives

some insight into their complexity. Traditionally, biochemists have stud-

ied primary metabolism and organic chemists have studied secondary metabo-

lism. In aromatherapy, it is of interest to have an overall picture of both meta-

bolic processes. Why some plants make essential oils is the subject of ongoing

scientiﬁc debate and is relevant to the therapeutic potential of the essential oil in

humans.

The process of extraction clariﬁes the need for unadulterated essential oils.

Unadulterated essential oils are required for clinical use, and the process of steam

distillation or expression can produce an essential oil with no residue. However,

there are new and exciting methods of obtaining extracts that may become part

of aromatherapy in the future. How essential oils are absorbed into the body is a

subject of heated discussion and is a topic I attempt to cover. There is no doubt

that new evidence will emerge after this book is published.

I am very appreciative of the help and advice given by the expert reviewers of

this section: James Duke, PhD; Howard Freund, PhD; Bob and Rhi Harris; Tom

Numark; Keith Shawe, PhD; and Neal Schultz, MD. I am also appreciative of the

published work of John Mann, PhD.

Part I: Basic Plant Taxonomy and Chemistry

The lovesick, the betrayed and the jealous all smell alike.

Colette

he Latin names of plants can seem a bit intimidating initially, but they are

the best way to be sure of what is in that bottle of essential oil, and they

are recognized the world over, from China to Peru. Latin has been used

for thousands of years in botany and was ﬁrst used in this context by Pliny in

AD. However, it was Carl Linnaeus (1707-1778) who established the basis for

naming plants in Latin (Stearn 1998).

A plant only has one Latin name, but it may have many common names, and

those common names may also be used for completely different plants. Take for

example bergamot. In aromatherapy, bergamot refers to the oil extracted from

the peel of the citrus fruit, Citrus bergamia. This should not be confused with the

medicinal plant Monarda didyma, which is also known as bergamot. Similarly,

the word geranium refers to the species geranium for gardeners, but in the world

of aromatherapy it refers to Pelargonium graveolens.

Every plant has a unique name in Latin composed of two words. The ﬁrst

word is the name of the genus, and the second is the name of the species—rather

like our ﬁrst name and surname. Classiﬁcation of plants is called taxonomy. All

plants can be grouped into categories. For plants to be properly identiﬁed they are

divided into division, class, order, family, genus, and species. This process takes

into account the number, shape, and position of leaves on the stem; the shape and

position of the ﬂowers; the number and shape of the petals; whether the plant is

hairy, prickly, or smooth; whether the stem is ridged; and so on.

Life on earth began about 4 billion years ago with a single-celled organism that

did not have a nucleus. Many of these basic organisms, including algae and bacteria,

are still living in our world today. Through gradual evolution a vast range of aromatic

plants evolved that presently produces 30,000 known volatile oils (Elpel 1998).

Lavender

Lavender belongs to a plant family called Lamiaceae or Labiatae: the mint fam-

ily. This family includes many species used in aromatherapy. Plants in this family

usually have ﬁve united petals with two lobes on the top and three on the bottom

forming lips (labia). The leaves are usually directly opposite each other on the

stem, and often the stem is square. The Latin name for the lavender genus is

Lavandula. The most commonly used lavender is a hybrid, lavandin, which is a

widely used cross between two Lavandula species: L. angustifolia and L. latifolia.

Chapter 3 Basic Plant Taxonomy 39

There is also another species of lavender, L. stoechas, which can be used clinically.

See Table 3-1. However, as frequently happens in the plant kingdom, two of the

species also have other names. Lavandula angustifolia is sometimes called L. vera

or L. ofﬁcinalis, although the correct name is L. angustifolia (Lawrence 1989). This

plant also has several common names: English lavender, French lavender, and true

lavender. Lavandula latifolia is sometimes called L. spica, and its common name

is spike lavender or spike. Spike is completely different from spikenard (Nar-

dostachys jatamansi), which is closely related to valerian and belongs to the family

Valerianaceae.

Lavandula angustifolia and Lavandula latifolia were listed in the British Phar-

macopoeia and supplied to hospitals in vats labeled simply “lavender.” However,

the two plants have very different therapeutic properties. L. angustifolia is a seda-

tive, relaxant, and hypotensor. L. latifolia is a stimulant and expectorant.

Chamomile

Chamomile can cause confusion to the newcomer, too. There are three main types

of chamomile used in aromatherapy: German, Roman, and Moroccan (Table

3-2). They are quite different and produce different-colored essential oils that

40 Section I Overview

Table 3-1 h Lavenders and Some of Their Properties

Latin Name Common Name Properties

Lavandula angustifolia True lavender Calming, sedative, good for

Lavandula vera burns, analgesic, antibacterial,

Lavandula ofﬁcinalis immune-system enhancer

Lavandula latifolia Spike lavender Expectorant, mycolytic,

Lavandula spica possible stimulant

Lavandula stoechas Stoechas Useful against Pseudomonas

spp., high in ketones

Table 3-2 h Chamomiles and Some of Their Properties

Latin Name Common Name Properties

Matricaria recutita German chamomile Dark blue, useful for skin

complaints and inﬂammation

Chamaemelum nobile Roman chamomile Pale blue or yellow, sedative,

useful for spasms

Ormenis mixta Moroccan chamomile Mainly used by perfume in-

dustry, some antibacterial

activity

have different properties, but they all belong to the same family: Asteraceae or

Compositae—the daisy family.

German chamomile (Matricaria recutita) is a smoky smelling, dark-blue oil

that contains chamazulene. The oil’s color depends directly on the amount of

chamazulene present and the method of extraction. It should be noted that

chamazulene is not present in the fresh ﬂower (or in its CO

extract) but is pro-

duced during distillation (Lawless 1992). It is possible to obtain a green or yellow

German chamomile oil that has less than 3% chamazulene, but the dark-blue va-

riety always has more than 7% (Svab & Sarkany 1975). The price of German

chamomile oil is usually related to the amount of chamazulene it contains.

Chamazulene is an antiinﬂammatory with a history of use in the treatment

of skin problems (Jakovlev et al 1983). German chamomile also contains a sec-

ond antiinﬂammatory compound called alpha-bisabolol, which is a monoterpenol

(Carle & Gomaa 1992). In addition, this species has antibiotic properties and is

effective against Staphylococcus aureus, hemolytic Streptococcus, and Proteus vul-

garis. Valnet, a French MD, claims that wound infections bathed with a solution

of 1 part German chamomile in 100,000 parts water have been healed (Valnet

1990). German chamomile is also thought to “stimulate liver regeneration and

subcutaneous treatments will initiate formation of new liver tissue”(Rose 1992).

-extracted German chamomile is brown and almost solid at room tempera-

ture. It smells of sweet apples with an earthy undertone.

Roman chamomile (Chamaemelum nobile) is a colorless to pale blue oil that

turns yellow with storage. Listed in the British Herbal Pharmacopoeia, it contains

up to 80% esters. Esters have antispasmodic properties, and essential oil of Ro-

man chamomile is traditionally used as an antispasmodic and relaxant whereas

the herb is used as a carminative. Roman chamomile also has mild antiinﬂam-

matory properties (Franchomme & Penoel 1990), particularly if the oil is col-

lected from white-headed ﬂowers instead of the classic yellow-headed ﬂowers

(Rossi et al 1988).

Moroccan chamomile (Ormenis multicaulis or O. mixta) is a relative new-

comer to the aromatherapy ﬁeld and is mainly used in the perfume industry. Lit-

tle is known about its clinical effects. In all respects it is different from the other

chamomiles and cannot be regarded as a substitute for either of them.

Different Parts

Occasionally, different parts of the same plant can produce different essential oils.

In the case of the bitter orange plant (Citrus x aurantium var. amara), three dif-

ferent types of essential oils can be obtained: Petitgrain from the stems and leaves,

Neroli from the petals, and bitter orange from the fruit. Neroli and petitgrain-

type essential oils can also be obtained from other citrus species. Bergamot es-

sential oil is obtained from the rind of a fruit that is a subspecies of the bitter-

sweet orange. The shorthand for Citrus aurantium subspp. bergamia (bergamot) is

Citrus bergamia (Guenther 1976).

Chapter 3 Basic Plant Taxonomy 41

Sometimes just the part of the plant is listed (for example, cinnamon bark or

cinnamon leaf ). Cinnamon bark contains approximately 50% eugenol (a phenol).

Cinnamon leaf contains 80 to 96% eugenol. Eugenol is strongly antimicrobial; it

can inhibit bacterial growth on food for 30 days (Moleyar & Narasimham 1992).

However, it is also dermacaustic and can dissolve metal, false teeth, and pearls

(Ryman 1991). Small amounts of cinnamon bark and cinnamon leaf are used by

the fragrance and pharmaceutical industries. Cinnamon is also one of the ﬂavo-

rants of Coca-Cola (Lawless 1992).

Clones and Chemotypes

To complicate the situation still further, some plants have been cloned or culti-

vated to produce different chemotypes (Table 3-3). This means the essential oil

has a speciﬁc chemical proﬁle that might make it more suitable for treating a par-

ticular ailment or safer to use. Common thyme (Thymus vulgaris) has several

chemotypes: linalol, geraniol, a-terpineol, thujanol-4, carvacrol, and thymol

(Vernet & Gouyon 1976). The ﬁrst four are all safe to use on the skin, because

they are high in alcohols. However, thymol and carvacrol are phenols and can

cause skin irritation. Red thyme, which commonly grows in garden lawns, is a

phenol type.

Tea tree, eucalyptus, rosemary, and German chamomile are other essential

oils that have commercial chemotypes. Chemotypes will become more com-

mon as aromatic plants are grown on a more global level as cash crops (Franz

1993).

42 Section I Overview

Table 3-3 h Some Examples of Essential Oil Chemotypes

Latin Name Chemical Constituents Research Paper

Achillea millifolium Caryophyllene, farnasene, Hethelyi et al 1988

azulene-free Oswiecimska 1974

Artemesia dracunculus Methyl chavicol, sabinene Tucker & Maciarello

1987

Ocimum basilicum Linalool, methyl chavicol, Sobti et al 1978

eugenol

Matricaria recutita Bisabolone oxide, Frantz 1993

bisabolol, chamazulene,

chamazulene-free

Salvia ofﬁcinalis - & -thujone, cineole, Tucker & Maciarello

thujone-free 1990

Chemistry of Essential Oils*

The chemical components that make up essential oils are produced during the

second stage of biosynthesis and are called secondary metabolites (Fig. 3-1). Ter-

penes make up the largest group of secondary metabolites with some 1000

monoterpenes and 3000 sesquiterpenes known (Harborne 1988). However, the

Chapter 3 Basic Plant Taxonomy 43

*I was greatly helped with revising this section by the following books: The Chemistry of Essential Oils

(Williams 1996), The Basic Chemistry of Aromatherapeutic Essential Oils (Bowles 2000), and Volatile Oil

Crops (Hay & Waterman 1993). These books are highly recommended for additional reading.

phenylalanine

COOH

apiole

MeO

OMe

PA L

COOH

cinnamic acid

chavicol

estragole

MeO

anethole

MeO

Figure 3-1 Biosynthesis of phenylpropanes. (Adapted from Waterman P. 1993. The Chem-

istry of volatile oils. In Hay R, Waterman P (eds.), Volatile Oil Crops: Their Biology, Biochemistry

and Production. Essex, UK: Longman Scientiﬁc and Technical, 47-61.)

number of phenylpropanes (which contain benzene rings) is much smaller—

approximately 50. Terpenes arise from the mevalonic pathway. Phenylpropanes

come from the shikimic pathway.

Mevalonic Pathway

This pathway depends on mevalonic acid, a chemical intermediate containing six

carbon atoms made by the plant and vital to its life (Waterman 1993). The plant

converts mevalonic acid to a 5-carbon structure (with the isoprene arrangement)

typical of all terpenes. This is then converted to geranyl pyrophosphate (GPP)—

the ﬁrst recognizable 10-carbon molecule. This process can continue with an-

other enzyme catalyst to result in the ﬁrst 15-carbon molecule, sesquiterpene

compound, farnesyl pyrophosphate (FPP). Once the plant has formed GPP, the

substance can be converted into alcohols or aldehydes.

Shikimic Pathway

This pathway utilizes an enzyme called phenylalanine ammonia lyase (PAL) to

produce phenolic compounds that include benzene rings (Waterman 1993). This

pathway also produces alkaloids such as morphine.

Terpenes, Isoprene Units

Terpenes make up the largest single class of compounds, although phenyl-

propenes tend to have the largest impact on the aroma (Waterman 1993). Ter-

penes found in essential oils are made up of the isoprene units (building blocks)

referred to previously. Each isoprene unit contains 5 carbon atoms, and some peo-

ple believe the shape resembles the skeletal proﬁle of a dog in ﬂight (Table 3-4)

(Williams 1996). One of the carbon atoms is attached by a double bond.

Monoterpenes have two isoprene units, sesquiterpenes have three, and diterpenes

have four. Because each isoprene unit has ﬁve carbon atoms, it is simple math to

work out the number of carbon atoms per molecule (Table 3-5).

Monoterpenes make up the largest number of terpenes and can be subdivided

into groups that indicate their structure. All terpenes end in -ene. They are light

molecules and evaporate quickly. Monoterpenes are often referred to as top notes.

They oxidize easily and combine with oxygen over time to become alcohols.

In aromatherapy, the term terpenoid is given to terpene molecules that in-

clude oxygen (Tisserand & Balacs 1995). Terpenoid is not a chemical term in a

44 Section I Overview

Table 3-4 h Structure of Terpenes

Molecular Structure Name Chemical Constituent

Chain, no ring acyclic -myrcene

One ring cyclic -limonene

Two rings bicyclic

strict sense, but it can be useful to distinguish between molecules that do not have

oxygen and those that do. All terpenes have antiseptic properties (Table 3-6).

Camphene, phellandrene, pinene, myrcene, and limonene are common examples

of monoterpenes. Limonene is thought to be antitumoral (Zheng et al 1992;

Gould 1997) and occurs in most citrus oils and in dill (Anethum graveolens).

Myrcene, found in lemongrass (Cymbopogon citratus), has analgesic properties

(Lorenzetti et al 1991)). Monoterpenes in general have a stimulating effect, but

they can become skin-sensitizing if used over time. Because they are insoluble in

water, the perfume industry frequently removes terpenes from an essential oil so

the oil can be used in toilet water. In this case the essential oil is said to be “ter-

peneless” (Guenther 1972).

Sesquiterpenes are less volatile but because they are larger structures, they

have a greater potential for stereochemical diversity (Waterman 1993). Sesquiter-

penes have stronger odors, are antiinﬂammatory and have bactericidal properties

(Table 3-7). As terpenes, they still oxidize over time into alcohols. In patchouli

Chapter 3 Basic Plant Taxonomy 45

Table 3-6 h Some Terpenes and Their Properties

-limonene found in many Antitumoral (Gould 1997)

citrus peel oils (60-90%) May dissolve gall stones (Igimi

et al 1991)

Myrcene found in Analgesic (Lorenzetti et al 1991)

Cymbopogon citratus,

Juniperus communis

Table 3-5 h Number of Carbon Atoms in Terpenes

Number of Number of

Chemical Constituent Isoprene Units Carbon Atoms

Monoterpene 2 isoprene units 10 carbon atoms

Sesquiterpene 3 isoprene units 15 carbon atoms

Diterpene 4 isoprene units 20 carbon atoms

oil this oxidation is thought to improve the odor. Chamazulene actually has 14

carbon atoms but is often included with sesquiterpenes. Chamazulene and

caryophyllene have antitumor activity (Mills 1991). Chamazulene is found in

German chamomile, bisabolene is found in black pepper, and caryophyllene is

found in ylang ylang (Cananga odorata).

The very few diterpenes found in essential oils tend to oxidize into alcohols.

This process produces sclareol in clary sage and viridiﬂorol in niaouli. However,

diterpenes may occur in solvent extracts. Taxol is a diterpene (Lewinsohn 2001).

Alcohols

Terpenic alcohols are found in many essential oils. Their names all end in -ol.

Structurally, they have a hydroxyl group attached to one of their carbon atoms

(Table 3-8). Monoterpenic alcohols (monoterpenols) are thought to be good an-

tiseptics with some antibacterial and antifungal properties. Isoborneol inhibits the

herpes virus (Armaka et al 1999). Some alcohols, such as terpinen-4-ol, are up-

lifting; others like linalool are thought to be sedatives. Usually essential oils with

a high percentage of monoterpenols are safe to use undiluted on the skin. Exam-

ples include geraniol in palmarosa (Cymbopogon martini) and citronellol in Euca-

lyptus citriodora (Lewis Walter & Elvin-Lewis Memory 1977). Isoborneol has an-

tiviral properties and is a potent inhibitor of herpes simplex virus type (Amarka

et al. 1999). Perillyl alcohol has been shown to regress pancreatic, mammary, and

liver tumors in animal studies and to revert tumor cells to a differentiated state

(Belanger 1998). However, in human studies, oral doses did not regress these tu-

mors. There have been no studies to date on topically applied or inhaled perillyl

alcohol that I could ﬁnd.

Sesquiterpenols have 15 carbon atoms and a variety of therapeutic effects

(Table 3-9). When -eudesmol was injected directly into the spinal cords of rats,

it signiﬁcantly reduced edematous effusion following brain injury (Asakura et al

46 Section I Overview

Table 3-7 h Some Sesquiterpenes and Their Properties

Chamazulene found in Antiinﬂammatory (Safayhi

Matricaria recutita et al 1994)

Sedative (Yamada et al 1996)

-caryophyllene found in Antiinﬂammatory

Cananga odorata (Tambe et al 1996)

Table 3-8 h Some Alcohols and Their Properties

Linalool in Lavandula Sedative (Buchbauer et al 1991;

angustifolia Re et al 2000)

Antispasmodic (Lis-Balchin &

Hart 1999)

Geraniol in Cymbopogon Antifungal (Carson &

martini Riley 1995)

Potentiates antiherpetic activity

of SON (Shoji et al 1998)

Terpinen-4-ol in Melaleuca Effective against Pseudomonas

alternifolia aeruginosa (Budhiraja et al

1999; Jedlickova et al 1992)

Table 3-9 h Some Sesquiterpenols and Their Properties

Farnesol found in Effective against Trichomonas

vaginalis (Viollon et al

1996)

Hypotensor (Luft et al 1999)

-bisabolol found in Antiinﬂammatory ( Jakovlev

Matricaria recutita et al 1979)

Patchoulol found in Effective against bacteria that

patchouli cablin cause foot odor (Yang et al

1996)

2000). It also appeared to reduce potassium- and electric shock-induced seizures

(Chio et al 1997). The anticonvulsant properties of -eudesmol were compared

to phenobarbitone in another study by Santos et al (1997). -eudesmol is found

in West Indian Sandalwood (Amyris balsamifera) and Psidium guyanensis.

Nerolidol, found in Melaleuca quinquenervia (a special chemotype of niaouli),

completely inhibited development of the malaria-bearing mosquito (Lopez et al

1999). The Amazonian Waiapi tribe treat malaria by inhaling the essential oil

from the leaf of Virola surinamensis (a rainforest tree that contains nerolidol). San-

talol found in sandalwood is an effective antiviral agent against early-stage cold

sores (Benencia & Courreges 1999) and was also found to work as a sedative in

mice (Okegawa et al 1995). Sclareol kills tumor cells in vitro (Dimas et al 1999)

and is used extensively for ambergris fragrance (Bauer et al 1990).

Phenols

A phenol is a hydroxyl group attached to a benzene ring (Table 3-10). Like alco-

hols, phenol names end in -ol, but this is where the similarity ends. There are only

four common phenols found in essential oils: thymol, carvacrol, eugenol, and

chavicol. There are two ethers from phenols: one from eugenol and one from

48 Section I Overview

Table 3-10 h Some Phenols and Their Properties

Thymol found in Thymus Antibacterial (Shapiro et al 1994)

vulgaris, Lippia sidoides Effective against Cryptococcus neo

formans (Voillon & Chaumont

1994)

Eugenol found in Syzygium Sedative & vasodilator

aromaticum (clove bud) (Hume 1983)

Carvacrol found in Anticonvulsant (Santos et al 1997)

Origanum vulgare Antibacterial (Consentino et al

1999) 1999)

chavicol. Benzene (aromatic) rings can easily be formed from aliphatic (nonben-

zene) rings, but the reverse reaction rarely occurs (Guenther 1972). Phenols need

to be treated with care because many of them are skin irritants. Most have very

strong antibacterial properties, and some have a stimulatory effect on both the

nervous system and the immune system. Thymol (from Thymus vulgaris) also has

anthelmintic properties. Eugenol is a powerful antiinﬂammatory (Sharma et al

1994) and decreases gut motility in diarrhea. It also inhibits prostaglandin syn-

thesis (Bennett et al 1988).

Aldehydes

An aldehyde has an oxygen atom double bonded to a carbon atom at the end of

a carbon chain (Table 3-11). The fourth bond is always a hydrogen atom (Bowles

2000). Aldehydes usually end in -al and often have sedative, calming effects, as

well as being important to the aroma of the plant. Examples include citral in

lemon balm (Melissa ofﬁcinalis), citronellal in lemongrass (Cymbopogon citratus),

geranial in lemon eucalyptus (Eucalyptus citriodora), and neral in lemon verbena

(Aloysia triphylla). Geranial and neral are isomers, meaning they have the same

molecular make-up but the carboxyl molecule is in a different place. For a long

time they were thought to be so similar they were combined and called citral.

Chapter 3 Basic Plant Taxonomy 49

Table 3-11 h Some Aldehydes and Their Properties

Citronellal found in Antifungal (Hmamouchi et al 1990)

Eucalyptus citriodora Antilouse (Mumcouglu et al 1996)

Neral & geranial (citral) Antibacterial (Onawunmi 1989)

in Cymbopogon citratus

Cinnamaldehyde in Selective effect against pathogenic

Cinnamomum intestinal ﬂora (Lee & Ahn

zeylanticum 1998)

Citral has strong antiseptic and antibacterial properties (Onawunmi & Oguniana

1981). Citronellal possesses antifungal properties (Hmamouchi et al 1990).

Esters

Esters are a combination of an acid and an alcohol and take their name from the

acid and alcohol (Table 3-12). Hence, acetic acid and linalool produce Linalyl ac-

etate. Acids do not occur in essential oils but can be found in ﬂoral waters. Esters

end in –ate, and have antispasmodic and calming properties. Some are also anti-

fungal. They often smell very fruity. Examples include Linalyl acetate found in

lavender (Lavandula angustifolia), clary sage (Salvia sclarea), bergamot (Citrus au-

rantium subsp. bergamia), and genaryl acetate found in sweet marjoram (Origanum

majorana). One essential oil with a very high ester content (85%) is Roman

chamomile (Chamaemelum/Anthemis nobilis), which includes angelic and tiglic esters

(Bauer et al 1990).

Ketones

A ketone is derived from an alcohol by oxygenation and has an oxygen atom dou-

ble bonded to a carbon atom, which is also bonded to two other carbon atoms

(Table 3-13) (Bowles 2000). Ketones end in -one with a single exception: cam-

phor. This substance has no relation to the plant camphor. Ketones should always

be treated with respect because certain ketones can produce convulsant effects

(usually when taken orally). Because ketones are resistant to metabolism, they can

build up in the liver. An easy way to remember that they are a potential problem

is to think of ketosis. Potentially toxic ketones include d-pulegone (found in pen-

nyroyal), which caused the death of a 23-year-old woman in 1897. It must be

stressed that this lady did drink a tablespoonful (15 ml) of undiluted essential

oil (Allen 1897). Pennyroyal tea caused the death of two infants. A child who

50 Section I Overview

Table 3-12 h Some Esters and Their Properties

Linalyl acetate found in Sedative (Buchbauer et al 1991)

Lavandula angustifolia Topical anesthetic (Ghelardini

et al 1999)

Geranyl acetate in Stimulates bile production

Cymbopogon martini (Trabace et al 1994)

developed hepatic malfunction and presented with severe epileptic encephalopa-

thy was tested for pulegone; results were positive (Bakerink et al 1996). Once

again large amounts of the essential oil had been ingested.

There are some nontoxic ketones. Most of these are good for the skin and for

scars, a view supported by Lavabre (1990). Safe ketones include jasmone in jas-

mine (Jasminum ofﬁcinale) (International School of Aromatherapy 1993), fen-

chone in fennel (Foeniculum vulgare var. dulce), and isomenthone in geranium

(Pelargonium graveolens). A special diketone found in everlasting (Helicrysum

italicum) has antihematoma properties and reduces contusions with great speed.

Oxides

Oxides in organic chemistry typically involve an oxygen bridge between two

neighboring carbon atoms (Table 3-14). The use of the term oxide in aromather-

apy is a little more general because the carbons are not neighbors. In chemical

terminology, an oxide is called an ether or a peroxide. However, the term ether

might be confusing because there is another group of phenolic ethers that have

different properties. An oxide has an oxygen atom in a chain of carbons, which

forms a ring (but not a benzene ring). The most common oxide is cineole—a

strong expectorant. Both 1,4-cineole and 1,8-cineole occur in essential oils

(Tisserand & Balacs 1995). Sometimes called eucalyptol, 1,8-cineole is found in

blue gum (Eucalyptus globulus), rosemary (Rosmarinus ofﬁcinalis CT cineole), and

bay laurel (Lauris nobilis). Other oxides are ascaridole found in wormseed

(Chenopodium ambrosioides var. anthelminticum) and rose oxide found in geranium

(Pelargonium graveolens) and rose (Rosa damascena). The freshly baked smell

Chapter 3 Basic Plant Taxonomy 51

Table 3-13 h A Ketone and Its Properties

Menthone in Mentha piperita Inhibition of platelet aggrega-

tion in decompression sick-

ness (Murauama & Kumaroo

1986)

Table 3-14 h An Oxide and Its Properties

1,8 cineole found in Antiinﬂammatory ( Juergens et al 1998)

Eucalyptus globulus Enhances pentobarbitol effects

(Santos & Rao 2000)

Expectorant (Duke 1992)

that wafts around bread counters in supermarkets is often due to an oxide called

2-furaldehyde (Bauer et al 1990).

Lactones

Lactones always have an oxygen atom double bonded to a carbon atom. The car-

bon atom is attached to another oxygen atom that is part of a closed ring (Table

3-15). Lactones are present in most expressed oils and tend to end in -lactone or

-ine. The percentage of lactones present may be low, but they play an important

role as expectorants and mucolytics. However, lactones tend to have the same

potential neurotoxic effects as ketones. Many essential oils belonging to the

Asteraceae family contain lactones that can also cause skin sensitivities (Gordon

1999).

Alantolactone is present in elecampane (Inula helenium) and is used to treat

purulent bronchitis (Rose 1994). Isolantolactone is found in sweet inule (Inula

graveolens) and is effective in treating bronchial congestion. Lactones that contain

15 carbon atoms seem to have distinctive antiinﬂammatory properties (Bowles

2000). Nepetalactone, found in catnip (Nepeta cataria), showed sedative and anal-

gesic effects in rats (Aydin et al 1998). A bicyclic lactone (a phthalide) is respon-

sible for the odor of celery root (Bauer et al 1990).

Coumarins

Coumarins are a type, or subgroup, of lactones. They have an oxygen atom dou-

ble-bonded to a carbon atom. That carbon atom is attached to another oxygen,

which is part of a closed ring, and they also have a benzene ring attached (Table

3-16). Coumarins usually end in -one (pronounced own), as in umbelliferone, or

with –in, as in coumarin. Coumarins may be present in small amounts, in essen-

tial oils but they are very potent. Franchomme states that coumarins augment the

antispasmodic effect of esters. Coumarins include khellin and visnagin, which are

52 Section I Overview

Table 3-15 h Some Lactones and Their Properties

Nepetalactone found in Analgesic & sedative (Aydin

Nepata caesarea (catnip) et al 1998)

Alantolactone found in Respiratory antiinﬂammatory

Inula graveolens (Mazor 2000)

strong vasodilators found in khella (Ammi visnaga) essential oil (Lewis Walter &

Elvin-Lewis Memory 1977). Khella is also a bronchodilator (Budavari et al

1996). Reconstituted compounds from Khella form the ingredients of the phar-

maceutical product Intal, an inhaled asthma medication (Rose 1992).

There is sometimes confusion regarding the chemical dicoumarol, which

forms the basis of warfarin, an anticoagulant drug (Mills 1991). Dicoumarol is

created naturally by the breakdown of sweet clover plant, but it is created syn-

thetically by drug companies (Budavari 1996). However, if you look at the chem-

ical drawing, you will ﬁnd a coumarin group within it (see Table 3-16) (Bowles

2000), although coumarin-rich essential oils have not yet been shown to have a

measurable anticoagulant effect.

Small amounts of furanocoumarins (up to 2%) are present in citrus-peel oils

and a few other essential oils such as angelica (Angelica archangelica) root, cumin

(Cuminum cyminum), and rue (Ruta graveolens) (Tisserand & Balacs 1995). Vir-

ginian cedarwood (Juniperus virginiana) and lemon verbena (Lippia citriodora)

are also phototoxic (Price & Price 1999).

Furanocoumarins react in the presence of ultraviolet light and can have a

phototoxic effect, resulting in burns or erythema. Higher percentages are needed

to have a phototoxic effect on darker skin (Zaynoun et al 1977). A phototoxic ef-

fect was produced with a 2.4% concentration on pale skin and an average of a 15%

concentration on dark brown or black skin. On some skin the resulting pigmen-

tation can remain for life. Bergamottin, a furanocoumarin, was found to be anti-

tumoral in vitro (Miyake et al 1999).

Ethers

Ethers occur when a methyl or ethyl group is attached to a benzene ring via an

oxygen molecule (Table 3-17). Ethers are thought to be responsible for some of

the hallucinogenic properties of certain essential oils when taken orally. The hy-

pothesis is that estragole and anethole could be metabolized into 4-methoxy-

Chapter 3 Basic Plant Taxonomy 53

Table 3-16 h Structural Similarities between Coumarin and Warfarin

Coumarin Enhances antispasmodic effect of esters

(Franchomme & Penoel 1991)

Reduces lymphedema (Casley-Smith

1999)

Warfarin Anticoagulant (Budavari 1996)

amphetamine or the corresponding ketone (Benoni et al 1996). Unlike phenols,

ethers are not aggressive on the skin.

Apart from Chemistry

Some people believe there is more to an essential oil than the sum of its parts:

there is a synergy of all those parts working together. Many people also believe

there is an energy or vibration to an essential oil, and it may be this part that plays

the major role in healing. Some people think of essential oils as having yin- and

yang-like qualities. Oils with yanglike qualities are thought to tone the whole

body, stimulate immune growth, support the metabolic response, raise internal

temperature, and stimulate the nervous system. Oils with yinlike qualities are

thought to reduce temperature, decrease activity in the nervous system, and have

a calming effect. This process of attributing yin- and yang-like properties to es-

sential oils is key to the work of Peter Holmes (1989) and Gabriel Mojay (1996).

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54 Section I Overview

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56 Section I Overview

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58 Section I Overview

Part II: Extraction, Biosynthesis, and Analysis

“It looked totally innocent, like a light tea—and yet contained, in addition

to the four-ﬁfths alcohol, one ﬁfth of a mysterious mixture that could set

a whole city trembling with excitement.”

Suskind P. 1986.

Perfume: The Story of a Murderer. London: Penguin Books, 62.

Essential Oils and Extracts from Aromatic Plants

There are several ways of extracting the volatile components from plants. Some

methods produce essential oils, and other methods produce extracts rather than

essential oils. See Figure 3-2 and Table 3-18 for comparisons of the extraction

procedures used for aromatic extracts and essential oils. Traditionally aromather-

apy has speciﬁed the use of essential oils, but some other methods of extraction

and the products they yield are becoming more acceptable.

Extraction of Essential Oils

Essential oils are either distilled or expressed (Arctander 1960). Distillation can

mean water distillation, water-and-steam distillation, steam distillation, or steam-

and-vacuum distillation (Arctander 1960).

Water distillation

Material from the plant is in direct contact with boiling water. Arctander (1960)

suggests that such direct heating methods may produce a burnt note to the es-

sential oil. Most water distillation stills have a grid. This protects the plant mate-

rial from the heating elements, and the process is similar to that of water-and-

steam distillation.

Water-and-steam distillation

In water-and-steam distillation, steam is blown into the mixture of water and

plant material.

Steam distillation

This method formerly involved a copper still, but now the still is more likely to

be made of stainless steel. The aromatic plant material is placed on a grid through

which steam passes, usually at a temperature not above 100°C (Bowles 2000). See

Chapter 3 Basic Plant Taxonomy 59

60 Section I Overview

Extracts vs. essential oils

Essential oils

obtained by

Aromatic extracts

obtained by

Distillation Expression

Distilled

essential oils

Citrus peel oils

Maceration with alcohol

Tinctures

Solvent extraction Enfleurage

Pomades

Enfleurage

absolutes

Concretes Resinoids

Absolutes

Figure 3-2 Extracts vs. essential oils. Adapted from Williams D. 1989. Lecture Notes on

Essential Oils. With kind permission of Eve Taylor, London.

Table 3-18 h Advantages and Disadvantages of Various

Extraction Processes

Extraction Process Advantages Disadvantages

Distillation Economical Changing constituents

Large quantities can be Depending on time/temp

processed

Simple apparatus

Little labor needed

Expression No heat required Some ﬂavoring left

Simple apparatus Only citrus peel oils

Oxidize quickly

Enﬂeurage Low temperature needed Time consuming

Possible problem with Labor intensive

solvent

extraction Constant product Expensive

No heat used

Solvent extraction Constant product Solvent residues

Fig. 3-3 for more details.The water boils at temperatures between 88

C and 930

C depending on the altitude at the distillation site. Altitude can be particularly

relevant when essential oils are distilled locally. A decrease in boiling point has

signiﬁcant inﬂuence on the hydrolytic effect of the steam on the essential oil

(Arctander 1960).

Most American or European stills use high-pressure steam. This is the

fastest way of distilling essential oils with high-boiling constituents such as ve-

tiver, sandalwood, and clove. The steam loosens the volatile nonpolar constituents

of the plant and they pass, with the steam, into a condenser that cools the mix-

ture. Steam also alters some of the components within an essential oil, for exam-

ple turning matricin to chamazulene. Some of the polar components from the

plant dissolve in the water producing ﬂoral water. The mixture of ﬂoral water and

essential oil come out together, but as essential oils and ﬂoral water do not mix,

they quickly separate. The majority of essential oils ﬂoat above the ﬂoral water,

but some sink, depending on their speciﬁc gravity.

Chapter 3 Basic Plant Taxonomy 61

Steam

Insulation Grid

Aromatic

water

Essential

oil

Cooling

water

Cooling

coil

Steam and

volatile oil

Plant material

Figure 3-3 Steam distillation. Reproduced from Price S. 1983. Practical Aromatherapy, with

the kind permission of Harper Collins, London.

The degree of heat and the amount of time are vital parts of the distillation

process as some components of plants are very sensitive to heat and others take

much longer to distill (Guenther 1974). The distillation process for Lavandula

angustifolia is approximately one hour, but it is considerably longer for sandal-

wood or vetiver. The length of the distillation process will affect the chemical

composition of the essential oil (Guenther 1976). Steam distillation is suitable for

the highly volatile components such as the terpenes. The heavier the molecule

(sesquiterpenoids), the longer the process will take. Until fairly recently the side

product, the ﬂoral water (otherwise called hydrolat) was thrown away, but now,

hydrolats (or hydrosols) are becoming known for their own therapeutic actions,

especially for babies, children, and the elderly.

Steam-and-vacuum distillation

This method uses steam distillation with partial vacuum (Arctander 1960). The

pressure used is typically 100-200 mmHg. The advantage of this method is the

speed with which the essential oil is extracted. The disadvantage is that a very ef-

fective and fast method of cooling is required.

Portable distillation Portable distillation equipment is simple to make and can

be used for small quantities of plants when essential oils must be distilled on

site (Alkaire & Simon 1992). Otherwise, small cooker-top stills can be pur-

chased for home use.

Subdivisions of steam distillation

Cohobation means the water used in the distillation process is reused many times

(Guenther 1974).

Fractional distillation means the essential oil is distilled at speciﬁc temperatures

for speciﬁc lengths of time to collect different factions (or functional groups)

within the essential oil. For example, peppermint contains terpenes that be-

come volatile at approximately 150° C and menthone and menthol that boil

at 200°-230° C (Guenther 1974).

Rectiﬁcation aims to separate the volatile and nonvolatile components of an es-

sential oil. If an essential oil is thought to contain impurities, it can be puriﬁed

by redistillation.This process is called rectiﬁcation. Sometimes peppermint and

caraway seed oils can take on an unpleasant odor if they have been in contact

with the wall of a hot still. This aroma can be removed through rectiﬁcation

(Guenther 1974). To give some idea of yield, 200 kg of Lavandula angustifolia

ﬂowers will produce 1 kg of essential oil. However, between 2 and 5 metric tons

of rose petals are needed to produce the same amount of rose oil.

Expression

Only involves the peel of citrus plants such as grapefruit. The peel of the fruit is

racked or abraded by mechanical scrapers, and the essence collected by centrifugal

separation. Sometimes the whole fruit is crushed prior to the essential oil being

separated from the juice and peel. Expressed oils will naturally contain a propor-

tion of waxes and other nonsoluble components that may cause phototoxicity.

62 Section I Overview

Methods for Producing Extracts (not essential oils)

There are other methods of extraction that produce compounds mainly used by

the fragrance and cosmetics industry. One such compound is called an absolute.

An absolute is not a true essential oil but an extract obtained using petrol-based

chemicals. It is impossible to remove all of the chemical solvent. In 1989, the In-

ternational Fragrance Research Association issued guidelines as to the recommended

level of benzene in an absolute: it should not exceed 10 parts per million (ppm)

(International School of Aromatherapy 1993). Residual solvent found in extracts

could provoke an adverse reaction.

Solvent extraction

This three-stage method was ﬁrst used on ﬂowers by French chemist and phar-

macist Pierre Jean Robiquet in 1835 and rapidly became a popular method

(Guenther 1974). The advantage was extraction could occur at room temperature.

However, this is a complicated process requiring an expensive apparatus.

1st stage: Solvents such as benzene, petroleum ether, and, more recently, hexane

have been used to extract the volatile parts from plants. This ﬁrst stage pro-

duces a waxy mixture called a concrete (often approximately 50% essential oil

and 50% wax). Hexane is believed to be safe and is used in several food-

extraction processes. However, it is impossible to remove all the solvent fol-

lowing extraction.

2nd stage: A solvent, usually ethanol, is used to dissolve the wax. This step is re-

peated several times.

3rd stage: The alcohol/wax mixture is evaporated by vacuum.

Enﬂeurage

This method was mainly used on fragile blossoms such as jasmine and tuberose

and is rarely used today. I watched this process in Grasse, France in 2000, and it

was very labor intensive. Animal fat is pounded until it is soft, and then glass

plates are coated with the fat. Each fat-covered glass plate is called a chassis. Fresh

blossoms are placed close together on the chassis and left until the fat becomes

saturated with essential oil. The chassis are constantly replenished with fresh

blossoms, and the old blossoms discarded. The resulting oil/fat mixture is called

a pomade. The pomade is mixed with alcohol to remove the fat, and the remain-

ing extract is called an absolute. However, 99% of jasmine and tuberose extract is

now produced by solvent extraction.

Carbon dioxide

Supercritical carbon dioxide (CO

) extraction, an innovative method using “ﬂu-

idized” CO

, has been available since the 1980s and is making signiﬁcant inroads

in the ﬂavor, perfume, and aromatherapy worlds. Brew masters in Germany were

looking for a hops ﬂavor extract that had no heat or chemical “off ” notes, and

German scientists found an extraction technique that did not involve heat or

Chapter 3 Basic Plant Taxonomy 63

chemical solvents. When the temperature of CO

is maintained at approximately

31° C, under pressure it acts like a ﬂuid and dissolves the CO

-soluble part of an

herb. The advantages are no heat or chemical solvents are used and the process

produces a gentle, “unstressed” extraction. However, the chemistry of the result-

ing extract differs from that of essential oils extracted via steam distillation. For

example, steam-distilled German chamomile (Matricaria recutita) essential oil is

dark blue because heat and water create chamazulene, a sesquiterpene. Matricine,

the colorless precursor to chamazulene, occurs naturally in the plant and is

thought to be a superior antiinﬂammatory. Matricine is present in the German

chamomile extract yielded by the CO

method.

supercritical extraction is an expensive and technologically sophisticated

process, but it is well accepted in creating pure ﬂavors and perfume oils. As there

is a great deal more published research on the therapeutic properties of plants, and

this method produces a concentrated and undistorted plant extract (with volatile

oils in it), this is a method to watch. It may become a more accepted part of aro-

matherapy within the next few years.

Florasol

A fairly new chemical process has been developed and patented in England by

rose-grower and scientist Dr. Peter Wilde (Tisserand 1994). His method involves

extracting essential oils by means of a new solvent. The unique character of this

solvent is that its boiling point is around 30° C. Plant material can be extracted

at room temperature and the solvent removed without boiling. This ensures the

plant material is not damaged by high temperatures. The solvent residue is 1000

times less than the hexane content in a concrete or absolute obtained using tra-

ditional methods. The extract is neither acid nor alkaline. (When using liquid

, some dissolves, which lowers the pH and produces a slightly acidic prod-

uct.) Florasol oils are used routinely by the ﬂavor and food industry and have the

approval of the European Commission on Foods for Human Consumption. The

United States Food and Drug Administration has accepted Florasol extracts as

generally regarded as safe. Of particular note is the fact that these products do not

produce concretes that require further reﬁning with alcohol (Wilde 1995).

Aroma Intensities

The aromas of essential oils have different intensities, and these may last for dif-

fering periods of time. The perfume industry refers to these properties as notes

and divides them into top, middle, and base notes (Price 1983). These divisions

indicate how rapidly the essential oil will lose its vitality. A top note might last,

in an unstopped bottle, for a few hours before losing its odor, a middle note might

last a couple of days, and a base note may last for several weeks.

In the 19th century, Septimus Piesse (1855), a chemist and perfumer, created

a classiﬁcation system for perfume that corresponded to a musical scale (Poucher

1993). In 1923, a man named Poucher built onto the work of Piesse and devel-

oped a classiﬁcation method based on a perfume’s evaporation rate scaled from 1

64 Section I Overview

to 100. Scents that evaporated quickly (1-15) were called top notes, for example,

mandarin (2) and nutmeg (11). Middle notes (16-69) included marjoram (18),

ylang ylang (24), and rose (43). Base notes lasted the longest (70-100), for exam-

ple angelica (94). Perfumes with the highest ratings last the longest and evapo-

rate the slowest (for example, frankincense, patchouli, sandalwood, and vetiver).

Poucher’s classiﬁcation system was updated in 1991 and is still used today by per-

fumers (Poucher 1993).

The odor of an essential oil deteriorates as a result of oxidation. Some essen-

tial oils evaporate more quickly than others. As an essential oil evaporates, certain

components within it combine with oxygen in the air. This process is called oxi-

dization. For example, alcohols combine with oxygen to become aldehydes

(Bowles 2000). The rate of evaporation depends on the volatility of the essential

oil, and volatility depends on the components within the essential oil. Citrus oils

such as bergamot or grapefruit will evaporate faster than ﬂower oils such as rose.

Therefore they will oxidize more quickly. The least volatile oils are the resins and

woods. Heat and sunlight can speed up oxidation. The oxidization of an essential

oil will affect the odor of an essential oil and its therapeutic potential (Tisserand

& Balacs 1995).

Resinoids are obtained from resins such as amber and mastic, balsams such

as benzoin, or gum-like substances such as frankincense and myrrh. Frequently

the method used to obtain resinoids is extraction by hydrocarbon solvents. Frank-

incense and myrrh can also be obtained by straight steam distillation. Resins are

soluble in alcohol but not in water; gums are soluble in water but not in alcohol

(International School of Aromatherapy 1993).

Biosynthesis: How and Why Plants Make

Essential Oils

Essential oils come from aromatic plants. Green plants are capable of synthesizing

complex carbohydrates from hydrogen, carbon, and oxygen. Life, as we know it,

would not continue if there was not an independent mechanism that synthesized

complex molecules from simple ones. The huge task of providing “energy for life”

is the sole responsibility of green plants, but this chemical process requires energy.

The energy required by plants to change hydrogen, carbon, and oxygen to complex

carbohydrates comes from the sun. This process is called photosynthesis.

Until the late 1950s, essential oils and all other secondary metabolites were

thought to be the waste products of a plant. This was because human energy had

been focused on the structure of compounds found in plants (and essential oils)

rather than on their function. Essential oils occurred in such small amounts

in plants that they were thought to be unimportant. However, some scientists sus-

pected that essential oils were relevant to the plant and began to explore their

therapeutic potential.

Not every plant produces essential oils; aromatic plants tend to congregate

in speciﬁc families like Asteraceae (chamomiles), Rutaceae (citrus oils), or

Chapter 3 Basic Plant Taxonomy 65

Lamiaceae (lavender and mints). Overall, only 1% of ﬂowering plants produce es-

sential oils in any signiﬁcant amount. However, plants produce more than

100,000 different chemical compounds, and the vast majority of these are not es-

sential to the physiology of the plant or its reproduction. Interestingly, some

chemical components found in plants, particularly some of the essential oils, can

actually be harmful to the plant and are stored in special cellular compartments

to prevent injury to the plant. Leakage of these essential oils can impair the

process of photosynthesis on which the plant depends for its life.

There are hundreds of aromatic plants, but not all of them produce essential

oils in sufﬁcient quantity for distillation to be viable. For example, hyacinth is

usually obtained by solvent extraction, and then the solvent is distilled (Lawless

1992). The same is true for lily of the valley and lilac (International School of

Aromatherapy 1993). Some plants produce essential oils that can be toxic, such

as thuja, wintergreen (Tisserand 1988), and arnica (Lawless 1992). (Arnica, the

herb but not the essential oil, is traditionally used in very small amounts in home-

opathic treatments.) The amount of essential oil contained in a plant varies

tremendously and so do the components within essential oil. Sometimes the

smallest quantity of a chemical in an essential oil has a major part to play. For ex-

ample, the smell of a rose (Rosa damascena) originates from a component found

in rose that is only 0.1 parts per million.

Photosynthesis

Photosynthesis is the process by which a plant, under the inﬂuence of sunlight,

can make, in its chlorophyll-containing cells, carbohydrates from the carbon diox-

ide of the atmosphere and hydrogen from the water in the soil. Photosynthesis is

vital to the survival of the plant because carbohydrates are essential for life. The

main function of carbohydrates is to store energy.This includes sugars, starch, and

cellulose. Cellulose is used for the structure of the plant.

Carbohydrates have the general formula (CH

O)n, when n represents the

number of CH

O “units” present. The name of the carbohydrate is determined by

the number of carbons it contains (Tables 3-19 and 3-20).

The last two, di- and polysaccharides, are known as complex carbohydrates and

are the types that occur in plants. When plants convert carbon dioxide and water

into complex organic molecules, oxygen is released back into the atmosphere. Ulti-

mately these complex organic molecules made by the plant will be degraded by

plant-eating animals back into carbon dioxide and water, along with the release of

energy required for further synthesis of compounds or metabolic processes.

 H

O  light, energy, chlorophyll  CH

O  O

Plant metabolism has two distinct stages. The ﬁrst occurs in light and is

called photosynthesis. The second takes place without sunlight and is sometimes

called the “dark reaction” (Mann 2001b). During this stage carbon dioxide is re-

duced to produce carbon sugars. Photosynthesis takes place in the green leaves of

66 Section I Overview

plants in tiny organs called chloroplasts,which are where the green pigment chloro-

phyll is stored. Chlorophyll is responsible for capturing sunlight’s energy and con-

verting it to chemical energy. The quantity of essential oil in aromatic plants in

dry, hot, Mediterranean countries peaks in the summer months. For example,

common sage (Salvia ofﬁcinalis) produces three times the amount of essential oil

in the summer as it does in the winter.

The light stage: photosynthesis

There are two stages to the light-mediated process (photosynthesis). The ﬁrst

part of the light stage involves light absorption by chlorophyll. The second stage

involves splitting of water molecules. Water from the soil enters the plant via the

roots and is transported to the leaves by a specialized system called the xylem.

From there it diffuses into the chloroplasts where photolysis splits the hydrogen

and oxygen bonds, producing high-energy electrons, then adenosine triphosphate

(ATP) and more water. ATP is a form of chemical energy.

The dark stage

In the dark stage, CO

from the atmosphere is converted into carbohydrates, the

main product being monosaccharide sugar. This process, when hydrogen is added

to the molecule, is called reduction. CO

enters the plant’s leaves from the air

through tiny pores on the underside of the leaf, called stomata. The CO

then

travels via large, air-ﬁlled spaces to the cells containing the chloroplasts. The re-

duction of CO

and the subsequent synthesis of carbohydrates is achieved by a

number of enzyme-controlled reactions, all of which require energy. The energy

is supplied by ATP, which is created in the light stage of photosynthesis and also

in another metabolic process known as respiration. Written chemically, photosyn-

thesis looks like this:

6CO

 12H

O → C

 6H2O  6O

Chapter 3 Basic Plant Taxonomy 67

Table 3-19 h Sugars Occuring in Plants

Six carbon atoms C

Hexose sugar (glucose)

Five carbon atoms C

Pentose sugar

Three carbon atoms C

Triose sugar

Table 3-20 h Sugars and Their Names

Sugar molecules in isolation Monosaccharides

Sugar molecules in pairs Disaccharides

Sugar molecules in chains Polysaccharides

Natural Products

There are two major classes of natural products: primary and secondary metabo-

lites (Mann 2001a). However the dividing line between primary and secondary

metabolism is rather blurred (Mann 2001b) as the two types of metabolism are

interconnected. Primary metabolism involves the synthesis and utilization of spe-

ciﬁc chemicals essential for the survival and health of the organism. Such chem-

icals are sugars, amino acids, fatty acids, nucleotides, and the polymers obtained

from them. Secondary metabolism uses a different metabolic pathway and in-

volves the production of chemicals that have no apparent importance to the or-

ganism (Mann 2001a). Secondary metabolism produces alkaloids, bitters, glyco-

sides, gums, saponins, steroids, and essential oils. Secondary metabolism is further

discussed in the section titled “Chemistry of Essential Oils” (see page 43).

Storage of Essential Oils in Plants

Essential oils are stored in speciﬁc parts of a plant (Table 3-21). For example, rose

essential oil is found in the petals of the ﬂowers, not the roots, leaves, or stem.

However, sometimes an essential oil is found in different parts of the same plant,

as in the case of angelica root and angelica seed. In this particular case the chem-

istry of each essential oil is different. The essential oil from the root of angelica is

phototoxic (can cause a skin reaction when ultraviolet light is used on the skin

within 24 hours of applying), but essential oil from the seed is not phototoxic.

68 Section I Overview

Table 3-21 h Parts of Plant Where Essential Oils Are Stored

Rose Flower

Angelica Root, seed

Eucalyptus Leaf

Juniper Berry

Sandalwood Wood

Cinnamon Bark, leaf

Clove Leaf, bud

Myrrh Resin

Black pepper Seed

Rosemary Whole herb

Mandarin Fruit peel

Pine Needles

Secretory and Storage Structures of Essential Oils in Plants

For additional reading, Svoboda and Svoboda’s excellent, illustrated book, Secre-

tory Structures of Aromatic and Medicinal Plants (2001), is a must, and the infor-

mation in this section is based on it. Essential oils are stored in special secretory

structures (Table 3-22), either on the surface of the plant or within the plant tis-

sue, and are found in many different types of plant: perennial, annual, biennial,

evergreen, and deciduous (Svoboda & Svoboda 2001). Secretory structures vary

and include single, secretion-containing cells that are similar to the surrounding

cells, secretory ducts, secretory cavities, osmophores, glandular trichomes, and

epidermal cells. Often the family or genus of a plant will have a similar secretory

system. This can be useful in plant identiﬁcation.

Single, secretion-containing cells are common in many aromatic plants such

as the leaves of lemongrass, rhizome of ginger, seed coat of cardamom, fruit wall

of black pepper, bark of cinnamon, and root of valerian. Secretory ducts are elon-

gated cavities found in plants such as coriander, cumin, angelica, dill, anise, and

fennel (all members of the Umbelliferae family). Secretory cavities are prevalent in

the fruit and leaves of lemon, orange, and bergamot in the Citrus family. They are

also found in the bark of myrrh and frankincense and in clove buds. Osmophores

are found in orchids and are areas of tissue with secretory cells different structurally

from the surrounding cells. Glandular trichomes are modiﬁed epidermal hairs

found on leaves and stems of plants such as basil, lavender, and marjoram in the

Lamiaceae family. Epidermal cells diffuse essential oil directly through the cyto-

plasm and cell wall to the outside, and the amount of essential oil diffused is very

low. Examples of aromatics with epidermal cells are rose and jasmine.

There are various theories as to why some plants produce secondary metabo-

lites such as essential oils. They could be a defense. Secondary metabolites appear

to protect the plant from being eaten by herbivores (plant-eating animals or in-

sects), by repelling them. For example, wild tobacco (Nicotiania sylvestris) can in-

crease its production of nicotine by three or four times when it is under attack,

and the bitter taste deters predators (Mann 2001b). Often a secondary metabo-

lite can reduce the growth or maturation of an insect eating the aromatic plant.

Grasshoppers eating Cyperus iria become sterile, and tenulin (a sesquiterpene

lactone) in Helenium amarum disrupts the growth and development of insect

Chapter 3 Basic Plant Taxonomy 69

Table 3-22 h Types of Storage for Essential Oils

Part Plant

Single secretion cells Ginger, black pepper, cardamom, valerian, lemongrass

Secretory cavities Citrus fruits, clove, myrrh, frankincense

Secretory ducts Tarragon, angelica, aniseed, pine

Secretory hairs Many plants in the Lamiaceae and Geraniaceae families

larvae (Mann 2001b). Although mammals can cope with terpenes in their diet,

many mammals and rodents ﬁnd the aroma (and taste) of terpenes repellent and

will not feed from aromatic plants. Voles, (a small rodent common in Europe) for

example, will not eat pine needles. However, there are obvious exceptions. Aus-

tralian possums and kangaroos are two mammals that have adapted and live off a

diet of Eucalyptus leaves.

Certain plants exude aromas that deter insects. The Lamiaceae family has two

well-known plants, pennyroyal and peppermint, that deter insects. The mosquito

that carries yellow fever is repelled by mugwort (Artemisia vulgaris), and recent

clinical studies have found that the mosquito carrying malaria is repelled by

Artemisia annua. Artemisinin (called qinghaosu in Chinese medicine) is a

sesquiterpene found in Artemisia annua and is responsible for repelling mosqui-

toes. This plant has been used in Chinese medicine for that purpose for 2000 years!

Another possibility for the purpose of essential oils is to increase pollination

by attracting insects. Many chemical compounds found in the odor glands of in-

sects are also found in ﬂower fragrances. Usually it is a mixture of compounds that

generates the aroma the insect is seeking. Each part of the fragrant area of the

plant may present a different volatile proﬁle. The rose, for example, produces dif-

ferent aromas in its petals than in the sepals and stamens.

Odor is thought to be more important to a pollinating insect than color. This

is obvious with night-ﬂying creatures. Some ﬂowers are pollinated by bats and

others are pollinated by moths. Insects are so sensitive to smell they can pick up

a scent at 1/100 the level discernible to a human. Floral fragrances such as

monoterpenes are important insect attractants. Some plants, such as Datura in-

noxia produce a narcotic, so the hawkmoth becomes addicted and returns regu-

larly for “ﬁxes” (Mann 2001a). Insects live in a world where actions are triggered

by smell rather than noise or light.

Another theory as to why plants produce secondary metabolites is to prevent

attack by bacteria, viruses, and fungi. Plants respond to attack from bacteria,

fungi, or viruses by producing stress metabolites called phytoalexins. Some phy-

toalexins are used by pharmaceutical companies to protect foodstuffs from infec-

tion or spoiling (Guenther 1972).

Allelopathy is the ability of a plant to prevent other plants from growing too

close to it. Bracken and ferns leach germinating inhibitors (usually phenols) into

the ground to deter other species from germinating or growing too close. Aro-

matic plants can use essential oils such as camphor to protect the land around

them from other plants. Terpenes are the largest group of chemical components

found in aromatic plants, and many terpenes can inhibit the respiration of other

plants (Mann 2001b). The sage bush (Salvia leucophylla), which is proliﬁc in the

near-desert terrain of southern California, contains chemical compounds 1,8-

cineole and camphor that deter other plants’ germinating.

Yet a further hypothesis for the production of essential oils is their antitran-

spirant activity. Essential oils aid survival in difﬁcult climatic conditions when a

haze of volatile oils may inﬂuence stomatal closure and prevent excess water loss

from the leaves.

70 Section I Overview

Quality of Essential Oils

Finally, there are many factors that can affect the quality of the essential oil (Table

3-23). The chemical makeup of all living plants depends on climate and environ-

mental conditions (such as rainfall, sunlight, soil acidity, altitude) and pollution

(Guenther 1972). The chemistry of the same species of rose grown in Bulgaria will

be subtly different from one grown in England. Similarly, Lavandula angustifolia

grown high in the mountains will contain more esters, which are thought to have a

greater antispasmodic effect, than Lavandula angustifolia grown closer to sea level.

If Lavandula angustifolia is distilled at a high altitude this will also increase the

amount of esters. Lavandula angustifolia essential oil with a higher percentage of es-

ters will have an aroma that is softer and fruitier. There are so many variables that

the simplest way to be sure of the composition of the essential oil is to use modern

analytical methods as well as the nose. This will be covered in the next section.

What Are Essential Oils Used For?

Of the hundreds of essential oils produced, there are classics in common, everyday

use the world over. These essential oils have research-based therapeutic properties

and a long history of use. Many aromatic herbs are used in cooking, such as basil,

thyme, coriander, rosemary, dill, oregano, and bay. Some are drunk in tisanes, in-

cluding peppermint, lime ﬂower, and chamomile. Several names of plants that pro-

duce essential oil will already be familiar. Some have been used in orthodox medi-

cines for centuries, for example peppermint in mouthwashes and eucalyptus in Vicks

VapoRub. Essential oils continue to play an important part in our lives. You may be

surprised at the uses for some of them, as illustrated in Table 3-24 (Guenther 1972).

Chapter 3 Basic Plant Taxonomy 71

Table 3-23 h Factors affecting quality of essential oil.

Soil type

Climate

Geography

Altitude

Use of fertilizers and pesticides

Time of harvest (including both time of year and time of day)

Genetics

Age of plant

Temperature at which essential oil is distilled

Length of time essential oil is distilled

Number of times essential oil is distilled

Analysis Tests for Purity in Essential Oils

Gas chromatography linked to mass spectrometry (GCMS) is one of the most

important tests to ascertain purity. The GC part separates the essential oil into

individual constituents (like linalyl acetate) and shows their relative concentra-

tions in a computerized printout showing a succession of peaks. The lighter

molecules will peak ﬁrst, and the MS part will identify those peaks. Although a

GCMS will identify and quantify the chemical components, it may not always

detect additional synthetic chemicals that have been added to extend or alter the

essential oil.

To begin the test, a minute amount (about 1 microliter) of essential oil is in-

jected into a tubular column temperature controlled to vaporize the sample. The

constituents are separated by the differences in their solubilities in a nonvolatile

absorbent that coats the inner walls of the tube. The vaporized sample is carried

through the tube in a slow stream of helium or nitrogen, and all constituents are

kept in the vaporous state by means of hot air circulating in the column. The re-

sults of the analysis are recorded as a series of peaks drawn by a pen recorder that

plots a trace of each of the components of the essential oil as it exits the column.

As the components exit, they are bombarded with high-energy electrons that

72 Section I Overview

Table 3-24 h Uses for Essential Oils

Adhesives, alcoholic beverages, animal feed, automobile industry

Baked goods

Candle makers, canning industry, ceramics, chewing gum, confectionery, contact

lenses

Dental preparations

Food industry (especially prepared foods)

Household goods (including furniture polish, lavatory cleaner, air-freshener, and

washing powder)

Ice cream, insecticides

Meat-packing

Paint, paper, perfume, pharmaceuticals, printing

Rubber manufacturing

Soap, soft drinks

Textile production, tobacco

Veterinary supplies (including meats)

fragment them. The characteristic fragmentation pattern for each molecule is

identiﬁed by comparing it with a computerized pattern in a database.

A second important method of analysis is through optical rotation. The mol-

ecules within essential oils have the ability to rotate a plane of polarized light.

This activity is measured by a polarimeter. Molecules that rotate counterclockwise

are called laevorotatory, or l for short. Those that rotate clockwise are called dex-

trorotatory, or d. This designation is indicated in the name of the molecule, as in

d-limonene. The angle at which the light is rotated is an important physical char-

acteristic by which an essential oil can be recognized. Almost all essential oils

show optical activity. This test can reveal synthetic compounds that alter the op-

tical rotation.

Another method of analysis is the refractive index. When light passes

through a liquid it is refracted. This refraction can be measured and is consistent

for a given essential oil. In scientiﬁc terms, it is the ratio of the speed of light of

a given frequency in a vacuum to the speed of light in a medium of some kind, at

a speciﬁed temperature. It is important that the test be carried out at the same

temperature as the reference (the standard).

A fourth analysis is the infrared test. Electromagnetic radiation can be passed

through an essential oil and produces a spectrum that is like the ﬁngerprint of the

essential oil. Adulteration of the oil will show up clearly with this method.

The ﬁfth and most important tool of analysis is the nose. When ﬁrst exper-

imenting with essential oils, you may ﬁnd it hard to notice differences between

synthetic and real essential oils and pure oils and adulterated ones. However with

patience the nose learns. To sample an essential oil correctly, do not smell directly

from the bottle. Put one or two drops on to a special smell strip (made from pa-

per a little like blotting paper). Recap the bottle. Holding the smell strip approx-

imately 6 inches in front of your face, move it slowly from one side to the other

and back again. The sense of smell may be different from one nostril to the other

as the aroma reaches different parts in the brain. One nostril may detect a sweeter

smell than the other. Move the strip back and forth several times. Closing your

eyes might aid concentration. It can be useful to rate the aroma on a scale of 0 to

10: 0 means disliking the odor intensely, and 10 means the odor is very pleasant.

Write down a word or sentence that describes the aroma. When testing essential

oils from an unknown source, ﬁrst try one known to be authentic to “ﬁx” the smell

imprint in the mind. Then try the new one. The trained human nose is the most

important piece of equipment in ﬁnding out whether the essential oil has been

adulterated.

Buying Essential Oils

In the last few years there has been a rapid increase in the number of essential-oil

companies. Many operate by direct mail. The commercial sections of healthcare

journals include advertisements for many essential oil distributors. In the USA,

most health-food shops, some drugstores, and certain department stores also

Chapter 3 Basic Plant Taxonomy 73

carry a range of essential oils. Many essential oil mail-order companies have been

set up quickly and with little knowledge of the oils. Customers believe they are

buying essential oils of the highest grade (Scholes 2001).

Although many companies appear to provide true essential oils, this is not al-

ways the case. Some dealers openly state in their literature or on the bottles that

their oils are diluted. Other companies are not so honest, and customers are led

to believe that they are purchasing 100% pure essential oil. The phrase “pure es-

sential oil” can mean many things. Essential oils are extremely easy to dilute or

adulterate (Guenther 1972). The most common method of dilution is the addi-

tion of a vegetable oil. When this occurs, the essential oil leaves a ring as it evap-

orates. If alcohol is added to dilute the oil, it is sometimes discernible in the

aroma. Adulteration by adding a cheaper substitute, for example, putting gera-

nium oil in rose oil or petitgrain or bergamot in neroli, is commonplace. Real

melissa oil is extremely difﬁcult to ﬁnd, because it is frequently adulterated with

lemongrass or citral. Sometimes particular components are added, such as cit-

ronella, geraniol, or linalol (Wagner et al 1984). Some of the best melissa is actu-

ally grown in Ireland.

When purchasing essential oils, Scholes (2001) suggests ﬁrst to determine the

purpose for which the essential oil is being purchased. He lists several categories:

1. Medicinal or internal use

2. Candles and soaps

3. Massage and therapeutic applications

4. Cleaning products or environmental fragrancing

The second important factor is the oil’s country of origin; several countries

produce the same essential oil but of varying quality. For example, rose is grown

and distilled in France, Bulgaria, Turkey, China, and Morocco. Scholes notes that

only a few essential oils are produced in the United States—mainly peppermint,

citrus, and some lavender. However, these are not suitable for the aromatherapy

market because they have been grown with pesticides. There would seem to be a

huge market out there for farmers wanting to grow something different!

For safety, you should only buy an essential oil that is correctly labeled. Much

more information is needed than just the generic name. Product lists and bottle

labels should bear the oil’s complete botanical name, the country of origin, the

part of the plant from which it was derived, and should note whether the oil is

wild crafted or organic. Some of the best suppliers tell the buyer whether the

whole ﬂowering plant was used, or just the ﬂowering heads. Reputable suppliers

are happy to provide gas-chromatography/mass spectrometry (GCMS) informa-

tion and material safety data sheets (MSDS) for their products. The chemotype,

when relevant, also needs to be speciﬁed. Also mentioned on the product list

should be the type of extraction used and whether the batch number is known.

Organically grown plants used for essential-oil production are certiﬁed, and the

bottles carry a stamp to prove it. There are various accepted organic stamps. In

the United Kingdom, most authentic distributors are members of the Essential

Oils Trade Association (EOTA) or the Aromatherapy Trade Council (ATC).

74 Section I Overview

In the United States, the National Association for Holistic Aromatherapy offers

the certiﬁcation label “true aromatherapy product” (TAP). French and German

oils usually have their own stamps of authenticity.

Bottles should contain integral droppers and be made of colored glass. “Pure

100 per cent essential oil” should be clearly marked. Basic safety precautions such

as “do not take by mouth,” “keep away from children,” and “avoid contact with

eyes” should also appear on the label. Apart from the label and the price, the only

reliable indicators of authentic essential oils are an experienced nose and pur-

chasing from a reputable company that would lose too much by compromising

itself. It is best to ask around. Qualiﬁed aromatherapists tend to buy from the

same small group of suppliers.

REFERENCES

Arctander S. 1960. Perfume and Flavor Materials of Natural Origin. Wheaton, IL:

Allured Publishing, 13.

Alkaire B, Simon J. 1992. A portable steam distillation unit for essential oil crops. Hort-

Technology 2(4) 473-476.

Bowles J. 2000. The Basic Chemistry of Aromatherapeutic Essential Oils. Sydney, Aus-

tralia: Pirie Printers.

Guenther E. 1972. The Essential Oils, Vol. I. Melbourne, FL: Krieger Publishing.

Guenther E. 1974. The Essential Oils: Individual Essential Oils of the Plant Families.

Melbourne, FL: Krieger Publishing.

Guenther E. 1976. The Essential Oils, Vol. V. Melbourne, FL: Krieger Publishing.

Lawless J. 1992. Encyclopedia of Essential Oils. Shaftesbury, UK: Element Books.

Mann J. 2001a. Chemical Aspects of Biosynthesis. Oxford, UK: Oxford Science Publica-

tions, 2.

Mann J. 2001b. Secondary Metabolism. Oxford, UK: Oxford Science Publications, 7.

Poucher W.1993. Poucher’s Perfumes, Cosmetics and Soaps, Vol 2, 9th ed. Chapman &

Hall.

Piesse S. 1855. The Art of Perfumery. London: Longman, Brown & Green.

Price S. 1983. Practical Aromatherapy. London: Thorsons.

Scholes M. 2001. Finding the true essential oil. Aromatherapy Journal. 11(1) 19-23.

Suskind P. 1986. Perfume: The Story of a Murderer. London: Penguin Books, 62.

Tisserand R. 1985. The Essential Oil Safety Data Manual. Brighton, UK: Tisserand

Aromatherapy Institute.

Tisserand R. 1994. Proﬁle: Peter Wilde. International Journal of Aromatherapy. 6(2) 3-7.

Tisserand R, Balacs T. 1995. Essential Oil Safety. London: Churchill Livingstone.

Svoboda K, Svoboda T. 2001. Secretory Structures of Aromatic and Medicinal Plants.

Wales, UK: Microscopix Publications.

Wagner H, Bladt S, Zgainski E. 1984. Plant Drug Analysis. Berlin, Germany: Springer-

Verlag.

Wilde P. 1995. Flavour, fragrances and essential oils. In 13th International Congress

Proceedings, Istanbul. Eskisehir, Turkey: Anadolu University Press, 351-357.

Chapter 3 Basic Plant Taxonomy 75

Essential Oil Toxicity

and Contraindications

UST BECAUSE essential oils are natural does not mean they do not have poten-

tial risks or hazards if used inappropriately. This section addresses toxicity and

contraindications. Put in context, essential oils are extremely safe and carry

few of the risks of many modern medicines. However, it is pertinent to the in-

creasingly high proﬁle of aromatherapy that all those using essential oils must be

aware of possible side effects and interactions. The author is grateful to the help

and advice of the expert reviewers of this section: Tony Balazs, PhD, and Ron

Guba.

Part I: Essential Oil Toxicity

A sensory problem associated with fragrances is that they become less intense with

repeated sniffs.

Schiffman (1992)

There is a certain amount of controversy about the toxicity of essential oils. There

are those who say essential oils are dangerous and should never be taken orally.

There are those who take essential oils orally or give them to their patients to take

orally and see no problem. There are those who use essential oils every day, and

there are those who believe taking an essential oil for longer than three weeks

could lead to liver damage. Each point of view is usually based on the kind of aro-

matherapy training the person has received.

Jellinek (1999) writes that because the concentrations of substances in essen-

tial oils enter the body in the vapor state, the amount is smaller than the usual

pharmacologic mode of application, and the likelihood of systemic side effects are

reduced. Guba (2000) believes much of the concern about toxicity of essential oils

is based on myth, and he gives a very strong argument to support his case. Scare

tactics are counterproductive. Essential oils have been in the public domain for

hundreds of years, and the number of toxicity problems is so few common sense

indicates that, when used sensibly, essential oils must be safe. Perhaps what is

needed is a large dose of common sense. Everything, even water, can be toxic if

taken in too large a quantity.

This is where most potential problems with essential oils lie: use of extremely

large amounts. For example, tea tree oil has become very popular and appears in

shampoos, gels, creams, and lotions. It has been recommended for treating ticks

and ﬂeas in pets. However, Villar et al (1994) showed that, in some circumstances,

large amounts of topically applied tea tree oil can be toxic to dogs and cats. Symp-

toms were depression, weakness, uncoordination, and muscle tremors. When tea

tree oil was withheld, these symptoms disappeared within 2 or 3 days.

Toxicity and Approaches to Aromatherapy

The English approach to aromatherapy focuses on using diluted essential oils (up

to 5%) applied to the skin in a massage. Essential oils are used mainly for relax-

ation, stress management, and sometimes for upper respiratory-tract infections.

There are no reports of toxic effects from using essential oils in this way. The

French approach to aromatherapy may use several milliliters of undiluted essen-

tial oil on the skin at a time, sometimes several times a day. Physicians may also

give patients gelatin capsules (each containing three or four drops of essential oils

diluted in a carrier oil or gel) to be taken orally three or four times a day. Essen-

tial oils given in this way are used to treat infection or chronic conditions and are

rarely used for relaxation. There is more chance of toxicity from the oral route, al-

though there have been virtually no cases recorded. The majority of French physi-

cians who use essential oils in this way are working alongside bacteriologists and

pharmacists, and are well aware of toxicity issues. A potential toxicity hazard

could occur when untrained people use essential oils orally and ingest too much.

Some aromatherapists (including myself ) are trained in both external and in-

ternal methods of aromatherapy. Clearly there is a need and a place for both ap-

proaches, and perhaps a compromise that uses both could be the best of both

worlds. However, each approach needs to take into consideration the experience,

training, and expectations of the person giving the essential oils. The internal use

of essential oils clearly means using them as medicines and, in the United States

at least, this might be seen as outside the license of many health professionals.

However, there is no licensing process for practitioners who wish to dispense

herbal medicine in the United States, and the oral method of aromatherapy

could easily be integrated under herbal medicine. There is an excellent chapter in

Chapter 4 Essential Oil Toxicity and Contraindications 77

Essential Oil Safety (Tisserand & Balacs 1995) that covers toxicity in depth. This

is recommended reading. There are also useful articles on the subject by Guba

(2000) and Burﬁeld (2001).

Ingestion Reactions

Toxicity can be nonspeciﬁc or speciﬁc. Nonspeciﬁc toxicity covers all essential oils

when used in very large amounts. Speciﬁc toxicity pertains to those essential oils

that can cause toxicity at lower levels, and these are outlined here (Table 4-1).

Speciﬁc toxicity is roughly divided into two types: acute (short term) and chronic

(long term). In acute toxicity, the worst scenario is poisoning. The symptoms of

78 Section I Overview

Table 4-1 h Reported cases of overdose with common essential oils.

Amount

Essential oil in ml Symptoms Source

Cinnamon 60 Pilapil 1989

Citronella 15 Mant 1961

Clove 5-10 Lane et al 1991

Hartnoll et al

1993

Eucalyptus 5 Craig 1953

Patel & Wiggins

1980

Hyssop 10-20 Convulsions Millet 1981

Dizziness, double vision,

nausea, vomiting, collapse

Vomiting, shock, frothing at

the mouth, deep rapid

respiration, cyanosis, con-

vulsions, brain hemor-

rhage, death

Severe acidosis, central ner-

vous system depression,

ketones in urine, deterio-

rating liver function, ex-

tremely low blood glu-

cose, generalized seizure,

deep coma

Vertigo, loss of coordina-

tion, abnormal respira-

tion, epigastric pain, cold

sweats

Lesser amounts: excess res-

piratory tract mucus

Greater amounts: de-

creased respiratory tract

mucus, pinpoint pupils,

rapid drowsiness, uncon-

sciousness

poisoning with ingested essential oils are nausea, vomiting, ataxia, confusion,

convulsions, and coma (Patel & Wiggins 1980). Many papers about essential-oil

poisoning cite instances when essential oils were taken orally; these cases usually

involve children. In most instances, the amount of essential oil taken was

substantially greater than is normally used orally, topically, or in inhalation

aromatherapy.

Burﬁeld (2001) cites an analysis of more than 100 pediatric poisoning acci-

dents involving ingested eucalyptus. The study indicates that in 74% of cases, ac-

cess to eucalyptus had been gained via the home vaporizer. The popularity of aro-

matherapy and today’s easy access to bottles of essential oils mean poisoning is a

potential hazard if someone decides to drink the essential oil. However most rep-

utable companies supply bottles with integral droppers. Symptoms of oral poi-

soning can occur rapidly and include a burning sensation in the mouth and

throat, abdominal pain, and spontaneous vomiting, although the latter may be de-

layed by up to 4 hours. Dangerous respiratory depression also can occur with deep

coma. Convulsions may occur in children, but are rare in adults. Some fatalities

have shown nephrotoxicity (Patel & Wiggins 1980). The range of when an es-

sential oil becomes lethal is wide. For example, the safe dose for internal use of

eucalyptus is 0.006 to 0.2 ml (Martindale 1977). Death in adults has occurred af-

ter ingestion of as little as 4 or 5 ml, which seems extremely low, and is usual af-

ter ingesting 30 ml (MacPherson 1925). However, people have recovered after in-

gesting up to 220 ml of eucalyptus essential oil (Gurr & Scroggie 1965).

Craig (1953) discusses the case of a 3-year-old who consumed 10 ml of eu-

calyptus (2 teaspoons). He became deeply unconscious; his pupils constricted,

muscle tone was markedly reduced, and there were no tendon reﬂexes. His

breathing was shallow and irregular at a rate of 10 breaths per minute. Insertion

of an endotracheal tube produced no gag reﬂex. Pulse was 70 beats per minute,

and blood pressure was 75/40 mm Hg. The child’s serum urea was 6.3 μmol/L

(38 mg/100 ml) with normal electrolytes. He was given gastric lavage with

sodium bicarbonate solution. Sodium sulphate (100 ml) was left in the stomach

as a cathartic. After 2 hours, his pulse, blood pressure, and respiration were nor-

mal. He was discharged after 48 hours in hospital.

Wilkinson (1991) discusses the toxic effect of ingested essential oils on three

children admitted to an emergency room in Australia. Their ages were 19

months, 23 months, and 25 months. The 19-month-old ingested an indetermi-

nate amount of lavender. The kind of lavender was not speciﬁed because poison

reports tend not to include botanical names, but the chemistry of Lavandula an-

gustifolia, L. latifolia, and L. stoechas are very different and therefore their toxici-

ties are different. L. stoechas, which contains ketones, would be more toxic than L.

angustifolia, which contains mainly linalyl acetate or linalol. It was also not spec-

iﬁed whether the lavender oil was synthetic or natural. The 25-month-old took

an unknown amount of tea tree oil, and the 23-month-old ingested 40 ml of eu-

calyptus oil. All three children were ataxic. All three were anesthetized and given

gastric lavage, and two were also intubated. Charcoal was given in all cases and

sorbitol in one. All three children recovered fully in the hospital.

Chapter 4 Essential Oil Toxicity and Contraindications 79

A fourth child who consumed 30 ml of eucalyptus became comatose after

falling against a coffee table. Gastric lavage was performed, and the child recov-

ered after 4 days of ﬂuctuating consciousness.

Much hype surrounds pennyroyal as an abortiﬁcant. However there are very

few cases reported. There are a few cases of toxicity, all of them situations in

which the essential oil was ingested. Pennyroyal, although not used frequently in

aromatherapy, is used in herbal remedies and teas, and some of the teas contain

the essential oil. Bakerink et al (1996) reported on two infant siblings who were

given home-brewed tea of pennyroyal. Serum levels of pulegone and its metabo-

lite menthofuran were then taken. The ﬁrst infant tested positive for menthofu-

ran (10 ng/ml) and manifested fulminant liver failure with cerebral edema and

necrosis, followed by death. The second infant tested positive for pulegone

(25ng/ml) and menthofuran (41 ng/ml) and manifested hepatic dysfunction and

several epileptic seizures. There have been no recorded instances of pennyroyal

toxicity following dermal application.

Temple et al (1991) reported on ﬁve cases of citronella poisoning. All involved

young children who drank varying amounts of the essential oil. Because citronella

is a nonspeciﬁc toxin, a large amount must be ingested to yield toxic effects. All

ﬁve children recovered. William Robertson, Medical Director of Children’s Hos-

pital and Medical Center, Seattle, Washington, comments at the end of the report

that he “would judge the risk of severe poisoning to be relatively remote.”

Even the ubiquitous linalol has been tested for toxicity. Following oral ab-

sorption in the gut of a mouse, 55% was rapidly excreted in the urine as urea, di-

hydro, and tetrahydrolinalool; 15% was eliminated in feces; and 23% was expired

with carbon dioxide after a lag period of several hours (Powers & Beasley 1985).

After oral administration, 3% remained in the tissues: 0.5% in the liver, 0.6% in

the gut, 0.8% in the skin, and 1.2% in the skeletal muscle. Acute systemic toxic-

ity was demonstrated with ataxia, a decrease in spontaneous motor activity, lateral

recumbency, vasodilation, rapid decrease in arterial blood pressure, and respira-

tory disturbance leading to death.

Measuring Toxicity

Much of the information available on toxicity is based on animal studies. Of

course, this is true of conventional drugs as well. Most essential oils have had ex-

tensive toxicologic studies carried out by the fragrance industry (for inhaled and

topically applied essential oils) and the ﬂavor industry (for ingested essential oils).

Guba (2000) draws attention to the way toxicology studies are carried out. Usu-

ally a very large amount of essential oil is given to the test animal in a very short

period. This is totally unlike the human situation in which small amounts of es-

sential oils are given during a longer period. The huge amounts given in animal

testing are never given all at once to humans, and rarely are such large amounts

given during an extended period.

There are two ways essential-oil toxicity can be measured: oral and dermal.

Both are tested on animals. Oral lethal dose is usually tested on laboratory mice

80 Section I Overview

or rats. The animals are force-fed essential oils until 50% of them die. The

amount the test group has ingested when this occurs is the median lethal dose,

which is know as LD50. This is the number of milligrams or grams of essential

oil per kilogram of animal body weight it took to kill half the animals.

There is a difference between a poison and a lethal substance. Whereas a

lethal substance kills the system, a poison is any substance that “irritates, damages

or impairs the activity of the body’s tissues” and is “harmful in relatively small

amounts”(McFerran 1996). A poison is not always lethal. So although the lethal

dose of an essential oil can tell us what will kill a patient, substantially less than

that can have poisonous effects. Even so, the amount required to produce poiso-

nous effects is staggeringly high, depending on the oil in question.

The LD50 dermal lethal dose is determined via a test on a shaved area of the

skin of animals, usually rabbits. Human skin is less permeable than rabbit skin.

When 50% of the test subjects die, that is the dermal LD50. There have been very

few clinical tests on human skin. Those that have been carried out involved vol-

unteers who were given a patch test for a 24-hour period (Watt 1991). The largest

patch study to date was carried out by Japanese scientists, spanned 8 years, and

involved 200 human volunteers who used 270,000 patch tests. Asian skin may be

more or less sensitive than Caucasian skin (International School of Aromather-

apy 1993).

Simple math can also be used to show how close to the toxic level a 5%

solution of an essential oil used as topical application can come. If the dermal

LD50 of eucalyptus globulus is 5 g/kg (actually it is more than 10% according to

Kligman), then the following equations determine toxicity:

Average woman of 150 lbs ⫽ approximately 75 kg

5 ⫻ 75 ⫽ 375 grams ⫽ approximately 400 ml (allowing for speciﬁc gravity).

If the solution is 5%, 8000 ml are required ⫽ 8 L

It is unknown exactly how much of the eucalyptus is absorbed through the

skin—certainly not 100%. Much depends on the skin’s integrity, its temperature,

and whether it is covered after application of the oil. Let us allow for 50% ab-

sorption (which is generous). It is impossible for 4 L of essential oil to be ab-

sorbed by the skin all at once. (However, there would be considerable effects from

inhaling the essential oil as well.)

Oral LD50 of eucalyptus globulus is 2.48 g/kg

Average woman of 150 lbs ⫽ approximately 75 kg

2.48 ⫻ 75 ⫽ 186 g ⫽ approximately 200 ml (allowing for speciﬁc gravity)

Skin Reactions

In skin tests, adverse reactions can be divided into irritation, allergic sensitivity,

and phototoxicity. Sensitivity and safety are covered in Chapter 4. Some essential

oils are thought to be dangerous when used undiluted on the skin. These include

essential oils high in phenols or aromatic aldehydes (like cinnamaldehyde). I have

Chapter 4 Essential Oil Toxicity and Contraindications 81

also found some oxide-rich essential oils can be irritating to abraded mucosa.

However, many phenol-rich essential oils are used in France at high dilutions to

treat infections Tiger Balm, a popular cream for aches and sprains, contains 60%

essential oils including cassia, clove, and camphor. However Tiger Balm applied

to a scratched skin surface is not comfortable, and it should not be applied to a

baby’s skin. Guba (2000) suggests using 90% nonirritant essential oil with 10%

phenolic oil if high concentrations or undiluted essential oils are required.

Inhalation Toxicity

Inhaled essential oils are unlikely to produce a toxic reaction. Hypothetically, a

toxic reaction could occur if a person was conﬁned to a nonventilated room, the

temperature was very high, and there was a constant diffusion of essential oil un-

til the air was saturated. However, the effect of this situation would be more like

suffocation than a reaction to the essential oil.

References

Bakerink J, Gospe S, Dimand R et al. 1996. Multiple organ failure after ingestion of

pennyroyal oil from herbal tea in two infants. Pedatrics. 98(5) 944-947.

Burﬁeld T. 2001. Safety of essential oils. International Journal of Aromatherapy. 10(1/2)

16-29.

Craig J. 1953. Poisoning by the volatile oils in children. Archives of Disease in Child-

hood. 55(5) 475-483.

Guba R. 2000. Toxicity myths: The actual risks of essential oil use. International Journal

of Aromatherapy. 10(1/2) 37-49.

Gurr F, Scroggie J. 1965. Eucalyptus poisoning treated by dialysis and mannitol infusion

with an appendix on the analysis of biological ﬂuids for alcohol and eucaluptol. Aus-

tralasian Annals of Medicine. 14(3) 238-249.

Hartnoll G, Moore D, Douek D. 1993. Near fatal ingestion of oil of cloves. Archives of

Disease in Childhood. 69:392-393.

International School of Aromatherapy. 1993. A safety guide on the use of essential oils.

London: Nurtured by Nature Oils, Ltd.

Jellinek S. 1999. Odors and mental states. International Journal of Aromatherapy. 9(3)

115-120.

Kligman A. 1966. The identiﬁcation of contact allergens by human assay. Journal of In-

vestigative Dermatology 47(5) 393-409.

Lane B, Ellenhorn MJ, Hulbert TV et al. 1991. Clove ingestion in an infant. Human

and Experimental Toxicology. 10(4) 291-294.

MacPherson J. 1925. The toxicology of eucalyptus oil. The Medical Journal of Australia.

2:108-110.

Mant A. 1961. A case of poisoning by oil of citronella. Association Proceeding VI. Med-

icine, Science, and the Law. 1, 170-171.

Martindale W. 1977. The Extra Pharmacopoeia, 27th ed. London: Pharmaceutical Press.

McFerran T (ed.). 1996. Oxford Dictionary of Nursing, 2nd ed. Oxford, UK: Oxford

University Press.

82 Section I Overview

Millet Y. 1981. Toxicity of some essential plant oils. Clinical and experimental study.

Clinical Toxicology. 18(12) 1485-1498.

Patel S, Wiggins J. 1980. Eucalyptus poisoning. Archives of Disease in Childhood. 55(5)

405-406.

Pilapil V. 1989. Toxic manifestations of cinnamon oil ingestion in a child. Clinical Pedi-

atrics. 28(6) 276.

Powers K, Beasley V. 1985. Toxicological aspects of linalool: A review. Veterinary and

Human Toxicology. 27(6) 484-485.

Schiffman S. 1992. Aging and the sense of smell: Potential beneﬁts of fragrance en-

hancement. In Van Toller S, Dodd G (eds.), Fragrance: The Psychology and Biology

of Perfume. London: Elsevier Applied Science, 54.

Temple W, Nerida A, Beasley M, et al. 1991. Management of oil of citronella poisoning.

Clinical Toxicology. 29(2) 257-262.

Tisserand R, Balacs T. 1995. Essential Oil Safety. London: Churchill Livingstone.

Villar D, Knight M, Hansen S et al. 1994. Toxicity of melaleuca oil and related essential

oils applied topically on dogs and cats. Veterinary and Human Toxicology. 36(2)

139-142.

Watt M. 1991. Plant Aromatics. Essex, UK: Witham.

Wilkinson H. 1991. Childhood ingestion of volatile oils. The Medical Journal of Aus-

tralia. 154:430-431.

Chapter 4 Essential Oil Toxicity and Contraindications 83

Part II: Contraindications

A good name is like a precious ointment; it ﬁlleth all around about, and will not

easily away: for the odors of ointments are more durable than those of ﬂowers.

Francis Bacon

any adverse reactions can be avoided if pure essential oils are used. Es-

sential oils are steam distilled, and therefore the potential for adverse re-

actions to something other than the essential oils (e.g., a solvent) is

eradicated. It is logical to assume that essential oils that have been adulterated, or

extended, are more likely to cause a problem, although this is difﬁcult to prove.

Nonetheless, the possibility of adverse reactions to pure, unadulterated essential

oils cannot be ruled out totally. These reactions may happen with patients who are

already on multiple drug regimens or who are allergy prone. Patch testing can do

much to detect, and therefore avoid, these reactions. There are also a few essential

oils that can cause dermal irritation if used undiluted.

The amount of essential oil used tends to be measured in percentages or

drops. However, there is some confusion over how big a drop is! Olleveant et al

(1999) investigated several suppliers of bergamot oil and showed that their drop

sizes differed. However, an average measurement used by aromatherapists is 20

drops of essential oil to 1 ml. Patch tests can be used to avoid skin reactions such

as irritation and sensitivity and are suggested for all potential-risk patients. Dilute

the essential oil to double the concentration to be used and put it on an adhesive

bandage. Place the bandage on the patient’s forearm and leave in place for 24

hours to assess any adverse reactions.

Possible Skin Reactions

Irritation

Skin irritation is produced by an irritant component within the essential oil and

occurs immediately, usually producing a red wheal or burn. The irritant compo-

nent is most often a phenol (found in clove, oregano, and thyme) or an aromatic

aldehyde (found in cinnamon). The reaction sensation is one of heat and burning.

Immediate dilution with a carrier oil is required, followed by washing with warm

water and nonperfumed soap. Do not use water initially; that pushes the essential

84 Section I Overview

oil into the dermis. This kind of instant irritation from a 2% to 5% dilution of a

pure, fresh essential oil is a rare event and is more likely to occur with much

higher concentrations. Essential oils with high percentages of phenols or aromatic

aldehydes should not be used undiluted on the skin.

Skin irritation caused by a chemical used in the extraction method may also

occur. Solvent chemicals are not used in true essential oils and their presence in-

dicates that the extract is an absolute, not an essential oil. There have also been

incidences of erythema following the use of topical benzoin (Rademaker & Kirby

1987; Lesesne 1992). Benzoin is sometimes used in a proprietary spray before ap-

plying an adhesive dressing. Old citrus peel oils (e.g., mandarin, bergamot, and

lemon) in which the terpene content has oxidized can also lead to irritation. Ex-

pressed oils do spoil quickly, and an opened bottle should be used within 6

months. The case is similar with pine oils. Cinnamon is thought to be responsi-

ble for an adverse reaction to trichlorophenol (TCP), a commonly used antisep-

tic in the United Kingdom (Calnan 1976). Cinnamon is no longer used in this

product.

Sensitivity: Contact Dermatitis

Sensitization to an essential oil is an allergic reaction that occurs over time. At the

ﬁrst exposure nothing much may happen. However, in a similar manner to some

drug sensitivities (e.g., penicillin), subsequent exposures produce stronger reac-

tions. These reactions can occur in the form of a rash, sneezing, or shortness of

breath. Sensitivity also can occur after long-term habitual use. Considering the

ubiquitous use of fragrance materials in everyday products, the actual risk of side

effects from a fragrance is small (De Groot & Frosch 1997). However, fragrance

allergy is the most common cause of cosmetic contact dermatitis, affecting 1% of

the population. Of greatest concern are the “fragrance-free” products that still

contain fragrance raw materials (Scheinman 1997).

On June 20, 2001, a meeting was held at the British Fragrance Association

in London to propose European Economic Council legislation requiring labeling

for the fragrance product industry. The proposal stated approximately 20 chemi-

cals thought to be allergens would need to be listed on future labels. This legisla-

tion would apply if any of the chemicals constituted 0.001% of the product or

more. The chemicals are common, occurring in essential oils such as linalol and

geraniol. There was no differentiation between synthetic and natural chemicals.

The label was to state “Can cause an allergic reaction.” This kind of labeling could

be enforced in the United States. Although it is laudable to try to curb the on-

slaught of synthetic aromas that bombard shoppers in every mall, labeling an es-

sential oil as a potential sensitizer because it contains something on a list gives the

wrong impression. Rose and lavender soaps have been used for hundreds of years

without incident. However, now that synthetic fragrances are introduced into al-

most every product, sensitivity may well increase.

Some reactions may build up throughout many years. Juniper took 25 years

to produce sensitivity in the case of a lady who sold food smoked and spiced in

Chapter 4 Essential Oil Toxicity and Contraindications 85

juniper oils. Eventually she developed a dry cough and asthma. Skin tests showed

sensitivity to juniper, although it was not established whether the wood resin or

the berries were to blame (Roethe et al 1973). In another instance, a 53-year-old

woman who was patch tested suddenly had eczema appear on various uncovered

parts of her skin: her neck, hands, and scalp (Schaller & Korting 1995). The

woman had been using aroma lamps continuously for more than a year in her

home, and it was presumed she had become sensitive to the scents of lavender,

jasmine, and rosewood. It is not clear whether she had been using pure essential

oils. However this example does underline that the same essential oils should not

be used continuously or as “blanket cover.”

I have found that patients taking several medications at the same time are

more likely to be sensitive to essential oils than patients who are not taking sev-

eral medications. Those who have an allergy-like illness such as asthma, eczema,

or hay fever may also be more sensitive to potential allergenic components, such

as lactones, found in essential oils. A ﬂorist who presented with an allergic reac-

tion to Roman chamomile (Chamaemelum nobile) was found to have a prior sen-

sitivity to chamomile herbal teas and ointments (Van Ketel 1982). Another

ﬂorist, who had had dermatitis of the face for 1 year, was found to be allergic to

the sesquiterpenes in German chamomile (Matricaria recutita) (Van Ketel 1987).

Lavender, thought to be the safest of all essential oils, caused an allergy in a hair-

dresser who used lavender shampoo several times a day for several years. The al-

lergen involved was believed to be linalol or linalyl acetate (Brandao 1986).

Sometimes the mixture of a chemical and an essential oil can trigger an al-

lergic reaction. This was the case when an aromatherapist sprayed her roses with

an insecticide, and 24 hours later developed acute, bilateral hand eczema. She had

been using French marigold (Tagetes patula) on a patient. The oil had been ob-

tained by solvent extraction (so it was not a true essential oil). Tests showed the

allergic reaction was caused by a cross-reaction between the synthetic pyrethroid

in the insecticide and the acetone-soluble extract of the marigold leaves and ﬂow-

ers (Bilsland & Strong 1990). French marigold is an unusual choice in aro-

matherapy; it smells unpleasant and always needs to be used with caution because

of its high percentage of tagetone, which can cause skin reactions. Its main use is

in the treatment of fungal infections, but it has been mostly replaced by tea tree

oil. One wonders whether the aromatherapist believed she was using common

marigold (Calendula ofﬁcinalis), which is a nonirritant and is used for its power-

ful skin-healing properties.

Citral is a potential sensitizer on its own, but essential oils of lemongrass and

melissa, which contain high percentages of citral, rarely produce sensitivity reac-

tions when used in aromatherapy. The presence of d-limonene in the essential oils

may produce a quenching effect. The wide range and complexity of components

in essential oils suggests that nature is offering a “balanced menu” so the receiver

can take the parts of the meal the body needs and leave the rest. This may be why

the effect of an isolated ingredient can be much stronger: it is no longer part of

the “balanced menu”.

86 Section I Overview

Sandalwood, thyme, and guaiacwood oils have caused sensitivity in those

sensitive to balsams (Tisserand & Balacs 1995). Sandalwood causes frequent al-

lergic reactions, which are thought to be related to its b-santalol content

(Nakayama et al 1974). Geraniol is a component of many perfumes and may

cause cross-sensitivity in those who have used perfumed products for many years.

Ylang ylang may cause a similar problem.

The most common allergic skin reaction is a stinging, painful wheal or gen-

eralized urticaria. These reactions are sometimes accompanied by bronchial in-

ﬂammation producing asthmalike symptoms (Watt 1991). Even tea tree oil, so

often recommended for its gentleness, has produced contact dermatitis when used

undiluted on the skin of someone allergic to a component found within tea tree.

In this particular case, the actual oil used was found to have a high eucalyptol con-

tent (De Groot & Weyland 1992). Another name for eucalyptol is 1,8-cineole,

which is an oxide. However, tea tree oil is supposed to have a high content of 1-

terpinen-4-ol, an alcohol, and a low proportion of 1,8-cineole.

Sieben et al (2001) investigated the effect of eight common components of

fragrances on 32 fragrance-allergic patients who had previously responded with a

positive skin-patch test. The eight common components studied were eugenol,

isoeugenol, geraniol, oak moss, a-amyl-cinnamic aldehyde, cinnamic aldehyde,

cinnamic alcohol, and hydroxycitronellal. These are the most common observed

contact allergens (Marks et al 1998). Data indicated positive patch tests are a cell-

mediated, antigen-speciﬁc phenomenon rather than a nonspeciﬁc irritating con-

dition. The authors believed the increase in fragrance allergies was a response to

the indiscriminate use of fragrances in food, household products, paint, and med-

icines. Larsen (2000) suggests cosmetic labels should include a list of common

fragrance allergens so people will know to avoid those to which they are allergic.

Phototoxicity

Phototoxicity is an interaction between a component in an essential oil, the skin,

and ultraviolet photons. This means exposure to sun-bed radiation or natural sun-

light can produce a skin reaction. Such reactions can vary from pigmentation of

the skin to severe full-thickness burns. The most common components causing

phototoxicity are furanocoumarins. Lemon oil contains oxypeucedanin and

bergapten, both furanocoumarins that produce phototoxic reactions. Lime

and bitter orange oils also contain these components, but in smaller quantities

(Naganuma et al 1985). Angelica root oil contains furanocoumarins and can also

produce phototoxicity (Tisserand & Balacs 1995).

Bergamot was used in self-tanning preparations until 12 cases of skin reac-

tion were reported after the use of this type of product. In two cases (in which

skin had been exposed to the sun immediately after application of the tanning

cream) symptoms of erythema as well as pigmentation were present (Meyer

1970). However, furanocoumarins can be removed from bergamot oil. The oil is

then classiﬁed as bergaptene-free or furanocoumarin-free (FCF). Some therapists

will not use FCF essential oils, and some distributors will not supply them,

Chapter 4 Essential Oil Toxicity and Contraindications 87

saying they will only use “whole” oils. However in areas with lots of sunshine,

FCF oils might be safer. Deterpenated citrus oils contain disproportionately

higher concentrations of furanocoumarins and are best avoided.

Chemical Burns

Parys (1983) reported on undiluted peppermint oil inadvertently spilled on skin

that had already been traumatized by skin grafts. The area necrosed and required

excision and further surgery.

Chronic Toxicity

Chronic toxicity is a term usually referring to the oral use of essential oils.

Chronic toxicity is dose-dependent but also related to the length of time spent

using a toxic substance. Death may eventually occur, but it is the preceding slow

tissue damage that is the main problem. It is unlikely that inhaled or topically ap-

plied essential oils would cause chronic toxicity, even if large amounts were used

over extended periods.

Reactions with Orthodox Drugs

Drug Combinations and Pharmacokinetics

Blashke and Bjornsson (1989) deﬁne an interacting drug combination as “one

that has the potential, documented in humans, to produce a clinically signiﬁcant

change in the pharmacologic response to its constituent drugs that is larger or

smaller than the sum of the effects when the drugs are administered separately.”

Hansten and Horn (1989) estimate that 7.4% of all hospitalized patients experi-

ence an interacting drug combination during their hospital stay. Compounding

this problem is the knowledge that individual patients respond in varying ways to

the same dose of the same drug. This variation is thought to be directly related to

pharmacokinetics: the mathematical description of the rate and extent of absorp-

tion, distribution, and elimination of drugs in the body (Gwilt 1994). These three

processes determine the movements of drugs within the body. However, despite

advances in understanding, a great deal is not yet known about drug combinations

and pharmacokinetics.

Because there are documented differences between individuals with regard

to the absorption of several orthodox drugs like phenytoin and digoxin, it is ex-

pected that the absorption of essential oils will also vary. Absorption depends on

the mode of delivery; the transdermal route is thought to be slower and more

controlled. It is thought to reduce the difference between the maximum and

minimum drug concentrations attained during a dosing interval (Blaschke &

Bjornsson 1995). The distribution of any drug is controlled by blood ﬂow to

the tissue or organ, as well as by the drug’s ability to bind to plasma proteins.

Distribution is also related to whether the drug molecules are lipid-soluble or

water-soluble.

88 Section I Overview

Elimination takes place at the same time as distribution and occurs primar-

ily in the kidneys, although metabolism (which can include deactivation) occurs

in the liver. Metabolism is the mechanism whereby drug action is terminated or,

in the case of drugs such as aspirin, activated (Grant 1994). Some lipid-soluble,

nonionized drugs can be completely reabsorbed in the liver. This metabolism in-

cludes a chemical conversion that allows the drug (or essential oil) to become

more water-soluble, and therefore easier to excrete in the urine. Essential oils that

are inhaled or applied topically do not go through the ﬁrst stage of metabolism

by the liver (Price & Price 1999).

Because they are lipid-soluble, components within essential oils gain easy ac-

cess to the brain. While being transported by the bloodstream, the components

travel readily to the adrenal glands and kidneys (Tisserand & Balacs 1995). The

rate of elimination of a drug from the body is proportional to the concentration

of that drug in the bloodstream. It is a complicated equation because the drug (or

essential oil) begins to be eliminated while it is still being absorbed (Balazs 2002)

In most instances, the biologic half-life (t

1/2

), rather than the elimination rate, is

documented. The half-life is the time taken for the drug concentration in the

blood to decrease by one half. It depends on both the volume of distribution of

the drug and the rate at which that drug is eliminated from the body (known as

clearance) (Gwilt 1994).

Drugs and essential oils are excreted via the kidneys, lungs, skin, and feces.

In addition, many nursing mothers also excrete drugs, and therefore components

of essential oils, in their breast milk (Berndt & Stitzel 1994). Theoretically, es-

sential oils could interact with orthodox drugs in several ways: by combining with

a cellular receptor (and thereby competing with the drug), by combining with

plasma protein, or by combining with and somehow altering the chemistry of the

drug to produce a different compound with different effects (Tisserand & Balacs

1995).

Cellular Receptors

Most drugs combine with a molecular structure called a receptor, which is found

on the surface of cells. This produces a molecular change in the receptor and leads

to a chain of events called a response. The same situation occurs with naturally

formed neurotransmitters and hormones secreted by the body itself. Some drugs

produce the same effects as naturally occurring substances because they combine

with the same receptors at a cellular level. An example of this is morphine mim-

icking the effects of endorphins (Fleming 1994).

It is known that receptors only react with a limited number of substances that

have a similar molecular structure. Therefore an essential oil with a molecular

structure similar to that of a drug known to bind to a particular receptor may also

combine with that receptor. An example of this is anethole and its polymers, di-

anethole and photoanethole, which bear a striking resemblance to the cate-

cholamine dopamines adrenaline and noradrenaline (Albert-Puleo 1980). Also

worthy of mention are the nonsteroidal compounds with estrogenic activity found

Chapter 4 Essential Oil Toxicity and Contraindications 89

in plants, which mimic the A-ring of steroids (Murad & Kuret 1990). However,

just because a molecule has a similar structure does not mean it will mimic a neu-

rotransmitter (Balazs 2002).

Combining at the Plasma Level

Most drugs found in the vascular compartment bind with one of the macromol-

ecules in the plasma. Compartmental modeling is used as a theoretical vehicle for

assessing the distribution of drugs (Blaschke & Bjornsson 1995). This binding is

reversible because only an unbound drug can diffuse through the capillary wall,

produce systemic effects, be metabolized, and then be excreted. As the macro-

molecule circulates within the bloodstream, so the vascular system works as a hu-

man drug distributor.

There is no reason to suppose an essential oil could not also bind with plasma

proteins. It could bind with one of the most important plasma proteins, albumin,

because most albumin-bound drugs are only slightly soluble in water. Drug bind-

ing at this level is nonspeciﬁc, and displacements frequently occur when a newer

drug with a higher afﬁnity comes along.This means the previous drug is suddenly

free to be distributed to another part of the body. In some diseases, such as ure-

mia, plasma-protein binding is reduced.

Changing the Action or Potency of a Drug

Certain components found in essential oils aid the penetration of drugs through

the skin of animals (Williams & Barry 1989). Therefore it is possible that the

topical application of an essential oil could increase the level of drug being re-

ceived by a patient using patch therapy (e.g., hormone replacement therapy) if the

oil is applied at the site of drug absorption. However, no documented informa-

tion has conﬁrmed this yet.

Freitas et al (1993) found that b-myrcene affected the metabolism of barbi-

turates in rats. The rats were given b-myrcene orally 1 hour before an intraperi-

toneal injection of pentobarbital. This enhanced the sleeping time and was at-

tributed to the pentobarbital-biotransforming enzymes found in b-myrcene.

However, when b-myrcene was given 1 day before the barbiturate injection, the

sleeping time was reduced by 50%. b-myrcene is found in lemongrass (Sheppard-

Hangar 1995).

Wintergreen and sweet birch are essential oils not commonly used in aro-

matherapy, mainly because they contain high levels of methyl salicylate (closely

related to acetylsalicylic acid or aspirin). Some safety data manuals call them haz-

ardous (Tisserand & Balacs 1995; Anonymous 1993). However, they are found in

many proprietary creams (such as Deep Heat) for sprains and strains, as well as

in chewing gum and candy (Guba 2000). Wintergreen and sweet birch essential

oils are easy to purchase. Guba (2000) suggests that 10 ml of a 2.4% mix of win-

tergreen in carrier oil would give approximately 250 mg methyl salicylate, equiv-

alent to one tablet of aspirin. Methyl salicilate is absorbed through the skin and

can affect warfarin anticoagulation therapy (Littleton 1990; Yip et al 1990). Guba

90 Section I Overview

(2000) suggests that because only 50% of methyl salicilate would be absorbed, the

amount produced from wintergreen oil in this experiment would be no more toxic

than rubbing half an aspirin on the skin. However, aspirin is known to affect the

blood-clotting mechanism and prostaglandin production. The combination of

regular amounts of an aspirinlike substance (wintergreen) and warfarin could lead

to hemorrhage. Collins et al (1984) showed that blood salicylate reached maxi-

mum level 20 minutes after Deep Heat cream was applied to the skin. Guba

(2000) recommends not using wintergreen for full body treatments or when the

patient is taking warfarin or some other anticoagulant therapy. However, several

proprietary brands of creams for arthritis contain similar acetylsalicylic acid-like

components and do not offer warnings. Many volatile chemicals are absorbed

though the skin (Riviere et al 1997). There seems to be a question as to whether

essential oils reach the bloodstream in sufﬁcient quantities after a topical aro-

matherapy treatment to have a pharmacologic effect (Balazs 2002).

Essential oils containing b-asarone or d-pulegone may increase the toxic ef-

fects of a drug because they both induce the detoxifying enzyme cytochrome

P450. (These substances are found in essential oils that are rarely used because

they are thought to be toxic themselves.) Drugs that induce this enzyme include

progestogens (found in the contraceptive pill), diphenhydramine (an antihista-

mine), pethidine, nitrazepam, phenobarbitone, and phenytoin, the last four being

frequently used hospital drugs (Tisserand & Balacs 1995). Fortunately, very few

essential oils contain b-asarone or d-pulegone, and few that do are in regular use.

They include wintergreen, cultivated carrot seed, calamus (which contains

b-asarone), and pennyroyal (which contains d-pulegone). Madhava-Madyastha

and Chadha (1986) found that 1,8-cineole, administered by inhalation, induced

the liver microsomal cytochrome P450 to a signiﬁcant extent in rats. However,

Tisserand and Balacs (1995) state the amounts used in aromatherapy is insufﬁ-

cient to induce changes in cytochrome P450 activity. Chiou et al (1997) found

that beta-uedesmol, a sesquiterpene found in West Indian sandalwood, alleviated

electric shock-induced seizures in rat tissue and may enhance the effect of

epilepsy drugs such as phenytoin.

A study by Perez Raya et al (1990) has shown that two different species of

mint enhance the effect of pentobarbitone in rats. Both Mentha rotundifolia and

Mentha longifolia signiﬁcantly enhanced sodium-pentobarbital induced sleep.

Lavender was also shown to enhance sodium-pentobarbital-induced sleep in rats,

although the effect ceased if treatment lasted longer than 5 days (Delaveau et al

1989). Guillemain et al (1989) also demonstrated the ability of lavender (Lavan-

dula angustifolia) to enhance neurodepressant effects. However, these ﬁndings are

a long way from proving a similar action on enzymes in humans.

Almirall et al (1996) found that 1,8-cineole, d-limonene, and pinene perme-

ated the skin and affected topical application of conventional drugs such as

haloperidol and chlorpromazine. Whereas 1,8-cineole and d-limonene enhanced

the transdermal permeability of haloperidol, d-limonene reduced the transdermal

permeability of chlorpromazine. The oxide 1,8-cineole (also called eucalyptol) is

Chapter 4 Essential Oil Toxicity and Contraindications 91

found in rosemary, cardamon, spike lavender, sage, and eucalyptus (Bowles 2000),

and d-limonene is found in many citrus-peel oils.

Jori et al (1969) studied the effects of several components of essential oils on

the metabolism of drugs in rats. The components, which were delivered by aerosol

or subcutaneously, were eucalyptol (1,8-cineole), guaiacol, menthol, and essential

oil of Pinus pumilio (which contained a-pinene, phellandrene, dipentene,

sylvestrene, and bornyl acetate). Eucalyptol was shown to increase the activity of

the microsomal enzymatic reaction and altered the metabolism of drugs. The dis-

appearance rate from brain and plasma of amphetamine and pentobarbital was

increased after eucalyptol administration, but eucalyptol had no inﬂuence on

phenylbutazone. An increased plasma disappearance was also shown to occur in

humans after 10 days’ treatment with eucalyptol aerosol.

Hohenwaller and Kima (1971) found that eucalyptol, either given subcuta-

neously or by aerosol, raised in vivo phenobarbital metabolism. The change of en-

zyme activity with time resembled the change of drug concentration in blood

serum. The mechanism of eucalyptol appeared to be quite different from the

mechanism of phenobarbital in three ways. First, unlike the rapid decrease of

phenobarbital, eucalyptol disappeared gradually. Second, enzyme activity contin-

ued after the end of treatment with eucalyptol. Third, a single treatment of euca-

lyptol caused reduction in enzyme activity, but several doses of phenobarbital

were required. Hohenwaller and Kima (1971) concluded “many other mecha-

nisms beside enzyme synthesis must be involved in producing the striking differ-

ences on the action of the two drugs.” Eucalyptol is used extensively in the phar-

maceutical preparations for external application and as a nasal spray. However,

Tisserand and Balacs (1995) state that because essential oils are used in such small

amounts compared with orthodox drugs, even if they are given orally, they are un-

likely to affect the therapeutic action of most orthodox pharmacology.

Certain essential oils may react with other medications. In some instances es-

sential oils may enhance the effects of orthodox drugs, whereas in other cases they

may interfere at a cellular level, reducing the effectiveness of medication. Ylang

ylang (Cananga odorata) enhances the dermal absorption of 5-Fluorouracil sev-

enfold (Williams & Barry 1989). Blue gum eucalyptus (Eucalyptus globulus) en-

hances the activity of streptomycin, isoniazid, and sulfetrone in Mycobacterium tu-

berculosis (Kufferath & Mundualgo 1954; Guillemain et al 1989). Eucalyptol

(1,8-cineole) found in gully gum (Eucalyptus smithii), and blue gum eucalyptus

(E. globulus and E. fruticetorum) produced a signiﬁcant decrease in pentobarbital

effects and dose-related effects on the liver-enzyme activity of rats ( Jori et al

1969). The reduction in sedative effect occurred even when the eucalyptus had

been administered 36 hours previously.

Roman chamomile (Chamaemelum nobile) was found to be incompatible with

the administration of products containing Peruvian bark, tannin, or silver salts

(Chiej 1984). These are sometimes present in old-fashioned preparations used for

pressure-area care.

92 Section I Overview

Acetaminophen (paracetamol) is a common analgesic that reduces the level

of glutathione in the liver. Glutathione is responsible for absorbing free radicals,

and when the level of glutathione falls, reactive molecules such as free radicals can

attack the liver cells with potentially fatal consequences. It is extremely unlikely

that the small amounts of essential oils used in aromatherapy could adversely af-

fect glutathione production. However, in a patient using the maximum recom-

mended dosage of Tylenol, it might be advisable to avoid essential oils containing

transanethole, estragole, and eugenol (Tisserand & Balacs 1995). This means

avoiding the following essential oils: fennel (Foeniculum vulgare), aniseed

(Pimpinella anisum), basil (Ocimum basilicum), and clove (Syzygium aromaticum).

Terpineol is thought to enhance prednisolone absorption through the skin

(Williams & Barry 1989). Terpineol is found in many essential oils, including

niaouli, ravansara, and tea tree. Godwin and Michniak (1999) found that

terpinen-4-ol and a-terpineol enhanced the dermal penetration of hydrocortisone

four to ﬁve times in mice. Both of these chemical components are found in tea tree

oil. Limonene is thought to increase indomethacin absorption through the skin.

Indomethacin is a drug commonly used in arthritis. Limonene is a monoterpene

that occurs in many essential oils from citrus peels. Menthol lowers the melting

point of testosterone (which is solid at room temperature) and increases the per-

meation of testosterone through the skin eightfold (Kaplun-Frischoff & Touitou

1997). Bowles (2000) suggests that there could be a remote possibility of myris-

ticin (found in nutmeg) compounding the effect of serotonin-altering drugs.

Cedarwood (Cedrus atlantica) reduces the effect of barbiturate-induced sleep

(Wade et al 1968). This study also showed that cedarwood could reduce the

amount of dicoumarol in the blood. Dicoumarol is an anticoagulant that can be

obtained from sweet clover (Budavari 1996). Eugenol has been shown to have an-

tiplatelet activity ( Janssens et al 1990), and should be avoided in patients receiv-

ing anticoagulant therapy. Eugenol occurs in clove leaf and bud, pimento berry

and leaf, and cinnamon leaf. Cinnamon leaf is thought to depress liver glu-

tathione levels in rats and may interfere with the body’s metabolization of acet-

amionphen.

Finally, some patients with particular enzyme deﬁcits or speciﬁc conditions

may be affected by certain essential oils. Male children of Chinese, West African,

Mediterranean, and Middle Eastern origin are susceptible to a deﬁciency of

glucose-6-phosphate dehydrogenase. This enzyme is responsible for liver detoxi-

ﬁcation of menthol. When the enzyme is missing, toxic build-up of menthol can

occur (Owole & Ramson-Kuto 1980). Large amounts of peppermint should be

avoided in these children.

Rosemary has been shown to interfere with calcium inﬂux into the myocar-

dial cells (Tisserand & Balacs 1995) and should be not be used orally in cardiac

patients. Patients with glaucoma should avoid taking oral citral-rich essential

oils (Leach & Lloyd 1956). Tisserand and Balacs (1995) suggest that hormone

replacement therapy (HRT) is not adversely affected by aromatherapy because

Chapter 4 Essential Oil Toxicity and Contraindications 93

the hormonal effect of the essential oil is considerably weaker than the effect of

the HRT.

Essential Oils and Homeopathy

Although Hippocrates may have been the ﬁrst to say “like cures like,” this tenet

is associated with homeopathic medicine, which dates back to 1810 and Samuel

Hahnemann, a German physician. Hahnemann discovered that cinchona bark

taken by a healthy person produced the symptoms of malaria. At that time, cin-

chona bark was administered as a herbal remedy to cure malaria. (Much later cin-

chona bark was found to contain quinine, a component that became a classic drug

to treat malaria.) Hahnemann thought giving a minute dose of the substance that

may have caused the disease would stimulate the body to ﬁght that disease.

He tested this hypothesis on himself and his family, compiling a huge ency-

clopedia of knowledge that now forms the foundation of homeopathic literature.

The ﬁrst homeopathic hospital opened its doors in 1850. In addition to “like cures

like,” homeopaths believe the more diluted the dose, the more potent it may be. Of-

ten their medicines are so diluted that there are no molecules of medicine left in

them. This has caused much derision among members of the medical profession,

who feel that leaving the curing of the patient to the “learned memory of water” is

something of a joke. However, rigorous scientiﬁc studies are now showing that

homeopathy is indeed a valid and useful form of medicine (Kleijinen et al 1991).

There is some controversy among homeopaths concerning the use of essen-

tial oils for patients receiving homeopathy. The traditional view has always been

that essential oils and homeopathic remedies do not mix. Many aromatherapy

courses teach that the two should not be combined. They are very different ther-

apies at opposite ends of the spectrum—one very concentrated and one very di-

lute. Peppermint, eucalyptus, thyme, and essential oils with strong aromas are

some of those best avoided by patients using homeopathy.

Stevensen (1995), who worked for many years using both homeopathy and

essential oils on a daily basis, wrote “I would ﬁnd it difﬁcult to envisage a clash of

effects between homeopathy and aromatherapy.” However, the safest option is to

restrict the choice of essential oil to ﬂorals such as rose, lavender, geranium, neroli,

and the softer herbs.

Speciﬁc Contraindications

Some essential oils are contraindicated in certain aromatherapy situations, or con-

traindicated altogether, although they may be used as food ﬂavorings or in per-

fumery. The amount of essential oil used in ﬂavoring is often very tiny. For ex-

ample, mustard, a well-known ﬂavoring, is contraindicated in aromatherapy

because it is extremely toxic. Tisserand and Balacs (1995) describe the dose used

by the food industry as one-hundredth of a drop of mustard to 50 g of pickle. It

would be impossible to measure one-hundredth of a drop in aromatherapy.

94 Section I Overview

However, if just one drop was used (1%), the resulting dilution would be 1000

times greater than that in pickles!

There are several safety data manuals available that go into detail regarding

why some essential oils are contraindicated. Essential Oil Safety (Tisserand &

Balacs 1995) is particularly recommended. If hospitals are to become involved in

the use of essential oils, they should have a safety data manual. Hazardous oils are

still on sale in many health-food shops, and sometimes in bottles without inte-

grated droppers.

Some essential oils are generally contraindicated for all therapeutic uses.

These include boldo leaf, calamus, cassia, bitter fennel, mugwort, mustard, rue,

sassafras, tansy, wintergreen, and wormwood. These oils all contain toxic con-

stituents. The essential oils contraindicated for undiluted topical application in-

clude oregano, clove bud and leaf, cinnamon bark, camphor, and red thyme. Es-

sential oils that should be used with caution in patients with hypertension include

rosemary, spike lavender, hyssop, juniper, thyme, and clove, although there is no

published report of blood pressure being substantially raised by essential oils.

Contraindicated in patients with epilepsy are hyssop, fennel, peppermint, and

rosemary, although there is no published report of any of these triggering a

seizure. However, Guba (2000) writes that large doses of ketones, in particular

camphor, pinocamphone, pulegone, and thujone have been found to cause

seizures (NDPSC 1998).

Contraindications in Oncology

Some malignant growths depend on estrogen, so perhaps the use of essential oils

that are mildly estrogenlike should be avoided. However, soy products, which also

contain phytoestrogens, have cancer-ﬁghting compounds (Weil 1998), so estro-

gen stimulating or estrogenlike essential oils may be good for estrogen-dependent

tumors. Barrett (1997) gives an interesting discussion of the pros and cons of us-

ing phytoestrogens. Franchomme & Penoel (1991) list the speciﬁc chemical com-

ponents associated with estrogen stimulation or estrogenlike properties as sclareol

and viridiﬂorol (sesquiterpenic alcohols), anethole (a phenyl methyl ether), and

“certain” ketones not speciﬁed. Citral was found to have an estrogenic action by

Geldof et al (1992). Animal studies suggest the topical use of citrus-peel oils such

as bergamot should be avoided in patients who have a history or symptoms of

melanoma (Elegbede et al 1986).

Contraindications in Pregnancy

The use of essential oils in pregnancy is a contentious subject, especially during

the vital ﬁrst 3-month period. Some aromatherapists will not treat expectant

mothers. Because lipophilic substances can diffuse between two circulations, it is

likely that essential oils cross the placenta (Burﬁeld 2001). Balacs suggests the

best advice is to “urge caution when giving oils to pregnant women and to avoid

pennyroyal at all costs.” However, to put this in context, remember that perfume

does not carry a warning not to be used in pregnancy. It is extremely unlikely that

Chapter 4 Essential Oil Toxicity and Contraindications 95

a nightly bath containing a few drops of essential oil will cause any problems for

the unborn child.

Many midwives are happy to use essential oils during labor to promote con-

tractions and for their analgesic properties. Mason (1996) suggests avoiding es-

sential oils during the ﬁrst 24 weeks of pregnancy. Tiran suggests avoiding them

during the ﬁrst trimester only (1996). Several hospital labor units using essential

oils during labor and delivery report that aromatherapy is useful, safe, and pleas-

ant. More details on obstetrics can be found in Chapter 21.

Safety and Storage of Essential Oils

Safety

Aromatherapy requires knowledge, and yes, in the wrong hands, essential oils can

be hazardous. Just like Tylenol and aspirin, which can be bought over the counter

almost anywhere, essential oils should always be kept away from children. See

Table 4-2 for potentially lethal dosages in children.

If a child appears to have drunk several spoonfuls of essential oil, contact the

nearest poison unit (often listed in the front of a telephone directory). Keep the

bottle for identiﬁcation and encourage the child to drink whole milk. Do not try

to induce vomiting. If essential oils (diluted or not) get into the eyes it is impor-

tant to irrigate the eyes as rapidly as possible with whole milk or carrier oil fol-

lowed by water and then to seek medical help. If there is a skin reaction to an es-

sential oil, dilute the essential oil with carrier oil, then wash the area with a

nonperfumed soap. The majority of the components found in essential oils are

nonpolar; therefore essential oils do not mix well or dissolve in water.

Storage

Essential oils are powerful, and it is important that they be stored away from chil-

dren, the confused, or those unaware of what essential oils are. It takes just 4 ml

(less than a teaspoonful) of ingested blue gum eucalyptus to produce severe ef-

fects. Gurr & Scroggie (1965) reported on a case that necessitated emergency

peritoneal dialysis, hemodialysis, and a mannitol infusion.

Essential oils kept in a hospital should be stored in a locked container. If

stored in a cool, dry, dark place, undiluted essential oils can stay fresh for up to 6

years. They should be kept in colored (blue or amber) glass bottles to protect them

from ultraviolet light, with the bottles sealed. Bottles should have an integral drop-

per contained in the lid to prevent spillage. All opened bottles should be stored

away from heat and sunlight (ideally in a refrigerator, similar to the storage of hep-

arin). All bottles should carry a ﬁrmly attached label, stating the botanical name,

the supplier’s name, and the batch number. Most reputable companies also include

a label warning that the oils should be kept away from the eyes, out of reach of

children, and not be taken by mouth. Some also have a note printed on them stat-

ing they are of medicinal strength. It is helpful to keep a record of when each es-

96 Section I Overview

sential oil was purchased, the supplier’s name, and the price. A separate list should

be kept with the patient’s name, the name of the physician, the dates the patient

received aromatherapy, and any therapeutic (or adverse) results. Recording this in-

formation makes a portfolio on the use of essential oils easily available.

Essential oils are highly ﬂammable, so they must be stored away from open

ﬂame such as candles, ﬁre, matches, cigarettes, and gas cookers. Sprinkling them

on top of light bulbs is not a good idea!

Although essential oils have been used for thousands of years, there have been

few recorded cases of sensitivity, allergy, or fatality. Lovell (1993) suggests that the

family Lamiacea, which contains many aromatic plants used in perfumery, cook-

ing, and medicine, could possibly produce allergic contact dermatitis. He cites

Canlan, who recorded six positive reactions to lavender oil patch tests in 1147

Chapter 4 Essential Oil Toxicity and Contraindications 97

Table 4-2 h Potentially Lethal Oral Doses of Essential Oil for a Child.

Oral Lethal Dose

Common Name Botanical Name for a Child

Basil Ocimum basilicum 8 ml

(estragole above 55%)

Aniseed Pimpinella anisum 25 ml

Clove Syzygium aromaticum 19 ml

Eucalyptus Eucalyptus globulus 5 ml

Hyssop Hyssopus ofﬁcinalis 19 ml

German spearmint Mentha longifolia 6.5 ml

Egyptian round leaf Mentha rotundifolia 10 ml

Oregano Oreganum vulgare 21 ml

Parsley seed oil Petroselinum sativum 21 ml

Pennyroyal Mentha pulegium 3 ml

Sage Salvia ofﬁcinalis 26 ml

Savory, Summer Satureja hortensis 19 ml

Tansy No botanical name given 5 ml

Tarragon No botanical name given 26 ml

Thuja Thuja occidentalis 10 ml

Wintergreen Methyl salicylate 5 ml

Adapted from Watt M. 1991. Essex, UK: Witham. This book discusses adverse reactions and

toxicity in greater detail. Not all the botanical names are given.

patients. The incidence of adverse reactions to essential oils is considerably lower

than the incidence of adverse reactions to synthetic drugs, and the reactions are

generally less severe. However, this could be because essential oils are used much

less often than orthodox drugs. In a Japanese study carried out between 1990 and

1998, a 2-day, closed patch test using 2% essential oil of lavender on people who

had suspected cosmetic contact dermatitis found a sudden increase in reactions for

the year 1997 (Sugiura et al 2000). Researchers suggested this increase could be

due to the trend of placing lavender ﬂowers in pillows and drawers. Essential oils

are wonderful things, but over-use may lead to sensitivity—even with the ubiqui-

tous lavender.

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Chapter 4 Essential Oil Toxicity and Contraindications 101

102

Psychology

“Why do women sniff bread?” I asked. It was something I often noticed Ma doing.

“To see if it is fresh I suspect,” Uncle Seth said. “I have never sniffed bread in my

life, which is the difference between me and a woman. ...And when a woman

comes to decide who to marry it comes down to the same test,” he added.

“You mean they sniff men?” I asked. I could not imagine what it would feel like

to have a woman sniff me.

“Yes, to determine if the fellow’s fresh,” Uncle Seth said. “I guess I don’t smell

fresh, which is why I’m a bachelor still.”

Larry McMurtry

Boone’s Lick

odd (1991) described stimulation of olfactory responses by odorants as “a

branch of molecular pharmacology that was similar to mood changes

brought about by some psychotropic drugs.” Responses to pleasant odors

are conducted unconsciously, although both olfactory nerve connections and

measured physiologic changes indicate that the response is of an emotional and

hormonal nature.

Jellinek (1999) describes four different mechanisms through which essential

oil odors affect psychologic states. He calls these mechanisms quasipharmaco-

logic, semantic, hedonic, and placebo. Quasipharmacologic refers to the small

amounts of essential oil components found in the bloodstream following inhala-

tion. Semantic refers to the odor within the context of life experience. Hedonic

refers to feelings of pleasure or displeasure on inhaling an essential oil. Placebo

refers to the expectations of the person inhaling the essential oil, which color his

or her response.

Pheromones

Smell is very important in life, beginning with newborn babies’ identiﬁcation of

their mothers (Macfarlane 1975) and continuing into old age. Even subliminal

smell is important. Partners, lovers, and friends are chosen through subliminal

smells called pheromones (Watson 2000). Pheromones are airborne chemicals in-

voluntarily expelled into the air that affect the physiology or behavior of other

members of the same species. Pheromones were discovered in the 1930s by

Adolph Butenandt, a German biochemist who won the Nobel Prize in 1939 for

his work on human hormones. He was forbidden to accept the award by Hitler,

and he changed his research focus to how female moths attract males at great dis-

tance. It took Butenandt the next 20 years to identify the ﬁrst pheromone,

bobykol, “a substance so powerful that if any one female moth were to release all

her store in a single spray, there would be enough to bring a trillion males to her

side” (Dossey 2001). Pheromones are linked to the vomeronasal organ: two tiny

pits just inside the nostrils (Watson 2000).

Although a person may not be aware of another person’s pheromones, they

are what really attracts him or her to that person. Couples going through mar-

riage breakdown often say their partner “no longer smells the same” (Needham

1999). This is much truer than they realize because the chemical attraction be-

tween them has changed from attracting mode to repelling mode, just as their

emotions have changed. Pheromones work in a subliminal way, meaning humans

are unaware of them, although they may still sense “something” is different.

Everyone’s body odor is unique—a “smellprint.” An electronic device known

as the Bloodhound, an artiﬁcial snifﬁng dog, was built at Cambridge University.

This device could identify a person’s smellprint, and by recording a particular per-

son’s unique body odor, the machine could recognize that smellprint anywhere in

the world.

Psychoaromatherapy

It is also possible, using psychoaromatherapy (environmental fragrancing), to ma-

nipulate mood or change perception through the use of subliminal smell. A cer-

tain amount of research has been conducted on this, and the results show people

can be encouraged or manipulated using this method of aromatherapy (Kirk-

Smith 1993). For example, customers in a store can be encouraged to purchase an

item, rather than another identical item, by impregnating it with a pleasant sub-

liminal smell. Companies can “persuade” customers to pay bills on time by im-

pregnating invoices with subliminal, offensive odors. The concept is disturbing,

and the possible repercussions arguably unethical.

Psychoaromatherapy is not just about subliminal smell. The perfume indus-

try is very concerned with how our choice of scent affects us (Mensing & Beck

1988). Millions of British pounds and American dollars are spent each year on

olfaction research (Dossey 2001).

Chapter 5 Psychology 103

Aromas have measurable effects on how we feel. Torii et al (1988) report on

the psychologically stimulating effect of jasmine. Manly (1993) found the effect

of lemon, lemongrass, peppermint, and basil to be psychologically stimulating,

and the effects of bergamot, chamomile, and sandalwood to be relaxing. Other

aromas found to be relaxing were rose and lavender (Kikuchi et al 1991). Pepper-

mint and lavender improved the efﬁciency of proofreaders (Kliauga et al 1995).

Sweet orange essential oil was effective in children for both induction of anes-

thesia and recovery time following surgery (Mehta et al 1998).

It is not necessary to be awake for an aroma to affect a person physiologically.

Whereas Sugano (1992) found jasmine stimulating to subjects who were awake,

Badia et al (1990) found the effect of jasmine was still stimulating when subjects

were asleep. Badia et al (1990) found that peppermint was also simulating. He-

liotropin relaxed some subjects and disrupted sleep in others. The aroma appeared

to cause changes in subjects’ electroencephalogram (EEG) results and blood pres-

sure, but did not affect respiration.

Yamaguchi (1990) found that aromas could affect heart rate. Van Toller et al

(1992) mapped the brain while subjects wearing a special 28-lead “hat” inhaled

aromas. Schulz et al (1998) used EEG activity to screen acute sedative effects of

several essential oils compared against diazepam, and the use of EEGs to moni-

tor the effects of aromas is becoming more commonplace. Lorig et al (1990) also

measured EEG activity during olfaction. Masago et al (2000), using lavender,

chamomile, and sandalwood, found that alpha 1 activity signiﬁcantly decreased

during odor conditions in which the subjects felt comfortable, and showed no sig-

niﬁcant change under odor conditions in which the subjects felt uncomfortable.

Alpha 1 is the 8.5-10.5 Hz frequency band of an EEG signal.

Smell is also a language, a method of communication. We involuntarily com-

municate through subliminal smell—our pheromones. We talk about “smelling

danger,” say that someone or something “smelled wrong,” or refer to “snifﬁng it

out.” The French have a saying, Je ne peux pas le sentir, which means “I don’t trust

him”; the literal translation is “I can’t smell him.” Unconsciously we choose our

friends and partners by smell. Research has shown that subliminal smell placed

on a waiting-room chair attracted a statistically signiﬁcant proportion of patients

entering that waiting room (Kirk-Smith & Booth 1987).

Learned memory is a reaction to a smell that has been learned through ex-

perience, for example, trauma linked to an aroma. When that odor is smelled

again, fear, or the emotion originally experienced, is triggered. An example of this

phenomenon of learned memory is the use of lavender in older adults. For many

elderly people in Europe, lavender is associated with linen chests, and for some

the odor is closely linked with care of the dying. Lavender has undergone a

tremendous revival thanks to aromatherapy, and although it appears to be univer-

sally enjoyed by those younger than 60 years of age, this learned memory associ-

ation between lavender and death could be why those Europeans in their 70s or

older are sometimes not quite so enthusiastic.

104 Section I Overview

Kirk-Smith (1993) tells the story of a 55-year-old man who, as a child, was

terriﬁed of a teacher who wore a particular perfume. In later life, that same per-

fume still evoked a sense of anxiety. Learned memory of smell is hard to undo.

The functioning of the human body is greatly affected by the mind. In recent

years, medicine has begun to accept the mind/body connection. Our immune sys-

tem has receptors for endorphins and is strongly affected by our sense of well be-

ing. Bereavement, anxiety, and stress (Quinn & Strelkauskas 1993) affect this

continual conversation between brain and immune system. By combining two ex-

ternal communicators, smell and touch, our patients’ abilities to communicate in-

ternally are greatly enhanced.

Smell is closely linked to taste (although smell is considerably more sensi-

tive), which is why when we have a cold, food does not smell appetizing. We eat

to live: food has a molecular structure, which our bodies break down into atoms;

this has both physiologic and psychologic effects. We also eat because food tastes

good. Smells can give us similar pleasure, and they too affect us physiologically

and psychologically. Aromas have also been shown to enhance the output of the

workforce, raise feelings of job satisfaction, and reduce sick-leave absences

(Chadwick & Mann 1983). Speciﬁc aromas have speciﬁc effects. Melissa has

been used for grief, lemongrass to mask offensive smells, marjoram and lavender

to aid insomnia in the elderly, and geranium and mandarin to enhance memory

recall in patients with Alzheimer’s disease.

Saeki and Shiohara (2001) investigated the physiologic response to inhaled

lavender, rosemary, and citronella on nine healthy women aged 21 to 23 who were

recruited from Nagano College of Nursing in Japan. The study measured the re-

sponses to R-wave intervals on an electrocardiogram, blood ﬂow in the ﬁngertips,

galvanic skin conduction (GSC), and blood pressure. Tests were performed in an

air-conditioned room at 22° to 25° C. The study began by measuring baselines.

Then 6 drops of one of the three aromas were heated in 10 ml of hot water in an

aroma pot. The subject entered the room and inhaled the essential oil for 10 min-

utes. A break of 90 minutes was allowed between each aroma to allow for aroma

dispersal.

The results showed lavender decreased systolic blood pressure within 10

minutes, decreased GSC within 2 minutes, and increased blood ﬂow within 6

minutes. The R-R interval did not change. Rosemary increased the systolic blood

pressure and decreased the blood ﬂow immediately, but these responses returned

to normal within minutes. There were also changes in the ECG, and the two fre-

quency components of heart rate variation, (which, simply put, means the ratio

between respiration and heart beat) increased signiﬁcantly and immediately. This

appears to conﬁrm that rosemary has stimulant effects, although they appear to

be transitory. Citronella did not change blood ﬂow or blood pressure, but it did

increase the R-R interval after 10 minutes, although GSC decreased immediately.

Each participant’s like or dislike of the aroma could explain these conﬂicting

results.

Chapter 5 Psychology 105

Mind/Body Connections

Sugawara et al (1999) found that a perception of fragrance is related to the type of

work a person does. In this study the difference between mental and physical work

altered perceptions of scent. Scores were recorded for seven essential oils before and

after speciﬁc types of work. Cypress had a more favorable impression after physical

work than before. (This is interesting because cypress has a deodorant effect!) Or-

ange had a less favorable reaction after physical work. Degel & Koster (1999) found

that ambient odor could have a negative or positive effect on a variety of tests. The

researchers gave 108 subjects a variety of tests in a room weakly scented with jas-

mine or lavender or in an odorless room. The tests included viewing slides of dif-

ferent surroundings (including the room in which they were located). Subjects were

asked to rate how well speciﬁc odors matched the slides. Jasmine appeared to have

a negative and lavender a positive effect on test performance.

Jelinek and Novakova (2001) give a moving account of how aromatherapy

had a positive effect on a 14-year-old boy in prison in Bohemia. The teenager was

aggressive and had behavior problems. What was most interesting was how each

aroma triggered his memory and how that memory allowed the boy to commu-

nicate his feelings. For example ylang ylang evoked the smell of his father’s

Sunday-morning shave and the good things they did together, but after smelling

peppermint the boy said “I don’t know any more.”

Aromas affect even the unborn child. A French study (Schaal et al 2000) ex-

amined whether prenatal exposure to aroma could inﬂuence selective response. In

this randomized study the test group of mothers consumed anise-ﬂavored candy

containing up to an estimated intake of 121 mg of anethole. When the newborn

babies were exposed to a swab with anethole, videos recorded facial and head re-

sponses in favor of the smell. The babies of the control mothers (who did not eat

any anethole candy) demonstrated an aversive or neutral response. The other ba-

bies turned toward the anethole swab.

Smell can help people cope with a traumatic experience, and may be of use

in treating panic attacks. Redd and Manne (1995) investigated the effect of using

aroma to reduce distress during magnetic resonance imaging. A small tube was

inserted in the nostrils of 57 participants who received either heliotropin (a

vanilla-like scent) or plain air. Patients who received the heliotropin reported 64%

less anxiety than the control group who had plain air, even though the respiration

and heart rate of the experimental group showed no change.

Not all aromatherapy studies have been successful in reducing perception of

anxiety. Wiebe (2000) found that vetiver (a common ingredient in men’s cologne

and aftershave), bergamot, and geranium did not reduce the stress of women

about to have an abortion. The essential oils were smelled for 10 minutes. The

control group smelled a hair conditioner containing synthetic scent.

Certain aromas may help reduce stress before and during examinations.

Fillian (2000) studied the effect of a mixture of lavender (Lavandula angustifolia)

and rosemary (Rosmarinus ofﬁcinalis) on 13 adult volunteers of an advanced

106 Section I Overview

physiology class at a graduate college All students were patch tested before the

study began. During the study, subjects were asked to apply 5 drops of 2% solu-

tion to their wrists, rub their wrists together and inhale deeply for 5 minutes be-

fore the examination.This could be repeated as necessary during the examination.

The average mean score of the tests taken previously by the subjects was 85.4%.

The average score of the tests when aromatherapy was used was 89.7%. Although

the students could have become more familiar with the testing procedure (this

was their ﬁfth test out of six), and the test itself could have been simpler, the stu-

dents all reported a feeling of calmness and clear thought.

Lavender and rosemary were the subjects of a randomized, controlled study

reported in Reuters Health (an on-line health bulletin service) on March 28,

2002. Either lavender or rosemary was given to 144 young adults; they were then

given tests of their working memory and reaction times. Mood tests were com-

pleted before and after the memory exercises. Study participants in the lavender

group reported feeling less alert in the lavender-scented cubicles, participants in

the rosemary group reported feeling more content after they completed the mem-

ory tests than they did before. The study ﬁndings were presented at the British

Psychological Society’s annual meeting in Blackpool, UK.

Age, sex, and exposure to noxious agents all affect our sense of smell. As we

become older our sense of smell deteriorates. Women are thought to have a

greater sense of smell than men. This is particularly interesting as most ‘noses’ or

professional perfumers are men. Results from a National Geographic Smell Sur-

vey (712,000 respondents) indicate that certain medicinal and environmental

agents adversely affect the sense of smell. Workers in a factory reported poorer

sense of smell after the suggestion that exposure to the factory workplace had im-

paired their sense of odor (Corwin et al 1995). Russell et al (1993) interpreted the

Smell Survey to show that there were marked changes in odor categorization

across the life span. After the age of 60, there was marked displacement for some

odors—some odors were more difﬁcult to smell or identify.

Essential oils make up very complicated aromas that are difﬁcult to emulate.

Rose oil is one of the most complicated and has bafﬂed synthetic chemists for

some time. Scientists suspect that the sweet component of rose odor is made by

the breakdown of carotenoids, a compound found in the petals that gives red roses

their color. Science News describes how Japanese researchers have identiﬁed an en-

zyme that turns carotenoids into the chemical precursor to beta-damascenone,

but have been unable to replicate it. (April 15, 2000).

Espenshade (1999) discussed a select mute child in the second grade who

had not responded in class to any questions since kindergarten. He had arrived at

the school 2 years previously. The child was from Sardinian parents but was born

in the United States. He behaved normally at home. Espenshade, a teacher,

worked with the family and suggested six essential oils for the boy to choose from.

The boy chose three: frankincense, bergamot, and Scotch pine. Each morning

when he arrived at school he came to Espenshade and selected one of the scents.

Several drops were placed on a tissue he kept in his pocket. There was a gradual

Chapter 5 Psychology 107

but deﬁnite change. A few weeks into the study, the boy spoke for the ﬁrst time

in class. One particular essential oil, Scotch pine, seemed to help him. When his

father learned his son had spoken in class for the ﬁrst time, he asked which scent

had worked. On hearing that it was Scotch pine, his comment was, “That is just

how Sardinia smells!” The boy had never visited Sardinia. Table 5-1 indicates

some essential oils and the research carried out on them regarding their psycho-

logic effects.

Depression

Depression is one of the most widespread mental-health problems in the world

(Yarnell & Abascal 2001). It is estimated that more than 20 million Americans

suffer from depression, but only one in three seeks professional help (Papoloso &

Papoloso 1997). Although the majority of patients are treated with medication or

psychotherapy, some medications can be unacceptable because of side effects, po-

tential drug interactions, or potentially dangerous overdose (Davidson et al 1997).

Psychotherapy can be rejected as an alternative to drugs because of time, effort,

and cost. Many patients in the United States are turning to complementary

108 Section I Overview

Table 5-1 h Selected Studies on the Psychologic Effect of Essential Oils.

Basil Manly 1993

Bergamot Manly 1993

Chamomile Manly 1993

Eucalyptus Berg 1987

Citronella Saeki & Shiohara 2001

Jasmine Sugano 1992, Torii et al 1988

Lavender Kikuchi et al 1991, Kliauga et al 1995, Yamaguchi et al 1995

Lemon Sakakibara et al 1995

Lemongrass Manly 1993

Orange Baron & Thomley 1994, Mehta et al 1998

Rose Kikuchi et al 1991

Peppermint Kliauga et al 1995, Warm et al 1992

Rosemary Kubota et al 1992

Sandalwood Steiner 1994

medicine and are either self-medicating or are being treated by therapists outside

conventional medicine.

Depression can go unnoticed and sometimes be misdiagnosed as exhaustion

(Castro 1997). Depression is not always caused by emotional stress. Alcohol, sub-

stance abuse, prolonged lack of sleep, environmental pollutants, and conventional

medicines such as antibiotics or the contraceptive pill can be contributors. Sea-

sonal affective disorder (SAD) thought to be caused by lack of sunlight which

manifests in depression is particularly relevant to those living in Alaska, or other

places in the far north. Postpartum depression was thought by many to have in-

ﬂuenced the mood and behavior of Andrea Yates, who drowned her ﬁve children

(Slater 2001).

Few patients are able to articulate their feelings of depression to a physician,

and may say they feel generally unwell. A diagnosis of clinical depression is made

when ﬁve or more of the following symptoms have been present every day, or

nearly every day, for 2 weeks or more (Diagnostic and Statistical Manual of the

American Psychiatric Association–IV [DSM-IV] 1994):

• Feelings of sadness, gloom, emptiness

• General lack of interest (apathy)

• Signiﬁcant weight loss or gain or increase in appetite

• Insomnia or hypersomnia

• Physical restlessness or lack of physical motivation

• Exhaustion, not helped by sleep

• Feelings of worthlessness or excessive or inappropriate guilt

• Difﬁculty making decisions, thinking, remembering, and concentrating

• Recurrent thoughts of death or suicide without speciﬁc plan

Since March of 1998, psychologists in New Mexico have had prescriptive

powers and this is set to be repeated in several other states across the USA.There-

fore it is pertinent to mention the most commonly prescribed anti-depressant

drug in the USA, which is imipramine, a tricyclic antidepressant. Unlike essential

oils, there are considerable side effects to imipramine that include lethargy, dis-

orientation, dry mouth, weight gain, impaired concentration, and memory disori-

entation (Lieberman 1998). These symptoms alone could lead to depression.

Although most people agree that a foul-smelling odor does not enhance their

mood but a pleasant one might, there has been little scientiﬁc research to sub-

stantiate this. Yarnell and Abscal (2001) suggest essential oils should not be over-

looked in the treatment of depression because “inhaled volatile oils pass through

the olfactory nerve directly to the cerebrum.” Whereas antidepressants work by

making the neurotransmitter serotonin linger in the gaps between brain cells, es-

sential oils may work as serotonin agonists, which can push the serotonin system

into overdrive. This makes the brain more sensitive, rather like turning up the vol-

ume on a radio: Suddenly you can hear very weak stations.

Erlichmann and Bastone (1992) found that odors could produce psychologic

effects similar to mood states. Subjects were presented with pleasant and un-

pleasant odors while engaging in mood-sensitive tasks. The pleasant odors tested

Chapter 5 Psychology 109

were almond and coconut, representing food, and muguet and water lily, repre-

senting ﬂowers. The unpleasant odors were pyridine and butyric acid, represent-

ing chemicals, and limburger cheese and cigar butt, representing natural sub-

stances. Synnott (1995) discusses the meaning of smell and relates that 50% of

people who use public transportation in the United States object ﬁrst and fore-

most to wearers of heavy perfume. Crying babies came after that!

Knasko (1992) tested the effect of ambient odor of lemon, lavender, and di-

methyl sulﬁde (DSM) on the creativity, mood, and perceived health of 30 subjects

(15 women and 15 men). The test room was scented by placing ﬁve perfume blot-

ters, each containing four drops of the essential oil or four drops of DSM, in the

ceiling ducts of the room, as well as under the table and chair of the subject. On

control days, blank perfume blotters were used. During testing the room’s vents

were closed to keep the aroma in the room. Between subjects the vents were

opened and the fans run for at least 1 hour to clear the room. Before the study, 12

people rated the intensity of all 3 aromas as weak-moderate.

Subjects in the DSM group appeared to be in a less-pleasant mood after ex-

posure to the scent. Subjects in the lemon group appeared to feel healthier. There

was no demonstrated difference in creativity, but relationships emerged between

the personality of the person and the effect of the odor. The lack of impact on cre-

ativity may have been related to the weakness of the odor. Ludvigson and

Rottman (1989) found an effect from lavender and cloves on cognition, memory,

affect, and mood, but the aroma had been classiﬁed as “strong.” Warm et al (1990)

also reported a positive effect from fragrances, but they used a facemask to deliver

an intermittent scent.

Knasko (1995) found that areas diffused with a pleasant smell produced a

more positive mood in the public. One of her studies involved an exhibit at an an-

thropological museum displaying North American crafts and clothing. Three

odors—bubble gum, incense, and leather—were tested during a 3-week period,

following a ﬁrst week with no odor. A surveillance camera recorded the length of

time an individual lingered by the exhibit and exit interviews were conducted.

The visitors reported the most positive mood effect during the bubble gum week.

However, visitors in the incense week felt they had learned more from the exhibit.

Itai et al (2000) found that hiba oil reduced depression and anxiety in 14 pa-

tients receiving hemodialysis in a controlled study. Hiba oil is obtained from Thu-

jopsis dolabrata, a Japanese tree (Guenther 1976). Hamilton rating scales for de-

pression (HAMD) and anxiety (HAMA) were used. Lavender reduced anxiety

but not depression.

Studies have shown the depression levels of elderly people living in assisted-

care facilities were reduced with the aromas of fruit and ﬂowers (Schillmann &

Siebert 1991). Citrus was found to relieve depression (and improve immune func-

tion) by Komori et al (1995). A number of essential oils, including lavender, jas-

mine, rosemary, rose, and chamomile are used for treating depression. They are

primarily given as inhalants, but Valnet (1980) also suggests taking thyme and

lavender orally using between 2 to 5 drops two or three times a day.

110 Section I Overview

Research indicates that there is a link between depression and increased

deep-limbic activity when the amygdala becomes overactive (Drevets et al 1992).

Herz (2000) found most people choose to lose their sense of smell rather than any

other sense or a part of their anatomy. However, people who did lose their sense

of smell though illness or accident reported a loss of emotional richness in their

lives and tended toward depression. The link between smell and emotion is very

strong. Following bereavement, a photo may elicit sad memories, but the smell of

a loved one’s clothes is more likely to produce tears.

Depression, anger, and fear are closely related. The amygdala is the key to our

sense of fear and is thought to play a pivotal role in survival behavior. So-

matosensory stimuli have direct input into the amygdala and do not go through

the thalamus to reach the cortex. This process is unique and is thought to occur

because the olfactory cortex has only four cellular layers. Every other part of the

frontal, parietal, occipital, and temporal lobes of the brain has six layers. To facil-

itate an instant response to stimuli, the amygdala is thought to control the auto-

nomic nervous system. The main outputs of the amygdala are to the hypothala-

mus and brainstem autonomic centers. These include the vagal nuclei and the

sympathetic neurons (www.limbic.html).

Dreams

Dossey (1999) describes the divide between how dreams are perceived by West-

ern culture and by traditional cultures. Whereas orthodox medicine perceives ac-

tivity of the mind as a local event happening solely within the brain, the approach

of many other health care systems is that dreams have the ability to make people

ill or restore them to health (Severson 1979). Therefore anything that impacts

dreams and their link to our subconscious is not to be taken lightly.

Badia et al (1995) investigated the impact of odor on the sleep and dreams

of 20 undergraduate students (6 male and 14 female) using a 5-band EEG (delta,

theta, alpha, beta 1, and beta 2). Previous research had shown that stimuli pre-

sented during sleep could be detected and that the right side of the brain, specif-

ically the frontal region, was more active during rapid eye movement (REM)

sleep. REM is the period of sleep when dreams occur. (Humans may not be the

only creatures who dream; dolphins also experience REM sleep.) Test subjects

slept in a room with either ﬁltered air or one of two odors: androsterone or pep-

permint. Contrary to expectations, there was no signiﬁcant difference found in

most subjects’ EEG bands. However, there was signiﬁcantly more power in the

theta band of subjects in the room with androsterone, suggesting androsterone

was disruptive to sleep, regardless of whether the subject could smell it. However,

there was little incorporation of either aroma into the participants’ dreams.

Trotter et al (1994) introduced 16 olfactory stimuli of different kinds (rang-

ing from roses and coffee to dog feces and hand lotion) for 1 minute after sub-

jects had displayed REM sleep for a minimum of 5 minutes. There were 5 sub-

jects, and they were examined during 15 nights with 48 tests during this time.

Chapter 5 Psychology 111

The scents were incorporated into the subjects’ dreams 22% of the time. One sub-

ject described a dream of walking by some gardenias that smelled like lemons.

Hoffman (1999) investigated the effect of frankincense on dreaming. Seven

subjects, who were all women and had been recording their dreams for many

years, took part in the study. During the ﬁrst week the scientists took base-line

measurements: number of dreams, vividness, color intensity, length, clarity, and

quality. Each measurement was graded between 0 and 10 (0 the lowest, 10 the

greatest). For the next 2 weeks, the women put 2 drops of frankincense on a cot-

ton ball and placed the cotton ball underneath their pillowcases each night. Three

participants had a signiﬁcant positive change in their dream recall. Another stated

she had solved a problem that, in her waking state, she had been working on for

some time. Two others believed that their dream recall was enhanced slightly. The

remaining two at ﬁrst believed that frankincense had decreased their ability to re-

call dreams, but during the second week the quality of their dreams was en-

hanced.

Fabrici (1998) carried out a similar study using the same methodology but

used angelica (Angelica archangelica). Her four subjects were all women and were

seasoned dreamers used to recording their dreams. Each of the four women found

that angelica either stopped her dreams or interfered with them in such a way that

she did not want to continue with the study. This is a fascinating area of research

and one that has hardly been touched. As we become more aware of the subtle

messages dreams can give us, anything that can encourage the messenger is po-

tentially very valuable.

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Chapter 5 Psychology 115

116

Evidence-Based

Aromatherapy in

Nursing Practice

Nurses are the real backbone behind the care delivered within our walls and the key

to patient and physician satisfaction.

Brian Keeley, CEO of Baptist Health Systems

(in Bender J 2001)

URSES COULD be described as an endangered species because an Internet

search for “nursing shortages” produces more than 58,000 sites. Although

nurses are the largest group of health care workers in the United States—

some 2.3 million—the number of people entering the profession has dropped

drastically since managed care came into being (Box 6-1). The American Med-

ical Association estimates there will be a shortage of 114,000 registered nurses by

2015 ( Jacob 2001). One could argue that managed care has managed the care out

of nursing because care itself is not reimbursable.

Disillusioned with their choice of career, many nurses are leaving the clinical

environment and setting up practice on their own. The situation is so devastating

that the nursing shortage dominates much of the discussion surrounding health

care concerns.

Of the 2.3 million registered nurses (RNs) in the United States, 1.8 million

work in hospitals (Nevidjon & Erickson 2001). There is a direct correlation be-

tween RN’s providing patient care and better patient outcome (DeMetro 2001).

Despite this rather obvious fact, managed care continues to reduce the number of

RNs and reduce the length of a patient’s stay in the hospital so the nurses’ work-

loads become more intense and demanding. Nurses often have to work 12-hour

shifts, and overtime is frequently mandatory. Burnout is commonplace (Crow

2001). Nurses’ morale was at an all-time low in 1999 (McNeese-Smith 1999) and

remains so.

Despite this, nurses are trusted by a society who ranks them above physicians

and other health care workers (Nevidjon & Erickson 2001). Although they are

frequently referred to as angels (Short 2001), nurses remain ﬁnancially underval-

ued. The average nurse’s salary of $46,782 in 2001 had not changed in almost 10

years. However, the reason nurses no longer want to enter the profession is not

just money. It is inﬂexible, long working hours. It is looking after an increasing

number of patients so quality of care becomes compromised, and the nurse leaves

the shift feeling frustrated and angry. It is forced overtime and a poor retirement

plan. Today’s workforce has many other career choices, and they are making it

plain nursing is no longer attractive.

Many believe the growth of complementary therapies among nurses is the

result of their frustration with the limited care they can provide (Thompson

2001). Others believe nurses are simply responding to the market and giving pa-

tients what they want. Certainly complementary therapies give nurses a means of

demonstrating they care at a deep level. Many nurses combine aroma and touch,

and this mixture is proving the most popular of all complementary therapies with

patients (Reid 2001).

For many years nursing has been called a profession, but it may be more

accurate to describe it as an “emerging profession with a concept of mission

which is open to change”(Leddy & Pepper 1993). This ability to change makes

nursing an art as well as a science. There have been many changes since Florence

Nightingale’s day. The nurse’s role has become increasingly technological, with

more and more medical breakthroughs. Surgical procedures became more intri-

cate, and a ﬁeld of critical-care nursing developed. Babies survived at 22 weeks

gestation, and neonatal nursing was born. Spare-part surgery became so normal

that donor cards vie for space with our credit cards.

Chapter 6 Evidence-Based Aromatherapy in Nursing Practice 117

BOX 6-1 Nursing Shortfalls

Percentage of nurses aged 50-64: 20%

Percentage of nurses aged 30-45: 65%

Percentage of nurses aged 30 or younger: 10%

Decline in entry-level nursing enrollment each of the past 4 years: 5-7%

Estimated increase in nursing positions by 2008: 23%

Percentage of New York hospitals that reported a shortage of nurses in April

2000: 82%

Average vacancy rate for hospital nursing jobs in ﬁrst quarter of 2000: 14.7%

Average time it takes to ﬁll an RN vacancy: 3 months

Average nurse’s salary (unchanged since 1992): $46,782

Salary offered by Kaiser (one of the largest health systems) for clinic nurses

in 2001: $15.84 per hour

Sources: AMA Council on Medical Service Report “Growing Nursing Shortage in the USA.

South Florida Business Journal (http://southﬂorida.bcentral.com); California Nurses Association.

However, even with all the changes, there is an enduring conceptual frame-

work that underlies nursing. Two other words share the same Latin derivation as

the word nurse. They are nourish and nurture. Nurses have nourished and nurtured

their patients to the best of their abilities no matter what the drug regime, surgi-

cal operation, or hospital constraints. Nursing the world over shares a common

aim: to facilitate a speedy return to health (or a peaceful and digniﬁed death)

through nurturing the body and nourishing the soul.

How do nurses know how to nurse? The answer is a mixture. Much of what

nurses do is based upon experience. However, some of what they do is learned in

the classroom, and some is based on research. If one accepts (as many do) that

nursing is a calling —a vocation—there is a prevailing belief that much of what a

nurse does is “learned” intuition. How many nurses just “know” a patient will not

make it through the night? How many nurses just “know” they must go into that

room before a patient crashes or “know” a child’s temperature has just returned to

normal? These are similar to the instincts of a mother for her child. It is the nur-

turing instinct in nursing that gives it the dignity of a noble profession.

Leddy and Pepper (1993) think nurses’ “body of knowledge” is derived from

the experience of thousands of nurses who have gone before and from their own

intuition. However, in recent years, nursing theorists have developed frameworks

to explain the experience of nursing and put it in a theoretical context. Nursing

diagnosis is a method of deﬁning what nurses do and the rationale behind those

actions.

There will always be resistance to change, and there will be those who ask

where the body of knowledge was when Florence Nightingale put lavender oil on

the brows of her soldier patients. Where was her nursing diagnosis and her nurs-

ing plan? There will be others who agree with Dossey (1993) who says “a body of

knowledge that does not ﬁt with prevailing ideas can be ignored as if it does not

exist, no matter how scientiﬁcally valid it may be.”

In today’s world, nurses are being asked to deﬁne their role, so the appear-

ance of nurse academicians is apposite as they struggle to give some kind of sta-

tus to nursing. A change in status usually brings with it a change in language. This

language needs to be understood by nurses, and by others outside the ﬁeld of

nursing, so everyone can be clear as to what nurses do, why they do it, and what

they hope to achieve by doing what they do.

Some might argue this is all reductionist and mechanistic. How can the the-

ory of nursing diagnosis have validity when every patient is different? The answer

is nurses are ﬁghting for their survival and need to show a clear protocol of what

they do. This can only help the development and future of nursing, which lies in

the ability to integrate holism, nursing theory, and nursing diagnosis symbioti-

cally. Nurses need to use the science of language to reveal the true art of nursing.

Behind the scientiﬁc framework of nursing is increased discussion of the role

of holism in nursing: the art or skill of the nurse to care for the whole patient,

rather than just for the symptoms the patient is presenting. No complementary

118 Section I Overview

therapy on its own can make a nurse holistic because holism is something that

grows from within.

Aromatherapy involves smell and touch, which are basic needs. They are also

both learned memories of (hopefully) pleasurable and comforting experiences for

nurse and patient: basic needs. Clinical aromatherapy uses essential oils to target

speciﬁc outcomes that are measurable, so it gives nurses a documentable way to

nurture their patients in a truly holistic manner. Nurses can argue their case for

using essential oils with nursing theory and nursing diagnosis.

Clinical aromatherapy empowers nurses as it allows them to use the art as

well as the science of nursing. In a nutshell, aromatherapy puts some “good

scents” back into nursing and, in the process, allows nurses to feel good about

what they do. Nursing is evolving, and it is wonderful to see nurses using com-

plementary therapies as they were intended: to complement nursing.

Nursing Diagnosis*

Bulechek and McCloskey (1985) state nursing interventions are “any direct care

treatment that a nurse performs on behalf of a client.” Using this deﬁnition, all

treatments initiated by a nurse are related to nursing diagnosis. So if aromather-

apy is part of nursing, then aromatherapy would be an appropriate response to a

nursing diagnosis. Many nurses believe nursing diagnosis allows them to assess

their patients and write care plans more easily.

The development of nursing diagnosis gives focus to the specifications of

nursing needs by creating an exact language to analyze how the nurse can reach

the correct decision. Although resented by some who feel this language is just

what nursing does not need, nursing diagnosis is probably exactly what nursing

needs: a practical tool to clarify the nature, origin, and manifestations of nurs-

ing needs. Nursing diagnosis can also give validity to a complementary therapy

(like aromatherapy) within the concept of a care plan. Gordon (1982; 1990)

suggests “a nursing diagnosis is a health problem a nurse can treat but does not

mean that non-nursing consultants cannot be used. The critical element is

whether nurse-prescribed interventions can achieve the outcome established

with the client.”

The term nursing diagnosis was ﬁrst introduced in 1953 by Fry, who was at-

tempting to set a standardized language for nursing care plans. However, nurses

disliked the idea of the word diagnosis, as it was too medical. They believed

nursing had a tradition of avoiding making statements about patients. Twenty

years went by before the ﬁrst meeting of the National Group for the Classiﬁca-

tion of Nursing Diagnosis was held. Eventually, in 1990, the North American

Chapter 6 Evidence-Based Aromatherapy in Nursing Practice 119

*For this section of the book, I relied heavily on the standard textbook Nursing Diagnosis: Applications

to Clinical Practice (Carpenito 1993). Sometimes similar examples have been used, followed by paral-

lel analysis to show how aromatherapy can be part of nursing diagnosis.

Nursing Diagnosis Association approved the following deﬁnition of nursing di-

agnosis: “Nursing diagnosis is a clinical judgment about individual, family, or

community responses to actual or potential health problems/life processes. Nurs-

ing diagnosis provides the basis for selection of nursing interventions to achieve

outcomes for which the nurse is accountable” (Carpenito 1993).

It is the independent function of a professional nurse to make a nursing di-

agnosis and decide upon a course of action to be followed for the solution of the

problem (Abdellah & Levine 1965). The practice of nursing often interfaces with

the practice of other health professionals; physicians and nurses collaborate in

common areas. This can necessitate a nurse having to choose between a nursing

or medical diagnosis. Sometimes a nurse can only attend to a medical diagnosis

because of time constraint. Sometimes the nurse may decide the medical diagno-

sis is more important than her own nursing diagnosis.

Looking at the areas of nursing diagnosis, it is obvious they carry very gen-

eralized headings under which more speciﬁc headings are given. There are many

headings that could lend themselves to the use of aromatherapy. These could in-

clude the following:

Altered comfort

Anxiety

Constipation

Fatigue

Fear

Grieving

Impaired communication

Infection

Pain

Powerlessness

Spiritual distress

Carpenito (1993) includes some 120 different nursing diagnosis headings on a

general level. Very few could not be helped via aromatherapy. Nursing diagnosis

represents a situation that is the primary responsibility of the nurse. Nurses may

also indicate collaborative problems in their nursing diagnosis, which would in-

dicate that both medical and nursing interventions are required, and they can pin-

point potential complications that might be collaborative problems or straight-

forward nursing problems.

For example, a patient with pneumonia would have potential complications

within the collaborative area of septic shock, paralytic ileus, and respiratory in-

sufﬁciency. The nursing diagnosis would be as follows:

Activity intolerance due to compromised respiration, high risk of ﬂuid bal-

ance deﬁcit due to fever and hyperventilation

Ineffective airway clearance due to pain and tracheobronchial secretions

Altered comfort related to hyperthermia, malaise,and pulmonary pathology

High risk for ineffective management of therapeutic regimen

120 Section I Overview

These diagnoses would be related to nutritional needs, home-care needs, restric-

tions, signs and symptoms of complications, and follow-up care. With the speci-

ﬁcation of precise needs for nursing it is easier to see those areas where aro-

matherapy could be used. These would be in the nursing diagnosis of altered

comfort and ineffective airway clearance. I shall consider the ﬁrst of these as a

separate issue.

Nursing Diagnosis of Altered Comfort

In this case the cause of the altered comfort is listed as follows:

Hyperthermia

Malaise

Pulmonary pathology

This means anything that is going to alleviate those causes could help enhance

the comfort level of the patient. Malaise might respond to an essential oil with

calming and soothing properties such as lavender, frankincense, sandalwood,or

ylang ylang. Hyperthermia might be helped with a spritzer containing lavender

and peppermint. Chest problems and infections might respond to an essential oil

known to be bronchodilating, like eucalyptus or ravansara, which also have an-

tibacterial or antiviral properties. A nurse could use a mixture of several essential

oils to address the three problems.

Gordon (1990) developed an 11-area system for organizing the assessment

of the functional health pattern of a patient:

Activity and exercise

Coping and stress

Elimination

Health management

Nutrition and metabolism

Perception

Relationships

Self-perception

Sexuality

Sleep and rest

Values and beliefs

It is easy to see that aromatherapy could ﬁt fairly readily into most of these cate-

gories. This kind of data enables nurses to make judgments on which the nursing

diagnosis will be based. As the care plan will be based on the nursing diagnosis,

careful analysis of the outcomes is necessary. Care plans are blueprints to enable

a continuous, consistent quality of care. They contain a diagnostic statement, de-

sired-nursing-outcome criteria, nursing interventions, and an evaluation of the

outcome.

The following case studies are true and were each carried out by a nurse in a

clinical setting.

Chapter 6 Evidence-Based Aromatherapy in Nursing Practice 121

122 Section I Overview

Case Study Alteration in Comfort Level: Malaise, Herpes

Outcome Criteria

Reduction of pain of lesion

Reduction of size of lesion

Increase time between outbreaks

rs. E was a 42-year-old female with a herpetic lesion on her nasal septum.

She had a history of cold sores and genital herpes. The nurse described

an intervention using aromatherapy, and the patient gave her informed consent

to aromatherapy. The nurse offered two essential oils, Eucalyptus globulus and

tea tree. The patient liked the aroma of eucalyptus and said it reminded her of

Vicks Vapor Rub. She was patch tested using a 100% dilution of Eucalyptus

globulus on her forearm. No irritation or sensitization was observed after 24

hours.

A 25% solution of Eucalyptus globulus in aloe vera gel was given to the patient

who applied it to the lesion using a cotton swab. The patient observed there was

an initial “slight burning sensation, which felt healing” immediately after the

ﬁrst application. The application was repeated every 2 hours by the patient.

Within 2 days the lesion had decreased in size. The pustular lesion gradually

dried. The pain was reduced from an 8 to a 4 on a visual analog scale of 0-10

within 4 hours. Within 6 days the lesion had healed completely. The usual

time-frame for lesions to heal for this patient was 10 days. Following this pro-

cedure the patient reapplied eucalyptus to lesions as they occurred. Follow-up

revealed the outbreaks appeared less frequently over a period of 1 year.

Note: The clinical aromatherapy objective to alter level of comfort was mea-

sured (by visual analogue) and achieved.

Choice of Essential Oil

Eucalyptus has a well-earned reputation for being a good all-around antimicro-

bial agent. Hmamouchi et al (1990) and Saeed and Sabir (1995) found Eucalyp-

tus globulus effective against all bacteria tested, and Benouda et al (1988) found

the action to be comparable to orthodox antibiotics. Eucalyptus was also found

to help the action of conventional antibiotics (Kufferath & Mundualgo 1954).

Used topically, it has analgesic (Weyers & Brodbeck 1989) and antiinﬂamma-

tory properties (Moscolo et al 1987). It is antifungal and is effective against

Cryptococcus neoformans, a common infection in immune-compromised patients

(Viollon & Chaumont 1994). It is antitumoral as well (Takasaki et al 1995).

Aqueous extracts of eucalyptus have been found to be antiviral (Takechi et al

1985), and anecdotal evidence indicates eucalyptus essential oil is very useful in

treating herpes and shingles.

Chapter 6 Evidence-Based Aromatherapy in Nursing Practice 123

Case Study Alteration of Level of Comfort:

Malaise, Psoriasis

Outcome Criteria

Reduce itching and cracking lesions

Reduce scaliness of lesions

Improve comfort level of patient

r. A, a 51-year-old male with psoriasis, was offered aromatherapy to en-

hance comfort levels. He had classic, raised, white, scaly skin patches with

red borders. These intermittent, itchy skin lesions occurred on the skin surface

with predominance over the joints, resulting in cracked skin. Discomfort level

was a 7 on a scale of 0-10. A history of allergies and sensitivity was taken. The

patient liked the aroma of lavender. Informed consent to aromatherapy was

given. A patch test of 4% lavender was applied on the upper, inner arm. No sen-

sitivity was recorded after 24 hours. A 2% solution (2 drops lavender to 5 ml

cold-pressed vegetable oil) was applied to one lesion twice a day. As 2 days

passed, the redness, scaliness, and size of the lesion decreased, but the itching re-

mained unchanged. The lavender solution was applied to all the lesions of the

same leg. Within 7 days there was marked improvement in the size, redness, and

scaliness of the lesions to the extent that aromatherapy was discontinued on that

leg. Discomfort was now a 0 on a scale of 0-10 for those areas. The lesions on

other parts of the body that did not receive aromatherapy remained the same.

Note: The clinical aromatherapy objective to alter level of comfort was mea-

sured (by visual analogue) and achieved.

Choice of Essential Oil

Lavender is a classic essential oil for skin problems. It was used for wound

cleaning in World War I and was approved by the French Academy of Medi-

cine. As well as proven antibacterial action against many pathogenic organisms

including methicillin-resistant Staphylococcus aureus (Nelson 1997), lavender has

local-anesthetic effects (Ghelardini et al 1999) and is skin regenerative (Valnet

1990). Lavender inhibits histamine release in immediate-type allergic reactions

in mice and rats (Hyung-Min & Seong-Hoon 1999) and may be useful in aller-

gic skin problems linked to immune deﬁciency. Lavender was also found to be a

mood elevator by Corner et al (1995) and a sedative by (Elisabtsky et al 1995).

Nachi (1990) reported on the calming effects of lavender with patients under-

going magnetic resonance imaging. Saeki (2000) found lavender to be relaxing,

and Itai et al (2000) reported on the antidepressant properties of lavender with

chronic hemodialysis patients. Many patients with psoriasis (though not neces-

sarily the one in this case study) have stress-related depression, which is another

reason lavender can be beneﬁcial. Lavender also enhances the sedative effects of

conventional pharmaceuticals (Stanassova-Shopova et al 1972), and lavender is

readily absorbed through the skin ( Jager et al 1992).

124 Section I Overview

Case Study Alteration of Comfort/Chronic Low

Self-Esteem: Vaginal Yeast Infection

Outcome Criteria

Reduce discomfort

Remove vaginal yeast infection

Improve self-esteem

iss C was a 21-year-old woman with diabetes. Her blood sugar was

around 130. Her diabetes was stabilized with diet and insulin injections.

She had a recurrent vaginal yeast infection and had previously used conven-

tional antifungal drugs (Terazol and Femstat). These gave temporary relief, but

only after 5 days of treatment. She was frustrated and unable to cope with the

recurrent infections, which were impacting her self-esteem. Her discomfort was

8 on a numerical scale of 0-10. The patient inhaled the aroma of tea tree and

commented it didn’t smell wonderful, but she just wanted some relief from the

itching. Informed consent was given and a patch test of 4% tea tree oil was car-

ried out. No irritation or sensitization was observed after 24 hours. The patient

was directed to dilute tea tree to the correct solution and apply it to a tampon.

She was told to apply it vaginally three times a day, each time with a fresh solu-

tion of 2% tea tree oil (two drops of tea tree in 5 ml cold-pressed sweet almond

oil). She said after insertion the tea tree tampon felt pleasantly tingly, rather like

the effect of toothpaste while cleaning her teeth. She carried out the treatment

and reported all evidence of vaginal yeast infection disappeared after 3 days, and

on a numerical scale the discomfort was a 0. On follow-up, 6 months later the

infection had not reappeared. She felt empowered and happy to look after her

own vaginal comfort. Her level of self-esteem was enhanced.

Note: The clinical aromatherapy objective to alter level of comfort was mea-

sured (by visual analogue) and achieved.

Choice of Essential Oil

Melaleuca alternifolia (tea tree) is one of the classic aromatherapy choices for

treating infection and is safe to use vaginally (Northrupp 1995). Tea tree is use-

ful for either bacterial infections such as abscesses, acne (Carson & Riley 1994),

or fungal infections including athlete’s foot, tinea (Tong et al 1992), impetigo or

viral infections such as cold sores and herpes (Hammer et al 1996). Pena (1962)

showed its effectiveness for yeast infection, trichomoniasis, and anaerobic infec-

tions (Blackwell 1991). For vaginal infection, dilute the essential oil in a cold-

pressed vegetable oil (for example sweet almond) and apply on a tampon. Mix

two drops of tea tree in one teaspoonful of carrier oil. Roll a tampon in the

mixture and insert into vagina. Repeat with fresh tampon every 4 hours and

leave in overnight. Relief should occur within 3 days. Vaginal thrush is unlikely

to reoccur (Buckle 2001).

Chapter 6 Evidence-Based Aromatherapy in Nursing Practice 125

The next case study discusses using aromatherapy during extubation (the

process of removing an endotracheal tube when a patient is capable of breathing

without artiﬁcial help). This is a common task within the remit of an intensive-

care nurse. Yang & Tobin (1991) state there is “no one method of weaning

which has clear superiority.” However, weaning requires patient physical and

psychological preparedness (Logan & Jenny 1990). Extubation is a skilled nurs-

ing maneuver because patients must be alert enough to breathe on their own,

but not so alert that the endotracheal tube is causing distress and they are ﬁght-

ing the ventilator.

Case Study Dysfunctional Ventilatory Weaning Response

Outcome Criteria

Achieve weaning goals

Remain extubated

Not be exhausted by the process of weaning

he nursing intervention consisted of the following.

Determined readiness for weaning

Asked if patient liked the smell of an essential oil such as lavender

Asked for permission to touch the patient

Explained the weaning process and demonstrated hand “m” technique using

lavender

Explained patient’s role in the process of weaning

Enhanced patient’s feelings of self-esteem through encouragement

Promoted trust through conversation and touch

Reduced negative effects of anxiety and fatigue through the use of aro-

matherapy

Created a positive environment with aromatherapy

Optimized comfort status through aromatherapy

Please see patient’s chart, Fig 6-1. The arrow indicates when the “m” technique

was used with 2% lavender.

126 Section I Overview

GRAPHIC TRENDS

100

125

150

100

125

bpm

150

07:58

29 Apr

Patient Name:

Bed Number: 166

Care Unit:

....

Aromatherapy was

applied topically here.

Date Printed: 29 Apr 1994

Time Printed: 16:01

Page: 1 of 1

09:58 11:58

(extubation)

13:58 15:58

29 Apr

Figure 6-1 Patient’s chart showing decrease in pulse when aromatherapy applied topically. (Courtesy Lori Mitchell)

Chapter 6 Evidence-Based Aromatherapy in Nursing Practice 127

Case Study Alterations of Comfort Level: Chronic Pain

Outcome Criteria

Relax patient

Reduce perception of pain

rs. G was a 74-year-old woman with cancer and bone metastases. She

was in severe pain (8 on the numeric pain intensity scale) despite having

a patient-controlled analgesia of morphine. She was unable to ﬁnd a comfort-

able position in bed and became withdrawn and depressed. Her muscles became

tight from attempting to “hold” her pain. Two drops of rose essential oil were

applied to a cotton hankie that was pinned on the patient’s nightgown. The af-

fect was almost instant: the patient took some deep breaths, opened her

clenched ﬁsts, and smiled for the ﬁrst time in many weeks. This treatment was

repeated every 4 hours, and an electronic diffuser was used at night. The aroma

of the garden appeared to alter the patient’s perception of pain, reducing it to a

3 on the pain scale, and although the terminal nature of her disease was not af-

fected, the quality of her life appeared to be considerably improved.

Note: The clinical aromatherapy objective to alter level of comfort was mea-

sured (by visual analogue) and achieved.

Choice of Essential Oil

Rosa damascena (rose) is the most popular and acceptable aroma in the world,

recognized by almost every culture and religion. Bulgarian research indicates

rose oil reduces hypertension (Kirov & Bainova 1988) and counteracts the ef-

fects of isoprenaline (Brud & Szydlowska 1991). This agrees with the histori-

cally held belief that rose strengthens and calms the heart (Lawless 1995). Rose

is also an antispasmodic and a mild sedative. It has antidepressant properties (as

anyone who has sat for a while in a rose garden can afﬁrm). A Russian study on

Rosalin (an ointment containing rose) showed the ointment had good antibac-

terial properties. This was presumably why Nostradamus used it to protect him-

self against the plague. Further studies indicate rose essential oil has an in-

hibitory effect on Helicobacter pylori (Boyanova & Neshev 1999). Rose has also

recently shown antiviral and antiHIV activity (Mahmood et al 1996).

Rose essential oil is useful to soothe radiodermatitis and is generally helpful to

all irritated skin. It is very important to use Rose otto (steam distilled) not Rose

absolute (extracted with petrochemicals) and to be sure to use pure rose oil.

Rose essential oil is expensive (between $1 and $2 per drop), but it is still less

expensive than conventional antidepressants as only a few drops are used at a

time.

128 Section I Overview

Case Study Spiritual Distress

Outcome Criteria

Continue spiritual practices as the patient knows them

Allow patient to express decreasing feelings of guilt and anxiety

Allow patient to express satisfaction with one’s spiritual condition

rs. H was an 85-year-old woman with depression. Many of her friends

were dead, and she lived a long way from her family who did not visit her

often. She did not sleep well and was prone to hyperventilation and palpita-

tions. She loved the smell of roses, which reminded her of a rose garden she

tended with her husband when he was alive. Informed consent was given. Two

drops of rose oil were inhaled on a facial tissue four times a day. In addition,

two drops of rose were added to a cotton ball placed under her pillowcase.

Within 1 week she was smiling, sleeping better, and discussing how she could

become involved with looking after the houseplants in the facility. Staff noted

she no longer hyperventilated and that she stopped complaining of palpitations.

The nursing intervention consisted of the following:

Provide privacy and quiet

Be open to the patient’s needs for spiritual peace

Contact the patient’s spiritual leader when required

Suggest aromatherapy might enhance the patient’s ability to meditate, pray,

or induce a state of peacefulness

Introduce the essential oils Boswellia carteri (frankincense) and Rosa damas-

cena (Rose)

Discuss the effects of both aromas

All people have a spiritual dimension, whether they choose to accept it or not

(Dickinson 1975). Spirituality is often at the core of a person’s distress, yet most

people ﬁnd spirituality the most difﬁcult subject about which to communicate.

During acute and chronic disease, many patients turn to their faith, lose their

faith, or seek a faith where there has been none previously. Despite this, nurses

commonly avoid addressing the spiritual dimension of a patient. Martin et al

(1978) suggest the spiritual part of nursing involves “being with” the patient

rather than “doing to” the patient. Stiles draws attention to the nurse-family

spiritual relationship in cancer care (Stiles 1990).

Aromatherapy allows nurses to “be with” their patients, even while they

may be “doing to,” in an intimate but professional way that nurtures the rela-

tionship between the nurse and the patient. This often allows a window of inner

reﬂection in which spiritual feelings (or needs) are verbalized. During my edu-

cation as a nurse, and subsequent to it, I noticed few patients are brought up the

subject of spiritual matters. Yet since I have been using aromatherapy, this sensi-

tive area has arisen time and time again, almost as though the aromas them-

selves provide an atmosphere of acceptance.

Conclusions

A few case studies have been presented above as a brief argument to support the

use of aromatherapy as an enhancement to nursing care. Nurses already use many

over-the-counter products not prescribed by a physician, such as scented soaps

and hair spray. Nurses also use synthetic sprays to mask human smells, and many

of the synthetic aromas in these sprays have not been tested for long-term effect

on patients. The time has come to think about what aromatherapy could mean in

nursing terms: how it could enhance what nurses do and how it could enhance

their job satisfaction.

One of my students said, “Aromatherapy has really changed my life; now I

notice what smells good and what doesn’t.” She went on to say, “So much in life

smells bad, doesn’t it? I wonder if that is because we have made a nonsense of na-

ture.”

We are making a nonsense of nursing care if we do not allow nurses the free-

dom to make their patients feel as comfortable as possible. What better way than

through gentle touch and the use of natural aromatics that are already part of

everyday life? Even before palliative care became an accepted specialty within

nursing, nurses still carried out palliative care. Then it became recognized as a dis-

tinctive and very caring form of health care. Before the ﬁrst heart transplant, peo-

ple thought heart transplants were not possible. Now there are countless books on

surgery and cardiac nursing. Nursing as a profession is evolving as world percep-

tion changes. Nurses are already using aromatherapy in many parts of the world.

They are using it because it has validity, whether one’s view of nursing care is in-

tuitive, derived through nursing diagnosis, or derived from conceptual nursing

frameworks and theories.

Chapter 6 Evidence-Based Aromatherapy in Nursing Practice 129

Dossey (1993) writes about the need for thought to be accepted as being as

genuine as any drug or surgical procedure. The thoughts generated by gentle

touch and pleasing smell have a powerful effect on our psyche and on our spiri-

tuality. It is not only what nurses do for patients, but also their good intentions

to “be with” them that can aid the healing process. Nursing has a curative po-

tential. Despite the fact that 15% of nurses feel they are not prepared to provide

spiritual care (Stiles 1990), they can provide spiritual support just by being

there. Aromatherapy gives nurses permission to be there. A leading Buddhist

teacher wrote about his own experience with his dying father, and his words are

very indicative of what nurses do as part of nursing care. “There wasn’t much to

say. I held his hand. He was frightened. He didn’t want to know about medi-

cine. He didn’t even want to talk. What mattered was that I sat there, not being

afraid, not rejecting his fear and his pain, simply by holding his hand. He died

after several more days” (Kornﬁeld 2000).

How Aromatherapy Could be Used in Hospitals

There are many potential uses for aromatherapy in hospitals. They range from the

simple mood-enhancing effects of smelling something pleasant to the speciﬁc ap-

plication of an antiseptic essential oil to combat cross-infections. At present most

hospitals do not smell nice, and science has shown how we feel affects how we

are. If it is possible to alter our environment to make it supportive in times of

need, surely this is something to be taken seriously.

Steele (1993) tested volunteers using an electroencephalogram to demon-

strate changes following the inhalation of certain essential oils. He discovered

changes in brain rhythms occurred within 15 seconds, and a positive change in

mood took approximately the same length of time.

Patients undergoing radiotherapy or computer-assisted tomography scans are

isolated in a room during treatment and have to lie absolutely still for lengthy pe-

riods of time. Many ﬁnd this experience stressful. A soothing, relaxing essential

oil such as lavender (Lavandula angustifolia), vetiver (Vetiveria zizanoides), or

bergamot (Citrus bergamia) might help them. Balacs (1991) reports on research

that showed 60% of patients exposed to a sweet, vanilla-like fragrance (he-

liotropin) experienced less anxiety than the control group.

Emergency rooms receive victims of trafﬁc accidents, burns, and poisoning

for whom immediate action is needed. Frequently relatives ﬁnd it difﬁcult to stay

calm enough to explain exactly what happened, and medical professionals ﬁnd it

hard to maintain patience, knowing that every second is vital but needing precise

information. By combining an antiseptic essential oil with a calming one, the en-

vironment is immediately made more reassuring and more hospitable.

Wards for long-term care often have unattractive smells: a mixture of incon-

tinent patients, hospital food, and lavatory cleaner. Helen Passant, a nurse, man-

aged to change that situation in an Oxford, England hospital when she intro-

duced the use of aromatherapy. Her elderly patients responded to the use of touch

and massage, becoming “alive” again: a situation reminiscent of the ﬁlm Begin-

nings. The aromas evoked memories, and the patients began to talk about their

lives and communicate their feelings. No longer isolated men and women wait-

ing to die, the patients became an active group: talking, then singing, then danc-

ing. In addition, the ward’s drug bill was reduced by a third. The hospital re-

warded her by reducing her budget by a third!

Many operating theatres have closed air conditioning. This means the same

air is ventilated constantly. It is much less expensive than open air conditioning,

which sucks in a constant stream of new air, warms (or cools) and ﬁlters it, then

vents it back into the outside environment. Research has been carried out on air-

borne infections and on the prevalence of postoperative wound infections. Cruse

(1980) found sufﬁcient data to indicate postoperative wound infections, from pre-

operatively clean wounds, are directly related with the length of operating time.

Diffused essential oils with good antibacterial and antiviral properties may reduce

130 Section I Overview

the cost of the additional days incurred for in-patients and for those with noso-

comial (hospital-acquired) wound infections.

Some enlightened hospitals are using antibacterial essential oils in their op-

erating rooms, with the added bonus of preventing cross-infection among med-

ical staff. Each operating room has speciﬁc bacteria and viruses that are most

prevalent, so a customized cocktail of several essential oils is employed. Use of a

pleasant and uplifting essential oil, such as pine (Pinus sylvestris) or lemon (Cit-

rus limonum) can also improve the concentration of operating staff at night.

The use of aromatherapy in hospitals in England, South Africa, Switzerland,

and, more recently, in the United States shows a progressive trend toward sup-

porting patients on a more holistic basis. Physicians and hospital managers are

becoming aware that how patients feel can affect the way they respond to treat-

ment, and therefore how quickly they recover.

Planetree Hospitals Inc. is an American group of hospitals whose staff strive

to put the patient and the patient’s comfort ﬁrst. It had a humble beginning in

1978; Angelica Thieriot found the routine medical treatment she received in the

late 1970s so dehumanizing she made it her mission to develop a new model of

patient-centered care.The concept of Planetree spread nationwide, and now there

are more than 40 similar hospitals and facilities throughout the United States. Pa-

tients are encouraged to take an active part in making decisions about their fu-

ture, and this begins with open medical records. Patients are also invited to have

a gentle massage prior to surgery and to ask their family and friends to bring in

their favorite food to prepare. There is a kitchen on every ﬂoor. Gentle music ﬁlls

the reception area, and nothing is too much trouble for the patient. It is no sur-

prise patients and staff gravitate toward Planetree!

Aromatherapy is a complementary therapy much accepted by the Planetree

philosophy. Desert Samaritan Hospital in Mesa, Arizona, is one of the ﬁrst Plan-

etree hospitals to have sponsored nurses not just through an 18-month clinical

aromatherapy training program but to become paid instructors themselves.

Touch is known to have a dramatic effect on patients, and yet patients lying

in a hospital bed are rarely touched, except for diagnostic (palpation) or proce-

dural reasons (changing a dressing, blood-pressure recording). One method gain-

ing popularity among nurses is the “m” technique. This method of touch is de-

scribed more fully in Chapter 8 and quickly acknowledges a patient’s worth as an

individual. A foot or hand “m” takes only 5 minutes, but that time can totally

change the way patients perceive the environment around them. Touch has also

been shown to reduce blood pressure, reduce lower back pain, relieve anxiety, and

alleviate depression (Montagu 1986).

Aromatherapy using touch and smell could be a complete hospital stress-

management package, producing a happier and more content workforce with

more secure and less anxious patients. The level of interest in aromatherapy

shown by patients and nurses suggests an overwhelming desire for such integra-

tion.

Chapter 6 Evidence-Based Aromatherapy in Nursing Practice 131

Hospitals are being run like businesses. Therefore, the cost beneﬁts of using

essential oils to promote healing need to be addressed, and I hope this book will

go some way toward that. There are a few ethical questions. What about consent?

Is it ethical to manipulate mood? What about a patient who does not like the aro-

mas? Yet how many patients sign a consent form approving the smell of antisep-

tics or air fresheners? How many nurses enter their place of work having used

scented soap, hair spray, or aftershave? How many patients are allergic or sensi-

tive to Lysol or other cleaning ﬂuids used in hospitals? It is difﬁcult to have one

set of rules for aromatherapy if there are no rules governing other types of scent.

Another area of concern is the potential use of synthetic or adulterated es-

sential oils that result in poor or negative results. It cannot be emphasized

strongly enough that it is the quality of the essential oil that will determine the

ﬁnal result. Essential oils need to be judged like good wine. Good wine is expen-

sive, and so are the best essential oils.

Perhaps one of the greatest concerns about using aromatherapy in hospitals

is incorrect use due to ignorance. Contrary to media hype, aromatherapy is not

the panacea for everything, a kind of “comfort-blanket” smell. Of equal impor-

tance is the quality of accompanying touch. A heavy, compressing, rapid stroke

will not produce the same effect as a light, slow, gentle one. The techniques used

in aromatherapy cannot be learned solely from a book; they need to be experi-

enced.

There is an urgent need for adequate training, and reading a book is not

enough. As well as learning the “m” technique, the use of essential oils in aro-

matherapy requires knowledge and experience. A simple name like lavender cov-

ers three completely different species, each with entirely different therapeutic ef-

fects. Lavandula angustifolia is a sedative, Lavandula latifolia is an expectorant,

and Lavandula stoechas is effective against Pseudomonas aeruginosa. For Nurse

Practice Acts please see www.rjbuckle.com or www.ahna.com.

Consider the following. A patient likes the smell of lemongrass and needs an

essential oil with sedative effects. The patient feels isolated. A daily foot “m” tech-

nique is chosen and added to the care plan. The patient also has a fungal infec-

tion that appears to lessen following a number of foot massages with lemongrass.

Although lemongrass had not been used ostensibly for its antifungal properties,

it cannot stop itself from being antifungal. But what if a health professional with-

out prescriptive powers had known about the antifungal properties and had cho-

sen lemongrass primarily because of them? Would he or she have crossed the

boundaries? The International Council of Nurses states that nurses’ “fundamen-

tal responsibility is to conserve life, to alleviate suffering and to promote health.”

Using aromatherapy in this way could be seen to be alleviating suffering. How-

ever if the targeted outcome of an essential oil is changed to one outside the ju-

risdiction of the provider, a different protocol might be required.

Appendix VI is a list of hospitals using aromatherapy or having sponsored

nurse’s training in aromatherapy.

132 Section I Overview

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Chapter 6 Evidence-Based Aromatherapy in Nursing Practice 135

136

Oral and Internal Use

of Aromatherapy*

Science and myth are one; the natural world is but a manifestation of thoughts and

impulses all occurring on endless metaphysical planes, all enveloped by the mind of

the healer.

Wade Davis

One River

HE TOPIC of oral and internal use of essential oils is controversial and con-

fusing. Much of the confusion is due to lack of knowledge and cultural

misconceptions because the oral and internal uses of essential oils are not

taught in most aromatherapy training programs in the United States or United

Kingdom.

There are three probable reasons for this omission.

1. Many training programs are intended for the lay public, not licensed

health professionals (LHPs).

2. Most adverse interactions with conventional medications are associated

with the oral use of essential oils.

3. There is a fear that oral use of essential oils may lead to poisoning.

However, this book is intended for LHPs who may wish (or need) to know

about the oral and internal use of essential oils so they can decide for themselves.

Ultimately, LHPs will need to decide if giving essential oils either orally or inter-

nally is within their license. The views in this chapter are mine, and this chapter

is intended to open a dialogue not provide an answer.

*I am greatly indebted to the aromatic medicine courses I took with Penoel, Franchomme, Schnaubelt,

Price, Harris, and Guba for this section. It is strongly recommended that the reader undertake a pro-

fessional course in aromatic medicine before using essential oils orally or in high concentrations, as

these methods are not covered in most aromatherapy courses.

The sale and use of essential oils, much like herbal remedies, is not controlled

in the United States (or England or France). Essential oils can be purchased by

anyone and used in any way. If, however, LHPs are using essential oils to enhance

care, they will need to decide if this use ﬁts within the parameters of their licenses.

Broadly speaking, LHPs can be divided into those who have prescriptive

powers and those who do not. Those who have prescriptive license may feel more

comfortable using the oral route of aromatherapy than those who do not. This

does not mean only those who have prescriptive license may use the oral route,

only that they may feel more comfortable doing so. Whatever the kind of license

a health professional has, he or she has accountability. Therefore the treatment of-

fered should be based on training received.

There are several anomalies in the practice of aromatherapy in the United

States (and England). The ﬁrst is over-the-counter herbal remedies and essential

oils are freely available, and many people self-medicate.

The second anomaly is that although aromatherapy uses different methods:

topical, inhalation, and oral, two major organizations in the United Kingdom

voted against the oral use of essential oils. This is important as the United States

has tended to look to the United Kingdom for aromatherapy guidelines. The

Aromatherapy Registration Council (AOC), the lead aromatherapy body in

the United Kingdom, stated the oral use of essential oils was not acceptable. The

Royal College of Nursing (RCN) in London (which decides what a nurse may

practice) also stated the oral use of essential oils lay outside the boundaries of

nursing care. The AOC may well have based its decision on the fact that the ma-

jority of aromatherapy practitioners in the United Kingdom are lay people. The

RCN may have made its decision because using the oral route of aromatherapy is

comparable to taking medicine, and nurses are not allowed to give medicines

without a prescription.

The third anomaly is the majority of aromatherapy courses focus on esthet-

ics or stress, where internal and oral methods would not be relevant. So the idea

has permeated the aromatherapy community that the oral route of essential oils

is somehow out of bounds. This is understandable, but it has never been formally

challenged or accepted. However, courses that are clinically oriented and intended

for LHPs need to address the oral and internal use of aromatherapy because these

methods could be very relevant.

The fourth anomaly is confusion between oral and internal use. The two

words are not synonymous. One includes the digestive process and the other does

not. The oral process involves taking essential oils by mouth, either in capsules or

diluted and swallowed. Very small amounts of essential oils are used in foods and

candy, such as peppermint and wintergreen, therefore thousands of people take

essential oils orally every day. The internal use of essential oils includes putting

them into any oriﬁce: mouth, ear, nose, anus, or vagina. However, in this case, the

essential oil is not swallowed. A clear example of this is a mouthwash. Several

proprietary mouthwashes state on their labels “do not swallow.” Clearly there is

an established, recognizable difference between oral and internal use. Ear drops,

Chapter 7 Oral and Internal Use of Aromatherapy 137

nasal irrigation, and vaginal douches and creams can be applied to the internal

skin of the body and absorbed that way. They are not digested. However, all

routes, including the rectal one, are excellent ways of getting oils into the system

while bypassing the liver (Schnaubelt 1998). Several products that utilize the in-

ternal skin and include essential oils are available at drug stores and health-food

stores.

The ﬁfth anomaly is the dilution or the amount of essential oil used. The

standard dilution for topically applied essential oils taught in aromatherapy train-

ing is between 1% and 5%. This is suitable for stress management and esthetics

and may be very effective for some clinical conditions. However in the case of an

infection, considerably higher percentages might be required. Some over-the-

counter remedies contain high percentages of essential oil components. For ex-

ample, Bengay analgesic cream contains 15% methyl salicylate (found in winter-

green) and 10% menthol (found in peppermint). Higher percentages, and in some

cases, undiluted essential oils may be required to treat chronic or acute infection.

The original concept of prescription medicine was to protect the public from

themselves. An extension of the Hippocratic oath, “ﬁrst do no harm” is “keep

them from harming themselves,” which includes instructions for safe use. For

aromatherapy, this would mean knowing the maximum amount of essential oil

that could be used safely.

The sixth anomaly is in other parts of the world, where aromatherapy is not

regulated, essential oils are frequently given orally by licensed and nonlicensed

practitioners.

The seventh anomaly is the size of a drop of an essential oil can vary consid-

erably. Much depends on whether the dropper is an integral one or a pipette. The

integral droppers produce approximately 20 drops per milliliter. The pipettes pro-

duce closer to 40 drops per milliliter. This becomes very important when the

maximum amount for a particular essential oil is measured in drops per day.

The Oral Route

There is a long history in the United States of nurses and physicians giving es-

sential oils orally to their patients prior to the advent of modern pharmaceuticals.

Several essential oils such as cinnamon, clove, peppermint, sandalwood, and eu-

calyptus are actually listed in the 8th edition of Useful Drugs, a handbook pub-

lished by the American Medical Association in 1930. Sandalwood was classically

given for urinary infections. The majority of animal studies on this oil have in-

cluded the oral route, and there is a great deal of information on toxicity.

One of the main reasons for using the oral method at all is to treat the in-

testinal tract, as almost every other system can be reached by the topical or in-

haled route. The oral method is perfectly safe and nontoxic, provided the giver is

trained in this method and appropriate dosages are not exceeded. However, not

all essential oils are safe to use orally. Burﬁeld (2000) cautions that certain essen-

tial oils such as hyssop, wormwood, and wintergreen should never be taken orally.

138 Section I Overview

Essential oils that are high in phenols should be diluted and contained in gelatin

capsules to avoid mucous irritation when administered orally.

Most insurance companies that cover aromatherapy exclude the oral use of

essential oils. However this route is a valid option, and there are several excellent

training courses available. I believe the fear of using essential oils orally is really

based on a lack of knowledge. Again, as always, education is the key. As essential

oils are very concentrated, doses are usually described in the number of drops

given. However, drop sizes vary (Olleveant et al 1999). Therefore it is more accu-

rate (and safer) to measure the amount of essential oil used in milliliters. Brinker

(2000), a naturopath, suggests the safe range for oral use is 0.5-1.0 ml/day, al-

though cautions apply for amounts greater than 0.5ml/day.

Method of Oral Use

Essential oils can be given orally in gelatin capsules, disper, activated charcoal, or

Vitamin C tablets. Some essential oils can be taken in honey for occasional use,

but not all therapists recommend this method. However some alcohol-rich es-

sential oils (such as palma-rosa) in honey can be excellent for a sore throat.

Gelatin Capsules

Size 00 capsules are ﬁlled with an essential oil or oils diluted in a vegetable oil.

The solution is made up ﬁrst (up to 20% strength), then poured into the capsules

and the capsules are taken like ordinary medicines. Each capsule holds approxi-

mately 0.75 ml. The process of ﬁlling the capsules is time consuming, but this is

an excellent way to treat the small and large intestine. Guba (2002) suggests clove

bud and cinnamon oil for diarrhea and recommends 12 drops per day of each.

However, the Australian drop size may be smaller than the US drop size, so closer

to six drops per day of each may be all that is required.

Disper

Disper is a lecithin-based emulsiﬁer that holds the essential oils in a stable dis-

persion. This emulsiﬁer is rapidly absorbed by the stomach and is therefore use-

ful for acute and chronic infections. Disper can be combined with herbal tinctures

and is available from several aromatherapy supply companies. The recommended

proportion is one part essential oils to nine parts disper. If 1 ml of essential oil

(containing 20 US drops or 40 French drops) is added to 9 ml of disper, there will

be approximately 200 drops. Ten drops of the mixture will contain two drops of

essential oil. The disper mixture is then diluted in water and drunk. The taste will

depend on the essential oil but should not be too bitter or overwhelming. This

method is very simple to use.

Activated-Charcoal Tablets

Activated-charcoal tablets are available in many health-food stores. Two hundred-

milligram charcoal tablets are useful as a simple, effective base for carrying essen-

tial oils to the gastrointestinal tract. Each tablet will hold different amounts of an

Chapter 7 Oral and Internal Use of Aromatherapy 139

essential oil. Some essential oils dissolve the binders that hold the tablet together

so tablets should not be premixed. Charcoal tablets are not recommended for

long-term use as they can be constipating, but they can be useful for short-term

use of up to 1 week.

Vitamin C Lozenges

Guba (2002) suggests Vitamin C lozenges are also a good way of introducing an

essential oil orally. Place a few drops of the essential oil on the lozenge and wait

until it is absorbed. The lozenge can then be chewed and swallowed with water.

Honey

Essential oils can be blended with honey water. Mix the drops of essential oil in

a teaspoon of honey, add warm water, and drink. Rose is an excellent antiviral oil

to use in this way.

Enteric-Coated Gelatin Capsules

Enteric-coated gelatin capsules do not release the essential oil until they are in the

small intestine (an environment of pH 6.8 or higher). This can be useful for irri-

table bowel syndrome.

Human Studies on Oral or Internal Use

Kline et al (2001) used enteric-coated gelatin capsules containing peppermint oil

in the treatment of irritable bowel syndrome symptoms. Fifty children took part

in a controlled, multicentered study. Between one capsule (187 mg) and two cap-

sules was given three times a day. During the study eight children withdrew for

various reasons. However, 76% of the peppermint group showed signiﬁcant re-

duction in symptoms compared to the placebo group (43%). No side effects were

reported, and there was no change in stool consistency.

Gravett (2001) prescribed a mixture of essential oils in honey water for pa-

tients with nausea, colicky pain, anorexia, and diarrhea who were undergoing

high-dose chemotherapy and stem-cell rescue. Eight patients took part in the

study. They took a daily dose of 15 drops of geranium, 10 drops of German

chamomile, 10 drops of patchouli, and 10 drops of turmeric (infused oil) in

honey water. The mixture was divided into three batches and taken orally at

equal intervals throughout the day. His patients had no ill effects from the es-

sential oils and felt better than members of the control group, who were using

conventional antiemetics. The cost of the aromatherapy treatment (28 pence ⫽

40 cents) was substantially less than the conventional treatment (138 pence ⫽

almost $2).

Belaiche (1985) carried out a double-blind study to examine the effectiveness

of Melaleuca alternifolia (tea tree) in the treatment of chronic cystitis. There were

26 participants in the study. The experimental group was given 24 mg of tea tree

divided into three doses of 8 mg each in enteric-coated gelatin capsules. The con-

trol group was given a placebo that had the odor of tea tree. After 6 months no

140 Section I Overview

one in the control group showed any improvement, but 7 of the 13 women in the

experimental group were completely cured (60%). During the 6 months of test-

ing, liver functions also were monitored. There were no liver problems, and no

side effects to the treatment.

Holmes (1995) describes a case study of a 23-month-old girl he treated for

cellulitis from an infected bite and a concurrent upper-respiratory viral infection

(tonsillitis). One drop each of tea tree, lavender, and calendula oils were added to

a small feeding bottle containing fruit juice, and the mixture was given to the

child to take orally, three times a day. The child also received a 20% solution of

lavender, Moroccan blue chamomile (Tanacetum annum), and calendula as a top-

ical treatment applied directly to the bite up to six times a day, as well as a 10%

dilution of tea tree, lavender, and calendula oils massaged into the chest and back

each morning and night. The fever subsided after the ﬁrst day, and 4 days later

the cellulitis and tonsillitis were gone. It is difﬁcult to extrapolate whether the oral

method would have worked on its own.

Suppositories

A suppository is another method of using essential oils not taught in many aro-

matherapy classes, but it has a place in clinical training. This internal method is

simple to use and very effective for treating many different systemic conditions.

The usual concentrations are 10% essential oil per suppository. This works

out to approximately 300 mg of essential oil per 3-g suppository. For children, one

drop of essential oil in a 25-mg suppository is appropriate. While molds are avail-

able, the standard 00-size gelatin capsule is just as effective. However, diluting the

essential oil in vegetable oil may result in leakage, so use cocoa butter, which is

solid but dissolves at body temperature. Melt the cocoa butter, mix in the essen-

tial oils, then ﬁll the suppository mold. Store in refrigerator. Avoid using only

phenol-rich essential oils in rectal suppositories as this would produce irritation

as the suppository dissolves.

De la Motte et al (1997) used German chamomile in the form of an enema

and/or suppository to control noncomplicated diarrhea in children. Other essen-

tial oils that could have been used to control diarrhea are geranium and turmeric.

Geranium was shown to have antidiarrhea properties in animal studies (Ofuji et

al 1998), and turmeric was found to alleviate upper-abdominal pain due to biliary

dysfunction (Niederau & Opfert 1999). The rectal route is particularly suitable

for children, for those with gastric ulcers or gastritis, or when essential oils are not

tolerated via the oral route.

Licenses, Prescriptions, and Essential Oils

A dilemma may occur when oral or internal essential oils are used by an LHP

who does not have prescriptive privileges. I think nurses should know about the

oral uses of essential oils, but when they are practicing with their nursing license,

Chapter 7 Oral and Internal Use of Aromatherapy 141

the oral route should be avoided. This was made clear when the Massachusetts

Board of Nursing voted to accept aromatherapy as part of nursing care but did

not include herbal remedies, as herbal medicines are taken orally. However, nurse

practitioners, physicians, and others with diagnostic skills and prescriptive privi-

leges may wish to learn to use essential oils in this way and use them to great ef-

fect. In some states, if a lay person was to “prescribe” an essential oil to another

person, he or she could be accused of practicing medicine without a license.

Conventional medicine is not accustomed to a single medicine having sev-

eral different therapeutic effects. But essential oils clearly do have several differ-

ent therapeutic effects. They have multiple medicinal properties, but they also

give pleasure and help people relax. The Webster’s Dictionary deﬁnition of a med-

icine is “any substance used in the treatment of disease.” The word medicinal is de-

ﬁned by the Oxford Dictionary as “something having healing properties.” Accord-

ing to several studies, prayer has a healing effect. Does this mean only a doctor

can pray? Does it mean when a rotation diet works, it is medicine and therefore

should be prescribed by a physician only? The idea is clearly absurd. Yet there is

something similar, but in reverse, happening in aromatherapy. To give an exam-

ple: when an essential oil is used for relaxation, it is not a medicine, but if that es-

sential oil is used for its antibiotic effect, it is a medicine. How could lavender be

a medicine (effective against methicillin-resistant Staphylococcus aureus) one mo-

ment and not a medicine (soothing and relaxing) the next? Does this mean a

medicine only becomes one when the giver intends it to be one?

There is growing interest and acceptance within conventional medicine for

the supplementary role of herbs in clinical practice, and some excellent studies

have been published on their efﬁcacy. The potential for interdrug reactions and

toxicity issues is very small compared to the hundreds of thousands of deaths from

conventional drugs or drug interaction each year. In some instances essential oils

can actually enhance conventional medicines (particularly those for infection).

This will become very advantageous as more pathogens become resistant to or-

thodox antibiotics.

It is extremely unlikely that essential oils will only be available by prescrip-

tion. However, if this did occur, it would be relevant not only to physicians but

also to the growing number of nonphysician clinicians (NPCs) who have pre-

scriptive license. The next part of this section explores this option. Many of these

nonphysican clinicians are referred to as doctors or physicians by state regulation

or custom and are listed as such on many insurance forms. Cooper et al (1998)

divides the nonphysician group into three sections. See Table 7-1 for details.

For many years, physicians held a monopoly as the main providers of health

care (Cooper et al 1998). However, changes in state laws and regulations com-

bined with an increase in the numbers of practitioners in training means the

number of nonphysician clinicians is growing rapidly. As a consequence of

this growth, several NPC disciplines will soon be as large as the major specialties

in medicine (Cooper et al 1998). In 2005, it is estimated the number of NPCs in

clinical practice will be equal to the number of family physicians (Weiner 1994).

142 Section I Overview

A great number of NPC practices are involved with wellness clinics and the

treatment of uncomplicated acute and chronic conditions. These types of condi-

tions make up 50%-75% of ofﬁce visits to primary-care physicians. Cooper et al

(1998) made projections as to the way each discipline would expand in 5 years.

See Table 7-2 for their estimates on the number of graduates in NPC disciplines.

NPCS are growing in popularity with the public, which perceives them as

providing a more caring service than conventional physicians, with more time to

listen to and be with their patients (Guglielmo 2001). According to the Ameri-

can Academy of Nurse Practitioners, more than 25% of NPs work in doctor-run,

Chapter 7 Oral and Internal Use of Aromatherapy 143

Table 7-1 h Types of Nonphysician Clinicians in the United States

Alternative

Conventional Medicine Practitioners Specialty Groups

Nurse practitioners (NPs) Chiropractors Optometrists

Certiﬁed nurse midwives Acupuncturists Podiatrists

(CNMs)

Physician assistants (PAs) Naturopaths Clinical nurse specialists

(CNRs)

Medical herbalists Certiﬁed registered nurse

anesthetists (CRNAs)

Table 7-2 h Projected Number of Nonphysician Clinician Graduates

in the United States

Discipline 1997 2001 (projected)

Acupuncturists 1030 2000

Certiﬁed nurse anesthetists 387 725

Certiﬁed nurse midwives 414 500

Chiropractors 4100 5200

Clinical nurse specialists 1365 2300

Naturopaths 170 350

Nurse practitioners 5350 7260

Optometrists 1235 1250

Physician assistants 2800 3400

Podiatrists 645 725

solo, or group practices. More and more health care insurance plans will begin to

cover NP and other NPC services as they are less expensive than physicians’.

This chapter has covered the oral and internal use of essential oils and has

also discussed the use of essential oils by LHPs who may or may not have pre-

scriptive privileges. The hope is that this information will start a dialogue to help

clinical aromatherapy become more accepted in health care practice.

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144 Section I Overview

145

Manual Therapies

And I realized that all the world wants to be held in spite of it all.

Jack Kornﬁeld

After the Ecstasy, the Laundry

IPPOCRATES DESCRIBED the importance of touch in the 5th century BC

and declared it his favorite of all health essentials. Aromatherapy is al-

ready being used in many manual therapies. This chapter is to encour-

age therapists to use it in a clinical way. The chapter has been divided into three

sections: massage therapy, chiropractic, and the “m” technique. These three sec-

tions have been subdivided into common ailments as examples of how aro-

matherapy could be used in each of these modalities.

Touch is a basic need. In times of crisis the need becomes overwhelming.

One of the most moving images of September 11, 2001 was of two ﬁreﬁghters

holding each other. Scores of massage therapists in New York and Maryland (and

many others from across the nation) rushed to the devastated areas. They worked

around the clock to treat rescue crewmembers who were stretched to their phys-

ical and emotional limits (Schwanz 2001). They treated emotionally traumatized

workers, many of whom had never had a massage (Pasquale 2001). Their com-

passionate and much-needed gift was huge, and the impact of touch was there for

the whole world to see.

Massage Therapy

In Florida, the deﬁnition of massage therapy was ofﬁcially changed from manipu-

lation of superﬁcial tissue to manipulation of soft tissue by Governor Jeb Bush on

July 19, 2001 (McGillicuddy 2001). Massage therapy has grown in acceptance dra-

matically throughout the last 10 years and is now the norm at sports events

worldwide, including the Olympics (Swantz 2001). In a recent survey, 17% of

Americans said they had received a massage in the past year. Thirty-ﬁve percent

of those were for medical reasons and 25% for stress relief and relaxation

(Schwanz 2001). Forty-two percent of Americans feel massage is a complemen-

tary therapy rather than just a beauty treatment, and medical practitioners ranked

massage therapy as the highest (74%) in terms of effectiveness over eleven other

modalities, including acupuncture (Anonymous 2001). Consumers spend $4 to

$6 billion annually on massage therapy. At Boeing and Reebok, headaches, back

strain, and fatigue have declined substantially since both companies began offer-

ing massage therapy to employees (Underwood 1998). Education requirements

for a massage-therapy license vary from state to state. Texas requires 250 hours

plus 50 intern hours, Oregon requires 330 classroom hours, and Nebraska re-

quires 1000 classroom hours. These ﬁgures were accurate in 1997 when only 22

states required licensing. Recently, New York and Washington states increased the

number of hours required for licensing to 1000 hours.

The physical effects of massage have been well documented throughout the last

10 years. Much of massage’s new-found respectability began in 1986 with Tiffany

Field, PhD, who found preterm babies who received massage therapy slept better,

took more milk, gained weight, and could leave hospital earlier, at a savings of thou-

sands of dollars per day, than their nonmassaged counterparts. She also found mas-

sage reduced depression (Field et al 1996) and enhanced wound healing (Field et al

1998). Research has also indicated massage enhances immune function (Harrison et

al 1992), reduces perception of pain (Nixon et al), and enhances sleep (Menehan

1997; Richards 1998). Massage, once a traditional component of nursing in the

1940s, is now returning to nursing (Mower 1997) with the beginning of the National

Association of Nurse Massage Therapists. Many massage therapists are interested in

adding aromatherapy as an enhancement to their profession (Enteen 2001).

In the state of Washington, insurance reimbursement covers whiplash injury,

provided the claim is ﬁled within 3 years. This is often covered under personal in-

jury protection, which is usually part of vehicle insurance. The value is between

$10,000 and $20,000. As part of this coverage, massage therapy will be covered for

8 weeks, when necessary. Treatment can be biweekly and may be extended at the

discretion of the therapist. A payment of $85 is allowed per treatment, and if hy-

drotherapy (hot packs) is also used, a further $15 is allowed. The patient is reim-

bursed directly by the insurance company. Hypertension and osteoarthritis are also

conditions eligible for health-insurance reimbursement for massage therapy costs.

Fibromyalgia Syndrome

Fibromyalgia syndrome (FMS) is the most common cause of pain seen by medical

practitioners (Bennett 1995) and affects 3 to 6 million Americans, 73%-88% of

which are female and 92%-100% of which are Caucasian (Muir 1999). The symp-

toms are widespread pain for more than 3 months with at least 11 of 18 speciﬁc

146 Section I Overview

points painful to palpation. There appear to be two different types of ﬁbromyalgia—

one involving myofascial pain and one more akin to chronic fatigue syndrome—

although both may appear in the same patient, and there is controversy as to

whether both are the same thing (Buchwald & Garrity 1994). Some patients with

chronic fatigue syndrome have been wrongly diagnosed. In one study of 68 pa-

tients with chronic fatigue, 68% had been wrongly given a psychiatric label in the

past (Deale & Wessley 2000).

There are many theories about FMS. Serotonin, a neurotransmitter in the

central nervous system that carries signals between nerve cells and interacts with

many other receptors such as dopamine, controls slow-wave sleep, and affects per-

ception of pain, is signiﬁcantly lower in those with FMS (Muir 1999). On the

other hand, levels of substance P, the chemical necessary for transmission of pain,

are three times higher (Russell 1994). Certain studies indicate ﬁbromyalgia may

be the result of a deﬁciency of relaxin, a neuropeptide with hemodynamic actions

(Geddes & Summerlee 1995). Relaxin is produced by the corpus luteum in the

ovary and until recently was thought to be involved only with labor (Alexander

2000). Other studies question the possibility of FMS being caused by a disorder

of the limbic system or exposure to a virus (Mountz & Bradley 1995).

FMS patients also complain of insomnia, depression, fatigue, and frequent ﬂuid

retention in the morning. Whatever the cause, aromatherapy can help either by af-

fecting the limbic system, alleviating muscle fatigue or other speciﬁc symptoms, or

ﬁghting a viral infection. For a more in-depth discussion on symptoms please con-

sult Chapters 5, 9, and 12 on psychology, viral infection, and pain, respectively.

Maija Grace (2001) reports on a controlled, crossover study of 20 patients us-

ing Fibromix, a commercial blend of nine essential oils diluted in carrier oil (see

Table 8-1 for details). Fibromix has been marketed in Finland for 3 years and was

Chapter 8 Manual Therapies 147

Table 8-1 h Essential Oils in Fibromix

Common Name Botanical Name

Ylang ylang Cananga odorata

Roman chamomile Chamomelum nobile

Neroli Citrus aurantium

Bergamot Citrus bergamia

Melissa Melissa ofﬁcinalis

Black pepper Pipe nigrum

Ravansara Ravansara aromatica

Sandalwood Santalum album

Ginger Zingiber ofﬁcinalis

formulated by the Maija Grace. The study was so successful in reducing FMS

symptoms that a second study followed with 14 women comparing Fibromix with

Chamomelum nobile (Roman chamomile) essential oil. The average age of the test

subjects was 52 years. Treatments consisted of weekly massage sessions for 6 to 8

weeks. One of the drawbacks to using just one essential oil was that patients and

therapists tired of it. However, sleep, pain, and stress all appeared to be positively

affected.

Lofgren (1998) investigated the use of antiviral essential oils (see Table 8-2

for details) for FMS using a single-case-study design. The study lasted 3 months

and included two treatments a week, producing 19 massage-therapy sessions.

Pain, sleep, and energy were measured using a visual analog (0-10). Although the

pain did not appear to change, the patient commented she had less pain in the

morning and improved mobility. She also said the cycles of pain were shortened

to hours instead of days. She also commented she no longer bruised so easily.

Lucas (1997) investigated the effects of a lemongrass, ginger, rosemary, and

Roman chamomile mix on three patients with FMS. Treatment was weekly mas-

sage with aromatherapy and daily baths with aromatherapy. The ﬁrst patient (59

years old) was diagnosed with FMS 2 years previously, although she believed the

symptoms had been present for many years before that. She believed her pain was

helped by the treatments, but it was difﬁcult to assess whether the daily bath or

the aromatherapy caused the improvement. The second patient (73 years old) had

also been diagnosed with FMS 2 years earlier. She had previously tried massage

but found “it didn’t help.” She found the baths not helpful (her bathtub was small

and uncomfortable, which may have been the cause), but the massage with es-

sential oils did seem to help a bit. The third patient (43 years old) had recently

been diagnosed with FMS. She was taking Klonopin regularly to sleep and said

massage usually helped her symptoms. She stopped taking the baths and used the

inhaled essential oils at night instead. The essential oils helped her sleep, and she

stopped taking sleep medication. Lucas used the “m” technique on this patient in-

stead of massage, as the patient requested something very gentle.

Hester (1999) used four essential oils in a jojoba carrier oil (see Table 8-3 for

details) for her study on four women who had each been diagnosed with FMS for

6 to 10 years. She measured pain perception, sleep, fatigue, and foggy thinking us-

ing a visual analog (0-10) for each condition throughout 4 weeks. Baseline mea-

148 Section I Overview

Table 8-2 h Essential-Oil Mix Used by Lofgren (1998)

Common Name Botanical Name Drops per Ounce Carrier Oil

Bergamot Citrus bergamia 5

Palma rosa Cymbopogon martini 9

Tea tree Melaleuca alternifolia 3

Ravensara Ravensara aromatica 3

surements were taken before the study. Two people had 80% improvement in

pain; two had 50% improvement. Clearer thinking received the lowest score with

an average of 35% improvement. Fatigue was improved by an average of 62.5%;

sleep was improved by an average of 72.5%. While these ﬁgures are encouraging,

the patients may have been biased to please the therapist!

Chiropractic

Chiropractic is growing exponentially—faster than massage, acupuncture, or

herbal medicine (Kessler et al 2001). The importance of massage was emphasized

at the 2001 Florida Chiropractic Convention where 150 massage therapists min-

gled with 1800 chiropractors and discussion topics included myofascial release

and neuromuscular therapy (Solien-Wolfe & McGillicuddy 2001). Many chiro-

practors either employ or actively refer patients to licensed massage therapists.

Many use massage techniques themselves to warm up the body prior to manipu-

lation. While some physicians still claim that they do not know for sure if chiro-

practic does more good than harm (Ernst 1998), the public is voting with its feet.

Stano and Smith (1996) studied 6183 patients via 2 years of insurance data and

found chiropractors were given higher satisfaction and quality ratings from pa-

tients than were medical practitioners, and they had lower costs as the initial-

contact provider. Shekelle et al (1995) found chiropractors were the primary-care

providers for 40% of back pain and had more patient visits than orthopedic physi-

cians did but at less cost.

Low-Back Pain

Eighty percent of adults suffer at least one episode of low-back pain in their lives

(Bigos et al 1994). Among patients who use alternative medicine, back problems

are the most frequently reported medical condition (Eisenberg et al 1993). In the

workforce, the cost of an average back-injury claim in 1989 was $8000 and ac-

counted for one third of worker’s compensation costs (Webster & Snook 1994).

The estimated national bill for the care of low-back pain per year is $38-$50 bil-

lion (Atlas & Deyo 2001). Seventy-ﬁve to 90% of patients with low-back pain re-

port improvement within 1 month, but 50% of patients have repeat episodes

Chapter 8 Manual Therapies 149

Table 8-3 h Essential Oils Used by Hester (1990)

Common Name Botanical Name Percentage

Lemongrass Cymbopogon citratus 3%

German chamomile Matricaria recutita 1%

Lavandin Lavandula intermedia 2%

Rosemary Rosmarinus ofﬁcinalis 2%

within 1 year (Carey et al 1999). Since 1999, four major, randomized, controlled

studies and one metaanalysis have indicated massage is beneﬁcial for low-back

pain (Crownﬁeld 2001). A 2001 study involving 263 patients (Cherkin et al

2001) found those receiving massage needed less medication and fewer days in

bed than those receiving acupuncture.

Essential oils can be used by chiropractors to reduce muscle spasm before

manipulation, to reduce inflammation, and to reduce pain. Costa (1997), a mas-

sage therapist who works with a chiropractor, conducted a small study on the

use of aromatherapy prior to chiropractic manipulation. She used 3% Lavan-

dula angustifolia in vegetable oil massaged into the backs of six patients for 20

minutes prior to manipulation. The chiropractor assessed the ease of manipula-

tion on a scale of 1-10, with 10 being the easiest to manipulate. The members

of the experimental group were aged 16-49 and included both men and women.

Twelve treatments were given to each of the six patients. Figures indicate the

lavender massage had made manipulation easier than plain massage. Further es-

sential oils were tested, and aromatherapy is currently used by the chiropractor’s

office.

Although efﬁcacy can be achieved with 1-5% essential oil solutions, some ther-

apists use up to 40% concentrations. Do not dilute the essential oil in a

petroleum- or mineral-based medium as this will prevent it from being absorbed

through the skin. There are speciﬁc analgesic, antiinﬂammatory, and antispasmodic

essential oils that can help low-back pain. The oils need to be applied topically.

Commonly used and effective antiinﬂammatory essential oils for acute low-

back pain are listed in Table 8-4 and include an essential oil that has a long his-

tory of use in Australia but is just becoming known in the United States (Webb

2000). Table 8-5 lists essential oils with analgesic qualities suitable for treating

low-back pain.

In a survey on management of rheumatic-disease symptoms in aromatherapy

practices in the United Kingdom, 55% therapists said they had patients referred

to them by conventional medicine (Osborn et al 2001). Musculoskeletal com-

plaints were the second most common condition treated by aromatherapists in

the United Kingdom, after stress. Aromatherapy in the United Kingdom is nearly

always used with massage.

Zivitz (2000) carried out a small pilot study on six women with low-back

pain. The subjects’ ages ranged between 24 and 73 years. Zivitz compared the ef-

fects of Boswellia carteri (frankincense) and Cymbopogon citratus (lemongrass) in

two separate 4% solutions, each diluted with sweet-almond oil. The control group

received a massage with plain vegetable oil. Each participant had experienced

low-back pain for a minimum of 2

⁄

years. A visual analog was used to rate pain

(0-10). Participants completed the pain scale immediately before treatment, im-

mediately after treatment, and 1 and 2 hours later. Despite favorable comments

from the participants, data analysis did not show any alteration in pain perception

beyond the control group (who received straight carrier oil with their massage),

although everyone enjoyed the aroma.

150 Section I Overview

Soltis (2000) compared the effects of Piper nigrum (black pepper) and Orig-

anum majorana (sweet marjoram) on patients with low-back pain. Again the sam-

ple was small, six participants. There were four women and two men. This time

each essential oil (2%) was self-applied twice a day for 1 week. Most participants

thought the black pepper was warming and this helped the pain, although two

participants did not like the aroma. Most participants believed sweet marjoram

helped, and one stopped taking Motrin for pain relief. However, there were many

Chapter 8 Manual Therapies 151

Table 8-4 h Antiinﬂammatory Essential Oils for Acute Low-Back Pain

Common Name Botanical Name Reference

Juniper Juniperus communis Mascolo et al 1987

Fennel (sweet) Foeniculum vulgare Mascolo et al 1987

Coriander Coriandrum sativum Mascolo et al 1987

Roman chamomile Anthemis nobilis Rossi et al 1988

Nutmeg Myristica fragrans Benet et al 1988

Everlasting Helicrysum italicum Franchomme & Penoel 1991

Yarrow Achillea millefolium Middleton & Drzewiecki 1984

German chamomile Matricaria recutita Tubaro et al 1984

Australian blue cypress Callitris intratropica Webb 2001

Lemongrass Cymbopogon citratus Seth et al 1975

Clove Syzygium aromaticum Guillleman et al 1989

Lavender Lavandula angustifolia Ghelardini et al 1999

Table 8-5 h Analgesic Essential Oils for Acute Low-Back Pain

Common name Botanical name Reference

Peppermint Mentha piperita Krall & Krause 1993

Lemongrass Cymbopogon citratus Viana et al 2000

Lavender Lavandula angustifolia Ghelardini et al 1999

Not known Artemesia caerulescens Moran et al 1989

Myrrh Commiphora molmol Dolara et al 2000

Spike lavender Lavandula latifolia Von Frohilche 1968

Clary sage Salvia sclarea Moretti 1997

variables, and it is difﬁcult to come to any conclusion with such a small number

of participants.

Port (1999) conducted a small, controlled study on the effects of lavender and

black pepper on osteoarthritis. Participants were seven women and one man. All

participants used analgesics and antiinﬂammatory medication, and several took

them daily. The participants were randomly allocated to two groups. The experi-

mental group received 20 ml of 3% black pepper and lavender oils in sweet al-

mond oil. The control group received 20 ml of plain carrier oil. Both groups were

instructed to rub the mixture into the painful joint once in the morning and once

at night for 7 days. At the end of this time they were to stop the treatment and

evaluate their pain and stiffness using a visual analog (0-10).

The control group did not have any measurable effect from this process. The

experimental group did experience a reduction in stiffness and pain. One woman

stopped taking her antiinﬂammatory medicine, but when the study was ﬁnished

her stiffness and pain returned, and she started taking her medicine again. Two

participants had signiﬁcant improvement in their range of motion. One person

was able to make a ﬁst for the ﬁrst time in years. This is a very small study but is

encouraging to those of us who are getting older!

The “M”Technique

The “m” technique is a registered method of touch suitable for the very fragile or

when massage is inappropriate (either because the receiver is too fragile or be-

cause the giver is not trained in massage). The “m” technique is a series of stroking

movements performed in a set sequence. Each movement, identiﬁed with a

mnemonic name (a name that acts as a “hook” to enable the giver to remember

it), is repeated a set number of times. Because the technique is structured in terms

of strokes, sequence, number, and pressure, it is completely reproducible and

therefore useful in research. The “m” is so gentle and soothing that a physician has

called it “physical hypnotherapy” (Merrill 1999).

The “m” ﬁrst arrived in the United States in 1994 when I began teaching in

Florida and Georgia. The “m” technique was registered by the United States

Patent and Trademark Ofﬁce in March 1998. Since 1994, the technique has been

taught in universities, nursing colleges, and massage schools across America. Stu-

dents have even created a new verb and talk about “m”-ing their patients! Cur-

rently more than 1000 people have learned the “m” technique, and the word is

spreading. The “m” was devised as a simple, easy to learn method of touch (one

weekend) that would allow a patient to feel relaxed as quickly as possible. Created

initially for nurses not wanting to train in massage but wanting to touch their pa-

tients, the “m” technique is used by many other licensed health professionals.

The “m” technique is quite different from massage as it follows a set structure

that never changes. Each movement and sequence is done in a distinctive pattern

that is not modiﬁed. Each stroke within each movement is repeated three times,

so a group of practitioners carrying out the technique would all be doing exactly

152 Section I Overview

the same stroke at the same time. The rationale for this set form of repetition is

simple: to build conﬁdence and remove anxiety in the receiver. The ﬁrst time pa-

tients experience an “m”-technique stroke, they will pay attention. The second

time they feel the same stroke, they will recognize it. By the third time, the re-

ceiver knows what is going to happen and will begin to relax. By experiencing

each stroke a set number of times, the receiver learns what is going to happen and

is lulled into a deep state of relaxation in a very short period of time. The “m”

technique also uses a set pressure. If pressure was measured on a scale of 0-10,

with 0 as no pressure and 10 as crushing pressure, the “m” technique ‘s pressure

should always be a 3. Conventional massage alters the pressure depending on the

situation.

Many massage therapists are learning this technique to use in their practice

alongside conventional massage therapy. Sharon Gibson, a massage therapist in

New Jersey, says normally 65% of her clients go to sleep on the table during a

massage. However, with the “m” technique, 100% fall asleep within the ﬁrst 10

minutes. Lori Mitchell, a critical care nurse in Kalispell, Montana, used the “m”

technique in critical care and said it brought rapid and prolonged relaxation to her

patients, some of whom had not responded to orthodox sedation. Aurora

Ocampo, RN, a clinical nurse specialist at Beth Israel Hospital in New York City

uses the “m” technique to relax patients prior to surgery.

In 1996 the “m” technique was used in the research laboratory at Columbia

Presbyterian Medical Center in New York City. The “m” technique was applied

to the feet of medical students and a measurable effect on their parasympathetic

nervous systems was recorded using an 8-lead electrocardiogram machine at-

tached to a heart-variation monitor. Slater (2001) measured the effects of the “m”

technique in a study on muscle tension, relaxation, and mood with 14 partici-

pants. Slater compared the effect of the “m” technique applied with and without

lavender essential oil. Data were entered into a database program and analyzed

using a two-sample t-test, assuming equal variances. The effects of the “m” tech-

nique were statistically signiﬁcant without the lavender (p⫽⬍0.005). However,

with lavendar, the effects were increased substantially (p⫽⬍0.00004). Limita-

tions of the study were lack of randomization, small study size, and dominance of

female participants.

Miller (2000), a critical care nurse at Desert Samaritan Hospital in Mesa,

Arizona, used the “m” technique on her patients. The ﬁrst was a female patient

with a history of multiple sclerosis who was ventilator dependent and very appre-

hensive about her caregiver. Postoperatively (tracheostomy) the patient was

pulling on the ventilator tubing constantly and complaining of discomfort. The

“m” was used on her legs and feet. She fell asleep before the treatment was com-

pleted (less than 10 minutes) and slept for 2 hours. She was much calmer upon

awakening. A second patient was a 37-year-old female with cancer metastasized

to the bones and now affecting her brain. Diagnosed 4 years previously, she had

been treated with chemotherapy and radiation. She was ventilator dependent. She

wanted to stay alert so she could “say good bye to her family in a digniﬁed way.”

Chapter 8 Manual Therapies 153

She chose rosemary essential oil to accompany her “m” technique, as she remem-

bered using it before. The “m” was used on her feet and legs. Her need for nar-

cotics decreased from every 2 hours to every 6 hours. Four of those hours she was

asleep. The third patient was a 72-year-old female who just had abdominal

surgery. She was very fragile, weak, and afraid. Pain medication was given every

2 hours. After the “m” to her hands, the patient slept for 3 hours and did not re-

quest any further pain medication for 2 more hours. The fourth patient was a 76-

year-old male who just had abdominal surgery. He rated his pain as a 7. After the

“m” to his feet, he belched and passed ﬂatulence, which greatly relieved his pain.

He slept without analgesics and later rated his pain as a 1 or 2. The following day

he was still thanking Miller for using the “m” technique on him. Miller noted that

as well as physical responses of facial expressions in her patients, often there was

a signiﬁcant drop in heart rate of 5-10 beats per minute.

The “m” is simple enough for a 5-year-old child to do and can be shared with

family members. It is empowering for the giver and beneﬁcial for the receiver.

The chaplain of Mercy Hospice in Scranton, Pennsylvania, learned the “m” tech-

nique to “give physical comfort at a soul level.” A hand or foot “m” takes only 5

minutes and has far-reaching effects. I have found teaching the “m” technique to

be one of the most satisfying aspects of my career. Details of training programs

and an instructional video can be found at www.rjbuckle.com.

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Chapter 8 Manual Therapies 157

section

Clinical Use

of Aromatherapy

General Clinical Subsection

Chapter 9 Infection

Chapter 10 Insomnia

Chapter 11 Nausea and vomiting

Chapter 12 Pain and inﬂammation

Chapter 13 Stress management

Part B Specialized Departments Subsection

Chapter 14 Cardiology

Chapter 15 Care of the Elderly

Chapter 16 Critical Care

Chapter 17 Dermatology

Chapter 18 Endocrinology

Chapter 19 Hospice/End of life care

Chapter 20 Immunology

Chapter 21 Obstetrics and Gynecology

Chapter 22 Oncology

Chapter 23 Pediatrics

Chapter 24 Psychiatry

Chapter 25 Respiratory Care

Introduction to Section 2

Aromatherapy is certainly viewed by many as being primarily concerned with

stress management. This may be the case today, but it would be a pity if the myr-

iad other therapeutic properties of essential oils were ignored now and in the fu-

ture. This section of the book is an exploration of how aromatherapy could be

used clinically, and is divided into two subsections: a general section and a spe-

cialized section.

In the general clinical section, I have focused on the broad-ranging problems

of infection, insomnia, nausea and vomiting, pain, and stress management. The

ﬁrst four of these areas have far-reaching effects on the quality and cost of health-

care, and are of interest to a wide range of readers. While the role of aromather-

apy in stress management has been covered by other authors, I have attempted to

place the role of stress management within a clinical context.

The ability of Western medicine to contain the increasing demands of

healthcare users is reaching a breaking point. Essential oils might provide a little

more elasticity because essential oils are much cheaper than conventional medi-

cines. Just compare the use of peppermint with Zofran in the treatment of nau-

sea. While there may be many incidences when Zofran is needed and the only

drug that will work, there are also many instances when peppermint will work and

it could be offered ﬁrst. So it is in the interest of healthcare providers to be con-

versant regarding what essential oils could achieve in a clinical setting.

The chapter on infection was an exciting one for me to write, as I feel there is

tremendous potential for essential oil to be used against emerging drug-resistant

pathogens. In vitro and animal studies indicating antimicrobial activity do not

prove that essential oils will necessarily be effective in a human, but such studies

are an encouraging beginning, particularly when the power of synthetic antibi-

otics is waning.

The specialized subsection focuses on a handful of speciﬁc problems within

each clinical specialty and how aromatherapy might help those problems, again

with reference to published research, my clinical experience, and case studies and

small pilot studies. The aim in writing Chapters 14–25 is to make licensed

healthcare professionals (LHP) aware of the clinical potential of aromatherapy

within speciﬁc departments. References have been given where possible although

many of them are in-vitro or animal studies. But at least it is a beginning. Where

the studies have been on whole herbs rather than essential oils, this fact is indi-

cated. There is a separate treatment of the oral use of essential oils back in Chap-

ter 7. This specialized, updated clinical section includes new chapters on

OB/GYN and psychiatric care. The chapter on immunology has been much ex-

panded and the number of references to this section has been doubled.

Obviously there will be some overlap among chapters, and the reader is ad-

vised to refer to the general index at the back of the book to ﬁnd other areas in

the book where the symptom will be addressed.

I am grateful for the input of many reviewers in this section whose help and

advice was most appreciated. The reviewers include: Ann Adams BSN, Ben

Evans MSN, Claire Everson BSN, Diana Guthrie RN, PhD, Susan Hageness

MSN, Dorathy Larkin RN, PhD, Lori Mitchell BSN, Gayle Newsham PhD,

Mary Poolos RN, PhD, Ganson Purcell MD, Scottie Purol-Hershey RN, PhD,

Linda Scaz RN, PhD, Neil Schultz MD, Kay Soltis MSN, Brenda Talley RN,

PhD, and Mark Warner, MD.

Section II Clinical Use of Aromatherapy 161

162

Infection

The use of perfumes, and especially that of lavender, is a more certain and pleasant

means of combating diseases and hindering the spread of epidemics.

Rene-Maurice Gattefosse (1948)

Hospital-Acquired Infections

Infectious diseases were, until recently, the most common cause of death (Mac-

Sween & Whaley 1992). Despite an improvement in living conditions among the

technically advanced countries of the world, infections such as the common cold

and inﬂuenza are major causes of working days lost. Smallpox may have been ir-

radicated and the incidence of diphtheria greatly reduced, but viral infections and

mutated or newly discovered bacteria are on the increase. Since September 11,

2001, anthrax and other bacteria that could be potential biological weapons have

gained publicity. Three essential oils, palma rosa, basil, and black cumin, are mod-

erately effective in vitro against anthrax. However, aromatic medicine has been for

the most part ignored as a possibility for combating the pathogen. Tuberculosis

(TB) is also on the increase and will infect 8.4 million people this year and kill 2

million (Reichman & Tanne 2001). Several essential oils are effective against TB

in vitro and others augment the effect of conventional medicines.

Animals are also falling prey to new infections or infestations. Of wild hon-

eybees, 90% have been killed following an infestation of mites. The mites, which

had become resistant to conventional pesticides, were thought to have been

brought into the United States with illegally imported bees several years ago. Bob

Noel, a farmer in Cumberland, Maryland, tried ﬁghting the mites using winter-

green essential oil mixed with shortening and sugar placed directly in the hive. It

killed all the mites but did not harm the bees. Peppermint, lavender, pennyroyal,

spearmint, and patchouli were also successful in killing mites, and the results were

posted on the Internet (Amrine 1996).

However, of greatest concern to all health professionals are the infections ac-

quired by patients as a direct result of being in a hospital (Ward 1993). Infection

is caused by organisms such as bacteria, viruses, fungi, protozoa, and parasites.

Gascoigne (1993), a British physician, suggests these organisms can be spread by

the methods listed in Table 9-1.

Being a hospital patient brings with it the threat of infection (Fig. 9-1).

Every year almost 2 million American patients acquire an infection in a hospital,

and of those 2 million patients, 80,000 die (Fisher 1994). Urinary-tract infections

increased the duration of hospitalization by 5.1 days. Rubinstein et al (1982)

found wound infections increased the period of hospitalization by 12.9 days, a

heavy price for a hospital budget.

Chapter 9 Infection 163

Table 9-1 h Spread of Infections

Spread by: Results in:

Droplet infection Common cold, inﬂuenza

Implantation Streptococcus, Staphylococcus

Direct contact Scabies, sexually transmitted diseases

Food or water contamination Cholera, Listeria

Injection, human or insect HIV virus, hepatitis, yellow fever, malaria

Lower respiratory tract

22.9%

Urinary tract

23.2%

Surgical wound

10.7%

Skin

9.6%

Septicaemia

6.2%

Gastrointestinal

4.9%

Other

22.5%

Figure 9-1 The frequency of different types of hospital-acquired infection. From Wilson

J. 2001. Infection Control in Clinical Practice, 2nd ed. London: Elsevier Science.

The most common hospital-acquired infections (HAI) are Campylobacter en-

teritis, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA),

and vancomycin-resistant enterococci. HAI (nosocomial) can be acquired from

an outside source, such as poor hygiene standards of the hospital staff, equipment,

or even visitors, or as a result of self-infection. Sometimes infection can be due to

the enforced relocation of a commensal. A commensal is a bacterium symbiotic

to the health of the host, such as Escherichia coli in the gut. However, when the

commensal is transplanted to another part of the body, an infection ensues. A

common example is E. coli, which, when transported from the gut to the urinary

tract, causes cystitis.

Common Forms of Hospital-Acquired Infection

Campylobacter enteritis

According to Sleigh et al (1992), C. enteritis causes one of the most common

forms of infective diarrhea. This form of diarrhea is caused by organisms that af-

fect the digestive tract, many of which have not yet been identiﬁed or are totally

new.

Pseudomonas aeruginosa

P. aeruginosa has become more common in hospitals. A strictly aerobic, gram-

negative bacillus, P. aeruginosa ﬂourishes in water and aqueous solutions. The or-

ganism produces a pigment called pyocyanin, as well as ﬂuorescein, and these

compounds together create the characteristic blue, offensive pus seen in P. aerug-

inosa infections (MacSween & Whaley 1992). Pseudomonas is rapidly becoming

resistant to antibiotics. Nearly 70% of people with cystic ﬁbrosis are chronically

infected with this bacterium.

Methicillin-Resistant Staphylococcus aureus

MRSA has been responsible for global outbreaks of infection. Staphylococcus

infections tend to remain localized, possibly because of the production of coagu-

lase, which clots ﬁbronogen (MacSween & Whaley 1992). Some essential oils

such as peppermint, thyme, lavender, tea tree, and juniper have been found effec-

tive against MRSA in vitro (Nelson 1997). Hospital-acquired S. aureus bac-

teremia continues to be a frequent and serious complication of hospitalization

worldwide ( Jensen et al 1999).

Multiple-Resistant Serratia marcescens and Klebsiella

Serratia marcescens and Klebsiella were the cause of an epidemic involving four

hospitals in the 1970s. The spread of infection was ﬁnally linked to the lack of

hand washing by personnel who worked in all four hospitals. By the time the in-

fection was brought under control, 400 patients had been infected, and 17 pa-

tients had died (Fisher 1994).

S. marcescens is a gram-negative bacillus that occurs naturally in soil and wa-

ter and produces a red pigment at room temperature. It is associated with urinary

164 Section II Clinical Use of Aromatherapy

and respiratory infections, endocarditis, osteomyelitis, septicemia, wound infec-

tions, eye infections, and meningitis. Transmission is by direct contact. Droplets

of S. marcescens have been found growing on catheters and in supposedly sterile

solutions. Most strains are resistant to several antibiotics. Between 1951 and 1952

the US Army conducted a study called Operation Sea-Spray to study wind-

currents that might carry biological weapons. They ﬁlled balloons with S.

marcescens and burst them over San Francisco. Shortly afterwards, doctors noted

a dramatic increase in pneumonia and urinary-tract infections (www.sunysccc.

edu/academic/mst/microbes/23smarc.htm). Recently the Azerbaijan Medical

Association announced on their Web site (http://azma.org) that S. marascens was

killed in 30 minutes in vitro by essential oil of Nepata transcaucasica (an aromatic

herb that grows wild in the Absheron region of Azerbaijan).

Streptococcus

Group A Streptococcus (GAS) is a bacterium found in the throat and on the

skin. Many people carry it with no symptoms. Most GAS infections are mild,

such as strep throat and impetigo. However, life-threatening GAS infections can

occur when the bacterium gets into a part of the body where it is not normally

found, resulting in necrotising fasciitis (ﬂesh-eating bacteria) and strep toxic

shock syndrome. Of patients with necrotising fasciitis, 20% die; more than 50%

of patients with strep toxic shock die. Approximately 10% to 15% of patients with

other forms of invasive GAS infections die. In 1999, there were 9400 cases of in-

vasive GAS in the United States. According to the Centers for Disease Control

and Prevention, people with chronic illnesses, those taking steriods, or those

who have low immune function are most at risk for this type infection (www.

cdc.gov/ncidod/dbmd/diseaseinfo/groupastreptococcal_g.htm).

Vancomycin-resistant enteroccoci

Vancomycin-resistant enteroccoci (VRE) were ﬁrst isolated in 1987. In some

hospitals, VRE are responsible for 20% of enteroccoccal infections (Leclercq et al

1988). VRE are directly related to the dramatic increase in vancomycin use in hos-

pitals in the early 1980s and 1990s (Ena et al 1993). A metaanalysis of 420 pub-

lished reports and 98 conference reports conﬁrms this view (Carmeli et al 1999).

Each of the bacteria mentioned previously are becoming more common in

hospitals, but there is a whole range of pathogenic organisms that surround us

every day. These common causes of HAI can be resistant to orthodox medication.

However, in-vitro studies suggest these pathogens are sensitive to the antibacter-

ial action of speciﬁc essential oils. Pathologists who are experts in the use of es-

sential oils as antibacterial agents stress that the “terrain” of the patient can affect

the efﬁcacy of the antibacterial action of an essential oil, and an individual aro-

matogram is required. However, the standard aromatograms described here give a

general idea as to which essential oils might be efﬁcacious in a particular patient.

Following a brief classiﬁcation of bacteria, there is a description of some the

published research into the antimicrobial effects of essential oils. This research

Chapter 9 Infection 165

suggests essential oils could be used to enhance antibacterial/antifungal/antiviral

drug therapy or to treat infections on their own.

Bacterial Classiﬁcation

Although the following information may seem elementary, it may be helpful to

have the basics reiterated to provide context for the information on essential oils.

Bacteria are ﬁrst classiﬁed according to their shape (Fig. 9-2). The two main

groups of bacteria are cocci and bacilli (Hope et al 1993). These two groups are

then subdivided into gram-positive and gram-negative bacteria. (Gram was the

microbiologist who devised the staining method.) Gram staining uses a mixture

of violet dye and iodine to stain the magnesium ribonucleate found in some bac-

teria deep purple. The purple stain cannot be washed out by alcohol. Bacteria that

can be stained purple are said to be gram-positive. Bacteria that do not contain

magnesium ribonucleate do not retain the purple stain and are described as gram-

negative (Ward 1993). Mycobacterium (the cause of TB and leprosy) is not re-

vealed by the gram-stain method and instead is stained with an acid-fast method

166 Section II Clinical Use of Aromatherapy

Figure 9-2 Four main groups of bacteria: Clockwise from top left: Gram-positive cocci,

gram-negative cocci, gram-negative bacilli (rods), gram-positive bacilli.

From Wilson J.

2001. Infection Control in Clinical Practice, 2nd ed. London: Elsevier Science.

called the Ziehl-Nielsen method (MacSsween & Whaley 1992). A second sub-

division of bacteria is between aerobic organisms, which need air to survive, and

anaerobic organisms, which do not require air. An increasingly common anaero-

bic bacterium causes vaginitis. In optimum in vitro conditions, bacteria divide ap-

proximately every 20 minutes (MacSween & Whaley 1992).

Coccus Bacteria

The cocci bacteria include Staphylococcus, named for the Greek word staphyl,

meaning grapes, because, seen under a microscope, the bacteria have this charac-

teristic shape. Staphylococcus is the cause of many skin infections. Streptococcus is

named after the Greek word streptos, meaning twisted, because the bacteria re-

semble twisted chains. Streptococcus often causes throat infections. Other members

of the coccus family include Pneumococcus, which causes pneumonia, and Neisse-

ria, which causes gonorrhea. Streptococcus can be further classiﬁed into A, B, or

nonhaemolytic types and aerobic or anaerobic types.

Bacillus Bacteria

The bacillius group includes Enterobacteriaceae such as E. coli and Salmonella,

both of which can cause diarrhea. It also includes Proteus mirabilis and Bacillus

anthracis, which cause proteus and anthrax, respectively. Other bacteria in the

bacillus group include Corynebacterium diphtheriae, which causes diphtheria,

Pseudomonas aeruginosa, and M. tuberculosis, which causes TB. Anaerobic bacilli

include Clostridium tetani, which causes tetanus, and C. difﬁcile, which causes

pseudomembranous colitis.

In addition to the two main groups, there are the spirochete group and a fur-

ther group of organisms that are neither viruses nor bacteria, but something in be-

tween. This group includes Rickettsia, which causes typhus fever, and Chlamydia

trachomatis, which causes genitourinary infections (Hope et al 1993). A classiﬁ-

cation of pathogens is shown in Fig. 9-3.

Antibiotics

The antibiotics industry has seen huge growth in the last 30 years, with sales in-

creasing from $94 million in 1971 to $8 billion in 1994 (Fisher 1994). Antibiotics

(which, roughly translated, means “against life”) are secondary metabolites of mi-

croorganisms and, at high dilutions, are inhibitory to most other microorganisms.

An antibiotic is capable of inhibiting the growth of a microorganism or destroy-

ing it (Tamm 1971). It does this by inhibiting the synthesis of the bacteria’s cell

wall, protein or nucleic acid production, or by reducing the permeability of the cy-

toplasmic membrane. This prevents the bacteria from reproducing so rapidly and

enables the host to work toward eliminating the organism (Lewis & Lewis 1977).

Although many antibiotics are synthetic, most are derived from natural sub-

stances. The most commonly used type is a broad-spectrum antibiotic that is

nonselective. Laboratory testing of a swab or blood sample indicates which

Chapter 9 Infection 167

168 Section II Clinical Use of Aromatherapy

LIFE

Animals Viruses

Vertebrates Invertebrates

Helminths Arthropods,

e.g., scabies,

lice

Eukaryotes

(⬎1 chromosome; intracellular

double-membraned structures)

Prokaryotes

(1 chromosome;

no nuclear membrane;

no mitochondria)

Plants Protists

Others

Nematodes Cestodes Trematodes

Fungi

(non-photosynthetic;

rigid polysaccharide wall)

Protozoa

(motile;

unicellular;

non-photosynthetic)

Bacteria Rickettsiae Chlamydiae

Flagellate

(motile; flagellae)

e.g.,

Trypanosoma,

Trichomonas,

Giardia, Leishmania

Amoeboid

e.g.,

Entamoeba

histolytica,

Cryptosporidium

Sporozoa

(non-motile)

e.g.,

Plasmodium,

Toxoplasma

Figure 9-3 Classiﬁcation of pathogens. From Hope R, Longmore J, Hodgetts T et al. 1993. Oxford Handbook of Clinical Medicine. Oxford, UK: Ox-

ford University Press, p. 172.

antibiotic is appropriate, but this method of testing has largely been abandoned

in favor of broad-spectrum antibiotics, mainly because of cost and time, but also

because physicians are under intense pressure to prescribe immediately. Broad-

spectrum antibiotics do not always succeed in killing the bacterium causing the

disease. Despite this, broad-spectrum antibiotics remain very popular and are

usually the ﬁrst line of defense. Broad-spectrum antibiotics usually destroy almost

every other “friendly” gut bacterium as well. As a result, a great many people now

support colonies of fungi that have taken the place of the friendly digestive bac-

teria. Candidiasis, the existence of which was once denied by the medical profes-

sion, is thriving in the gut of millions of people who have taken broad-spectrum

antibiotics and have not replaced their friendly bowel ﬂora.

The majority of antibiotics are (or have been until recently) active against

gram-positive microorganisms (such as Staphylococcus and Streptococcus). Although

manmade antibiotics are becoming increasingly sophisticated in an attempt to

compete with organisms that can mutate and thereby initiate resistant colonies,

they are not as complicated as most essential oils. Essential oils have 100 or more

components, so it is arguable that an organism would ﬁnd it more difﬁcult to be-

come resistant to them. Without a doubt, synthetic antibiotics have saved lives

and will continue to do so. However, the overuse and improper use of antibiotics

during the last few years has led to a growing population of antibiotic-resistant

bacteria (Fisher 1994).

Penicillin, the ﬁrst antibiotic, was found to be effective against Staphylococcus but

completely ineffective against E. coli. As early as 1942, Fleming (who discovered

penicillin) was advising the medical profession of the possibility that Staphylococcus

could become resistant to penicillin. Today, 95% of Staphylococcus is resistant to peni-

cillin. Antibiotics are also listed in the group of drugs most frequently associated with

adverse reactions such as nausea and gastrointestinal problems, skin rashes, and

headaches (Blaschke & Bjornsson 1995). In addition, antibiotics are thought to be

linked to an increase in food allergies and to chronic fatigue syndrome (Schmidt

1995). Some bacteria can be killed within a few hours with direct exposure to sun-

light, and most are killed at 100° C (the boiling point of water). However, some bac-

teria are notoriously difﬁcult to eradicate, especially in a person with a compromised

immune system. Fig. 9-4 shows how many bacilli and cocci have become resistant to

antibiotics, resulting in the development of the so-called “superbugs.”

Resistance to Antibiotics

Some strains of bacteria have become resistant to antibiotics for various possible

reasons, such as the following:

1. Patients have not completed the prescribed course of antibiotics. This means

the bacteria are not completely eradicated and become immune to the next

dose of that particular antibiotic.

2. Antibiotics have been prescribed for viral illness such as the common cold. In

the United States, some 900,000 prescriptions per year are written for antibi-

otics to treat the common cold (Fisher 1994).

Chapter 9 Infection 169

170 Section II Clinical Use of Aromatherapy

Key: 1 ⫽ susceptible, first choice; 2 ⫽ susceptible, second choice; R ⫽ resistance likely to be a problem; 0 ⫽ usually inappropriate

Penicillin V/G

Flucloxacillin

Amp/Amoxycillin

Carbenicillin/Ticarcillin

Piperacillin/Azlocillin

Cephradine/Cephalothin/Cefazolin

Cefuroxime/Cephamandole/Cefotaxime

Ceftazidime

Imipenem

Erythromycin

Lincomycin/Clindamycin

Tetracyclines

Chloramphenicol

Trimethoprim

Aminoglycosides

Vancomycin

Metronidazole

Ciprofloxacin

Staphylococcus aureus

(penicillin sensitive) 1 0 0 0020022RR2RRR22R2

Staphylococcus aureus

(penicillin resistant) R 1 R R R 20022RR2RRR2R2R2

Streptococcus

(group A) 1 0 0 0020022RRRRRR 0RR

Streptococcus pneumoniae

102 0022022RR2RRRR0RR

Enterococcus faecalis

RR1 R2RRR2 0RRRRR2RRR

Neisseria meningitidis

102 00020200R2RRRR0

Listeria monocytogenes

201 00RRR2RR02020R0

Haemophilus influenzae

R R 1R 0 R R 2 0 2 R R 2R R R 0 R R 2

E. coli

RR1RRRR2RR2RRRR1R2RRR2

Klebsiella

species R R R R R R 2R 2R 2 RRRR1R2RRR2

Serratia/Enterobacter

species R R R R R R 2R 2R 2 RRRR1R2RRR2

Proteus

species R R 1R R R R 2R R 2 RRRR1R2RRR2

Pseudomonas aeruginosa

RRR1R1RRR2R2RRRRR1RRR2

Bacteroides fragilis

RR2RRRRRR2R22R2RRRR1R

Other

Bacteroides

species R R R RRRRR2R2R2R2RRRR1R

Figure 9-4 Susceptibility of selected bacteria to certain antibacterial drugs. From: Hope R, Longmore J, Hodgetts T et al. 1993. Oxford Handbook

of Clinical Medicine. Oxford, UK: Oxford University Press, p. 176.

3. Antibiotics have been used prophylactically. In the United States, until 1992,

a 48-hour course of antibiotics was given preoperatively to patients thought to

be at risk for infection.

4. During the past 40 years, the antibiotics penicillin and tetracycline have been

added to animal feed.

5. Antibiotics are regularly used by the food industry to protect fruits and veg-

etables and are also used in the ﬁsh industry.

Over-prescription of antibiotics has been widespread. In 1991, 240 million

prescriptions for antibiotics were written in the United States, one for every per-

son in the country (Fisher 1994). This dropped to 110 million prescriptions for

antibiotics in 1995, but 50% of these are thought to be inappropriate for the dis-

ease being treated (Schmidt 1995).

Antibiotics are given to animals to increase growth: in some cases chickens

fed with a broth of antibiotics have grown to three times larger than normal

( Jukes 1973). Although only minute amounts of antibiotics produce this growth,

animals destined for human consumption regularly contain antibiotics, leading to

a potential immunity or resistance in humans to those antibiotics. This immunity

ﬁrst manifested itself with an outbreak of Salmonella in England in 1965. Nor-

mally, Salmonella would have been swiftly brought under control with antibiotics.

However, on this occasion, investigations showed that the bacterium was resistant

and six people died (Corpet 1987).

Following this outbreak, the Swann Committee (composed of microbiolo-

gists and physicians) led an intensive enquiry. Their recommendation was a ban

on the use of antibiotics used in human medicine for promoting animal growth.

Although England, Scandinavia, the Netherlands, and most European countries

agreed to the ban, the US government never approved the ban and still allows

farmers to use the same antibiotics employed in human medicine as growth stim-

ulants for animals (Fisher 1994).

In fact, shortly after penicillin was discovered, researchers found some strains

of Staphylococcus could manufacture an enzyme called penicillinase, which ren-

dered penicillin inactive (Abraham & Chaine 1940). This resistant strain spread

through hospitals, and by 1955 80% of patients infected with Staphylococcus died

if penicillin was the only antibiotic used to combat the infection (Fisher 1994).

Methicillin and cephalosporin were introduced in the 1960s in an effort to

control penicillin-resistant Staphylococcus. They appeared to be effective, but then

gram-negative bacteria such as Serratia and Klebsiella began to show resistance to

these new drugs. Another antibiotic, gentamycin, appeared on the market and

seemed to have the situation under control until Staphylococcus reappeared, this

time more resistant than before, the ﬁrst MRSA. The pharmaceutical business re-

grouped and produced a new antibiotic, ciproﬂoxacin (Cipro), but MRSA quickly

became immune. By 1980, MRSA was resistant to everything except vancomycin.

Vancomycin had been held back, not only because it was toxic, but because it was

feared that if MRSA became resistant to it there would be nothing else to throw

at the bacterium. These fears became reality in the late 1980s when hospitals

Chapter 9 Infection 171

began to report vancomycin-resistant infections. Today, a growing number of

pathogens are becoming resistant to conventional antibiotics.

Resistant bacteria are still often treated with cephalosporin, an antibiotic de-

rived from a fungus. Cephalosporin was discovered by Giuseppe Brotzu, a bacte-

riologist from Cagliari in Sardinia (Fisher 1994). The disadvantages of the

cephalosporin group of antibiotics are the hypersensitivity they cause in more

than 10% of patients and their adverse effects on blood-clotting mechanisms

(Hope et al 1993).

Many sexually transmitted diseases, including gonorrhea and chlamydia, now

are multiple-drug resistant. Shigella, the cause of many fecal-contaminated gastric

upsets, is multiple resistant, as are many respiratory infections. Chowdhury

(1998) carried out studies on monkeys infected with mutiple-resistant Shigella

ﬂexneri and found oral doses of black cumin (Nigella sativa) essential oil (1 to 3

ml diluted in soybean oil) were very effective. The experimental group of mon-

keys became entirely free of infection within 2 days, whereas the control group

was still infected after 6 days. According to a Web site dedicated to black cumin

(www.nigella-sativa.com), the essential oil is made from the plant’s seed and was

found in Tutankhamen’s tomb. The essential oil contains 46.8% p-cymene and

21% carvone. In addition, cumin seed essential oil was found to be effective against

E. coli, Staphylococcus aureus, and Streptococcus faecalis ( Jain & Purohit 1992).

Essential Oils as Potential Antibacterial Agents

Essential oils are not just pleasant aromas. Many have speciﬁc antibiotic, antivi-

ral, and antifungal properties and have been classiﬁed accordingly (Natural Med-

icines Comprehensive Database 2002). The responsibility for prescribing an an-

tibiotic usually lies with a physician or nurse practitioner. For many other health

professionals, antibiotic prescription is outside their boundaries or scope of prac-

tice and is inappropriate. However, the use of an essential oil to reduce stress

caused by an infection is acceptable. What is needed is a more detailed look at es-

sential oils’ antibacterial properties. Can they be used to enhance orthodox med-

icine? Can they be used when antibiotics are ineffective? In a world where

pathogens are mutating faster than synthetic medicines can be created to kill

them, essential oils might have a very beneﬁcial role to play. They may even turn

out to be the antibiotics of the future.

There is a long history of essential oils being used against pestilence. A large

number of perfumers and glovemakers appeared to survive the Black Death in Eu-

rope. This could be because glovemakers were licensed to impregnate their wares

with essential oils and because perfumes were made of essential oils. Deinenger

(1995) cites Schweistheimer, who wrote that the English town of Bucklesbury was

spared from the plague—at the time Bucklesbury was the center of the lavender

trade. Lavender has antibacterial properties and has recently been found effective

against MRSA. Nostradamus was supposed to have successfully treated the plague

with pills of crushed roses placed under the tongues of plague victims. Rose

172 Section II Clinical Use of Aromatherapy

contains l-citronellol, geraniol, nerol, linalol, and phenylethyl alcohol (Guenther

1952). Alcohols are thought to be strong antiinfection agents with antiviral prop-

erties (Franchomme & Penoel), so the actions of Nostradamus seem to be logical.

Approximately 58% of all isolated antibiotics are produced from Streptomyces,

a bacterium. Another 9% are derived from other bacteria, 19% from fungi,

lichens, and mosses, and 14% from higher plants. Lewis writes that “the total 909

antibiotics known in 1967 represent only a fraction of those found in nature. Not

a single one, used therapeutically, is from the higher plants, even though these

possess the largest single group of antibiotics for which there is no known use”

(Lewis & Elvin-Lewis 1977). Tamm (1971) reported on ansamycins, a group of

antibiotics characterized by an aliphatic bridge linking two nonadjacent positions

found in an aromatic nucleus.

Some of the plants known to have antibiotic properties include yellow cy-

press, wild ginger, golden seal, poplar tree, turnip, wallﬂower, hops, cabbage, sweet

clover, common bean, cashew, black walnut, potato, corn, and garlic. Each has

been tested against bacteria, fungi, viruses, or protozoa and found to be effective

in vitro (Lewis & Elvin-Lewis 1977). Valnet (1990) suggests if essential oils were

used to treat pathogens, the surrounding tissue would not be adversely affected.

Conventional medicines can sometimes destroy the surrounding tissue along with

the infection, because antibiotics typically kill bacteria by puncturing their cell

walls, which allows toxins to spill out (Service 1994).

In the case of burns, in which the breakdown of tissue causes the body to re-

absorb pathogenic toxins, Valnet (1990) suggests the use of essential oils could be

a suitable or alternative method of treatment, because many essential oils have

tissue-protecting properties that prevent putrefaction. However, essential oils

with a high phenol content can cause dermal irritation and should not be used

to treat burns. Please see Chapter 3 for more information about phenols and

phenol-rich essential oils.

Research on the Antibacterial Properties

of Essential Oils

The primary effect of essential oils on bacteria and viruses appears to be on the

cell membrane (Harris & Harris 1995) where they seem to alter the osmotic reg-

ulatory function (Savino et al 1984). Fifty years ago antibiotic researchers were

investigating possible plant alternatives. The Second National Symposium on

Recent Advances in Antibiotic Research was held in Washington in 1945, under

the auspices of the National Institutes of Health. During the proceedings, the ef-

fects of lupulon, a lipid-soluble, antibiotic-like substance prepared from hops

(Humulus lupulus) were discussed. Chin et al (1949) found lupulon inhibited the

growth of Staphylococcus aureus, Mycobacterium phlei, and Mycobacterium tuberculo-

sis in vitro at concentrations of 1.56, 5.0, and 25 g/mL, respectively. Combining

lupulon with a 2% solution of sodium chloride increased the antibiotic activity.

Hops produce an essential oil (Budavari 1996).

Chapter 9 Infection 173

Maruzella and Sicurella (1960) reported on the antibacterial activity of 133

essential oils in vitro. These were tested against six pathogens, namely E. coli,

Staphylococcus aureus, B. subtilis, Streptococcus faecalis, Salmonella typhosa, and My-

cobacterium avium. Of the essential oils tested, 71% were shown to be effective

against M. avium, 19% against B. subtilis, 14% against Staphylococcus aureus, 12%

against Streptococcus faecalis, and 6% against E. coli. Among the most effective es-

sential oils were lemongrass, oregano, savory, red thyme, and cinnamon. This re-

search was conducted just 2 years after an earlier paper (Maruzella & Percival

1958) investigated the antimicrobial activity of perfume oils.

Deans and Svoboda (1987) found that marjoram (Oregano majorana) was ef-

fective against Pseudomonas aeruginosa, Salmonella pullorum, and Yersinia enteroco-

litica in vitro at a concentration of 1:10 in absolute ethanol. All three organisms

are of signiﬁcance in public health. Essential oils of black pepper (Piper nigrum),

geranium (Pelargonium graveolens), nutmeg (Myristica fragrans), oregano (Orig-

anum vulgare), and thyme (Thymus vulgaris) were tested against 25 different gen-

era of bacteria, and each was found to exhibit considerable inhibitory effect

(Dorman & Deans 2000). Peana et al (1999) found sage (Salvia ofﬁcinalis) and

clary sage (Salvia sclarea) effective against various bacteria including Staphylococ-

cus aureus, E. coli, and S. epidermidis.

P. aeruginosa appears to be less susceptible to tea tree than many bacteria, and

this tolerance is thought to be because of the bacteria’s outer membrane. How-

ever, the addition of polymyxin B nonapeptide (PMBN) to the essential oil ap-

pears to permeabilize the outer membrane, allowing tea tree to become effective

(Mann et al 2000). PMBN may also help other essential oils become effective

against P. aeruginosa.

Zakarya et al (1993) examined the antimicrobial activity of 21 essential oils

of eucalyptus. The effects of the volatile constituents of lemon gum (Eucalyptus

citriodora) were found to be the most effective against E. coli (gram-negative) and

B. megaterium and S. aureus (both gram-positive). Although, when the whole es-

sential oil was used, sugargum (Eucalyptus cladocalyx) was most effective. This

brings up the point, which has been paralleled in many other studies, that isolat-

ing the active, common constituents of essential oils will not produce the same ef-

fects as using the whole essential oil. It is interesting that E. globulus, E. smithi,

and E. radiata were not among the eucalyptus types selected for testing, as they

are regularly used in aromatherapy to treat infections (Penoel 1991/1992).

Ferdous et al (1992) studied the effect of black cumin (Nigella sativa) essen-

tial oil on the treatment of dysentery, and it was shown effective against several

multiple-drug-resistant organisms, such as Shigella, Vibrio cholera, and E. coli. The

activity of the oil was compared with that of ampicillin, tetracycline, cotrimoxa-

zole, gentamycin, and nalidixic acid and was active against all of the bacterial

strains tested, except for one strain of Shigella dysenteriae (strain 1548). Black

cumin is commonly known as Roman coriander, nutmeg ﬂower or fennel ﬂower,

although it is not in any way related to fennel. It actually belongs to the butter-

cup family. The French formerly used the seeds as a substitute for pepper, and in

174 Section II Clinical Use of Aromatherapy

India the seeds are commonly used in curries (Greive 1931). Lemon essential oil

(Citrus limon) was found to completely inhibit Vibrio cholera in a further study by

de Castillo et al (2000). Vibrio species also showed a high sensitivity to basil and

sage essential oils in a study by Koga et al (1999).

Helichrysum picardii, a member of the everlasting ﬂower family, was shown to

be effective against gram-positive bacteria such as Staphylococcus aureus, Bacillus

subtilis, B. cereus, B. maegaterium, and gram-negative E. coli. Its antibacterial ac-

tivity was thought to be less potent than clove and thyme (de la Puerta et al

1993). Helichrysum is used as a tobacco ﬂavorant.

Deans and Ritchie (1987) of the Department of Biochemical Sciences, at the

Scottish Agricultural College in Auchincruive, Scotland, tested the effect of 50 es-

sential oils against 25 genera of bacteria in vitro. Their research found that the most

effective essential oils were bay, cinnamon, clove, thyme, marjoram, pimento, gera-

nium, and lovage. One year later, Deans and Svoboda (1988) found French tarragon

(Artemesia dracunculus) to be effective against P. aeruginosa, S. aureus, S. faecalis, and

Yersinia enterocolitica. In this study, the whole oil was tested against several of the

main chemical constituents such as eugenol, limonene, linalol, menthol, cis-ocimene,

anisaldehyde, and ␣-pinene. This same study produced ﬁrm evidence that the con-

stituents of essential oils change, depending on the time of their harvesting. In this

instance, tarragon plants harvested midseason were the least potent of the tarragon

plants tested. That the constituents of tarragon essential oil alter according to the

time of harvesting is not new to aromatherapy, but this is one of the few studies that

actually demonstrates this. Also of interest is the way the physical conﬁguration of

the molecule affected the essential oil (the difference between cis- and transisomers).

In tarragon, the cis conﬁguration produced a more antimicrobial plant. Tarragon is

used as a ﬂavor ingredient in many foods, as well as in alcoholic beverages and soft

drinks. It is also an important ingredient of bearnaise sauce. Several hybrids (man-

made cultivars) of lavender, sage, savory, and thyme were also tested against 25 bac-

teria in vitro. All four hybrids showed substantial antibiotic activity, but each was

most potent against speciﬁc bacteria. See Table 9-2 for details.

Chapter 9 Infection 175

Table 9-2 h Hybrids and Their Antibacterial Properties

General Common Name Bacteria Affected

Thymus thyme Moraxella spp., Clostridium sporogenes

Salvia sage Acinetobacter calcoacetica, Brevibacterium

linens, Clostridium sporogenes, Moraxella

spp.

Satureja savory Brevibacterium linens, Enterobacter aero-

genes, Klebsiella pneumonia, Moraxella spp.

Lavandula lavender Brevibacterium linens, Clostridium sporo-

genes, Moraxella spp, Staphylococcus aureus

In another paper Deans et al (1992) demonstrated the antibacterial proper-

ties of Oregano ofﬁcinalis (a specially bred strain from Israel) and West Indian

lemongrass (Cymbopogon citratus). Other essential oils found to have antibacter-

ial activity were tarragon, basil, sage, thyme, and celery. Among the bacteria tested

were Salmonella pullorum, E. coli, Klebsiella pneumonia, P. aeruginosa, Staphylococ-

cus aureus, Streptococcus faecalis, and Proteus vulgaris. Deans and Svoboda (1989)

also found summer savory (Satureja hortensis) to be an effective antibacterial agent

against the previously mentioned organisms.

The antibacterial properties of lemongrass were the subject of a detailed in-

vestigation by Onawunmi and Ogunlana (1986). This particular lemongrass is

grown in Nigeria, where it is traditionally used for the treatment of rheumatism.

German chamomile (Matricaria recutita), renowned for its deep-blue color and

antiinﬂammatory properties, also has substantial antimicrobial activity, especially

against gram-positive bacteria such as Staphylococcus aureus and Streptococcus fae-

calis. The antibiotic component is thought to be ␣-bisabolol, which is more ac-

tive than chamazulene (Kedzia 1991).

Balacs (1993) reviewed the antibacterial properties of the plant family Lami-

acae, which includes rosemary (Rosmarinus ofﬁcinalis), wild basil (Calamintha

nepeta), thyme (Thymus vulgaris), and savory (Satureja montana). The effective

chemical parts of these plants are thought to be carvacrol (in savory), ␣-pinene

and 1,8-cineole (in rosemary), thymol (in thyme), and pulegone and para-cymene

(in wild basil).

Benouda et al (1988) tested essential oils against hospital-pathogenic bacte-

ria. This study examined essential oils of armoise (Artemesia herba alba), oregano

(Thymus capitatus), and eucalyptus (Eucalyptus globulus) against Staphylococcus

aureus, Streptococcus C and D, Proteusspp., Klebsiella spp., Salmonella typhi, Haemo-

philus inﬂuenza, and P. aeruginosa and found that the three essential oils had an

action comparable to standard antibiotics. Thyme was the most effective essential

oil, although none of the oils were found to have any impact on Pseudomonas.

A review paper by Carson and Riley (1993) found that tea tree (Melaleuca al-

ternifolia) was an effective antibiotic against Staphylococcus, Streptococcus, and

many gram-negative bacteria, and they concluded that the full therapeutic po-

tential of tea tree had not yet been realized. In The Cowthron Report, Cooke and

Cooke (1994) found manuka (Leptospermum scoparium) and kanuka (Kunzea eri-

coides), New Zealand’s answer to tea tree, produced impressive results. This study

was supported by Maori funds and covered the effects of these two essential oils

against various bacteria and fungi. Manuka appeared to be very effective against

Staphylococcus aureus and ringworm. It was believed manuka could be a useful es-

sential oil in cases of MRSA infection, although the paper stated that no clinical

trials had been carried out.

An additional paper by Carson et al (1995) showed tea tree was effective

against MRSA. It was tested against 64 methicillin-resistant and 33 mupirocin-

resistant isolates of S. aureus and was found to be effective in all cases, using

dilutions of 0.25% and 0.50%. These results were duplicated in a UK study using

176 Section II Clinical Use of Aromatherapy

similar methods. The tea tree used in the UK study was chemotype terpineol

greater than 30%, and the cineole content (an oxide and harsher on the mucous

membrane) was less than 15%. Chan and Loudon (1998) carried out an in vitro

study on 28 isolates of MRSA and eight clinical isolates of coagulase-negative

staphylococci at Manchester Royal Inﬁrmary in Manchester, England. The min-

imum inhibitory concentrations (MICs) were repeated three times and ranged

from 0.25% to 0.5% tea tree. No resistant isolates were found. Many cosmetic

products contain 2% to 5% tea tree. Carson found an added bonus; although tea

tree inhibited MRSA, it did not inhibit CNS and therefore preserves the skin

ﬂora.

Human Studies

For skeptics who may argue the effective antimicrobial activity of an essential oil

in vitro does not guarantee a similar action in humans, Caelli et al (2001) carried

out a study on humans using 4% tea tree nasal ointment and 5% tea tree body

wash against a control of 2% mupirocin nasal ointment and triclosan body wash

on MRSA. The tea tree combination appeared to be better than the conventional

one. However, because of the small number of patient participants (n ⫽ 30) no

statistical signiﬁcance could be drawn.

A study by Sherry et al (2001) indicates that essential oils can be effective in

humans and may be effective when nothing else works. The authors reported on

a chronic case of MRSA osteomyelitis. A 49-year-old man sustained an open

fracture to his left tibia. He underwent debridement and insertion of an in-

tramedullary nail. He underwent a free-ﬂap procedure to the lower tibia 2 months

later to reposition the nail, and a femoral-popliteal bypass graft. Debridement of

the ﬂap was done 8 months later. Debridement of an infective focus of the left

tibia was performed 15 months later. He subsequently developed chronic os-

teomyelitis (MRSA). Long-term antibiotic therapy (oral and intravenous) of 1 gr

ﬂucloxacillin and 1 gr dicloxacillin every 6 hours had been unsuccessful. Ampu-

tation was being considered.

In December, 2000, via a 3-cm percutaneous incision, the lower tibia was

drilled and washed out with 4000 ml of saline. Then it was packed with calcium

sulfate pellets impregnated with lemongrass, eucalyptus, tea tree, clove, and

thyme essential oils in an ethanol base. A catheter was left in situ to allow deliv-

ery of further essential oils. One ml of antiseptic essential oil mixture was ad-

ministrated daily. The dilution and ratio of the essential oils was not given by the

authors. The wound healed and the culture was clear within 3 months. The symp-

toms resolved, and a plain x-ray examination showed resolution of the infective

process with incorporation of the bone graft. The authors commented that es-

sential oils have a strong antimicrobial action, are cheap, simple to use, and can

be used topically (Sherry et al 2001).

Many essential oils, at a dilution known to be safe, have also been shown ef-

fective against drug-resistant pathogens. In 1994, a workshop was given at the

Royal Society of Medicine in London, England, on aromatograms and the use of

Chapter 9 Infection 177

essential oils as antibacterial agents. Michael Smith, a London-based pathologist

who conducts aromatograms for several London hospitals, gave his analysis of the

antibacterial properties of several essential oils on MRSA. Every one tested was

effective. The essential oils included oregano, thymol (Thymus vulgaris CT3),

Moroccan chamommile (Ormenis mixta), Dutch mill lavendar (Lavandula x in-

termedia CT Super), Italian cypress (Cupressus sempervirens), peppermint (Mentha

piperita), ravensara (Ravensara aromatica), juniper (Juniperus communis), lemon,

palmarosa (Cymbopogon martini), eucalyptus, and gully gum (Eucalyptus smithi).

Most of these are essential oils that are commonly used for stress management

and are generally accepted as being safe. Many of them are used by health pro-

fessionals in the United States. The time is right to consider using essential oils

for all their properties.

My students have had some impressive case-study results using essential oil

compresses on wound infections and infected bedsores. Swabs to indicate infec-

tious pathogens were taken, and the relevant essential oil selected. One particu-

larly impressive case study was conducted by a nurse practitioner. A female pa-

tient had a chronically infected bedsore. This patient had been on systemic

antibiotics without effect. A wound swab showed the infection had been caused

by Clostridium. Searching through her notes, the nurse practitioner found a ref-

erence to a paper by Ross et al (1980). After she had discussed the safety and po-

tential efﬁcacy of sweet marjoram (Origanum majorana) with the patient’s physi-

cian and had shown him the monograph, he gave his consent for her to use this

essential oil. The treatment was discussed with the patient and consent obtained.

A compress was applied directly to the infected site, using a 5% solution of

sweet marjoram. The compress was reapplied three times a day. Within 24 hours

there was a dramatic improvement, and within 5 days the wound was healed. In

other case studies, essential oils with antibacterial properties have been selected

without a swab being taken. Dilutions of up to 10% have been used. Not one case

has shown any negative side effect to date. In most instances, the infection has

healed very rapidly. For more information on wounds and protocols please see

Chapter 15 on care of the elderly.

Further research is required. Animal testing has already been done for po-

tential toxicity of essential oils; atoxicity studies on human tissue have indicated

a safe level at which essential oils can be used. What is needed now is a series of

controlled trials to explore the antimicrobial efﬁcacy of essential oils in humans.

As Peter Mansﬁeld, MD, (1996) writes, “Science is really a method for answer-

ing questions. If we ask stupid questions, scientiﬁc methods will faithfully pro-

duce for us a stupid answer.” It is not stupid to ask questions relating to aro-

matherapy and stress, but it is perhaps stupid not to ask questions about

aromatherapy and infection. Just because these oils are natural does not mean

they are not powerful. Norman Farnsworth, Director of Pharmacognosy at the

University of Illinois College of Pharmacy is quoted as saying,: “There is not a

dime’s bit of difference between chemicals in plants and synthetics” (Sears 1995).

178 Section II Clinical Use of Aromatherapy

The Aromatogram

Just like synthetic antibiotics, many essential oils are effective against particular

pathogens. The skill lies in knowing which essential oil to use for which infection.

Conventional medicine regularly takes wound or throat swabs, or urine or blood

samples to cultivate and identify a pathogen.

Gattefosse used exactly the same principle of this process, which is called an

antibiogram, in France and renamed it an aromatogram. The only difference in

the procedure is with an aromatogram an essential oil is added to the Petri dish

instead of an antibiotic. A hypothetical example of an aromatogram is shown in

Fig. 9-5.

The Petri dish is lined with a culture medium such as agar-agar. A culture

broth of the pathogen is spread across the plate. Several small paper circles, each

impregnated with different essential oil, are placed on the agar-agar, and the Petri

dish is incubated for 24 hours. If the essential oil is the correct antidote, an area

of inhibition occurs in a circle around the impregnated paper. Sometimes an es-

sential oil not effective on its own is effective when it is close to a second essen-

tial oil. Sometimes two essential oils together give a large area of inhibition but

individually produce no area of inhibition. Aromatograms are used in France and

England and could be of great use in the United States. So far I have been unable

Chapter 9 Infection 179

Figure 9-5 Hypothetical example of an aromatogram. Six different essential oils, here

identiﬁed only by number, are being tested against one bacterial culture from the body of

a patient. The shaded area in each square is known as the “area of inhibition” and shows

how effective each oil is against the bacteria. In this case essential oils 3 and 5 would be

used to treat the patient.

From Tisserand R. 1988. Aromatherapy for Everyone. Har-

mondsworth, UK: Penguin Books.

to ﬁnd a laboratory in the United States prepared to conduct an aromatogram,

but this is obviously the way of the future. Belaiche (1979), a French doctor, has

created many tables illustrating the speciﬁc uses of essential oils against speciﬁc

bacteria and their effects.

In England, Deans and Ritchie (1987) used the aromatogram technique in a

comprehensive and impressive study that examined 25 genera of bacteria and 50

essential oils. This kind of sensitivity testing for essential oils in the treatment of

bacterial infections is being carried out by several London hospitals, and there is

active campaigning to increase the understanding of how aromatograms work

(Blackwell & Smith 1995). It is hoped that this scientiﬁc method of selecting es-

sential oils in sensitivity testing will become more widespread as it becomes bet-

ter understood. However, a new microdilution method using the redox dye Re-

sazurin has also been developed for determining the MIC of an essential oil

(Mann & Markham 1998). This method overcomes the problem of adequate

contact between an essential oil and the test bacteria and obviates the need for a

chemical emulsiﬁer.

Blackwell and Smith (1995) and Valnet (1990) both emphasize that standard

organisms do not respond in exactly the same way as a host organism. Even though

a pathogen is known and named, it may not respond in an identical way; the host

must be taken into consideration. To illustrate this, Valnet writes that a colibacillus

in one patient may respond to the essential oil of pine, whereas in another patient

it may respond to the essential oil of lavender or thyme. This is quite different from

the Western approach in which everyone is given the same antibiotic (usually

broad-spectrum). However, the selection of essential oils for testing via an aro-

matogram is based on the antibacterial properties reported in the literature.

Viruses

A virus is different than any other pathogen because it is a coiled strand of nu-

cleic acid protected by a protein coat, which can only survive and reproduce in-

side a host cell (Roberts 1986). Because viruses are so small, their biology was not

understood for many years until electron microscopy revealed what they looked

like. Many biologists still do not classify them as living organisms in their own

right but only when they are inside a host cell. There are basically two types of

virus: those that attack bacteria and those that attack the cells of other living or-

ganisms, such as animals and humans. The basic structure of a virus is illustrated

in Fig. 9-6.

Viruses are classiﬁed as either DNA viruses or RNA viruses. The DNA

viruses are subdivided into single-strand and double-strand viruses. RNA viruses

also occur as single or double strands, with retroviruses, such as AIDS, in the

single-strand group. A retrovirus contains an enzyme called reverse transcriptase

that allows the RNA in the virus to be reverse-transcribed into DNA. Drugs such

as zidovudine (AZT) and zalcitabine (HIVID) are designed to inhibit production

of reverse transcriptase. Resistance acquired by viruses during antiviral therapy

180 Section II Clinical Use of Aromatherapy

has been well documented and usually occurs when the virus mutates (MacSween

& Whaley 1992).

Viruses that cause glandular fever, hepatitis, inﬂuenza, warts, the common

cold, mumps, and measles are well known; less common is the rabies virus. More

recent viruses are herpes and Lassa fever. Of these viruses, only smallpox has been

eradicated through immunization. A compulsory immunization program in the

West has controlled mumps and measles, although they remain potential killers

in developing countries. Patients with immune deﬁciency (or dysfunction), both

primary and secondary, are more vulnerable to infections of any kind than persons

with intact immune systems.

Synthetic Antivirals

Geoffrey Carr (1996) of The Economist wrote, “No viral epidemic has ever been

stopped by drugs.” Synthetic viricides are difﬁcult to manufacture, and none of

Chapter 9 Infection 181

Naked icosahedral

(e.g., poliovirus)

KEY:

Spikes (glycoprotein)

Envelope (protein and lipids)

Proteins making up

the capsid

Nucleic acid

Enveloped icosahedral

(e.g., herpesvirus)

Enveloped helical

(e.g., influenza virus)

Figure 9-6 Structure of viruses. From Ackerman B, Dunk-Richards G. 1991. Microbiology:

An Introduction for the Health Sciences. Australia: WB Saunders.

them appear to be totally effective to date. Most have moderate to severe side ef-

fects. They work in one of three ways: through immunological control, through

stimulation of the natural resistance mechanism of the host, or through

chemotherapy. One of the most successful, AZT, stops the phosphate linkage

from being formed. This means the virus cannot manufacture DNA (Craig &

Stitzel 1994). Other synthetic antivirals include acyclovir (Zovirax), famcyclovir

(Famvir), Vidarabine (Vira-A), and rimantadine (Flumadine).

Highly active antiretrovial therapy (HAART) is a powerful weapon that has

greatly affected the AIDS epidemic—an epidemic that may well turn out to be

more devastating than the plague itself. AIDS/HIV has killed three times more

Americans than the Vietnam war (Sullivan 1995). Unfortunately HAART drugs

also have potent side effects and it is difﬁcult for patients to completely adhere to

the treatment regimen.

Antiviral Properties of Essential Oils

Many plants and their aqueous extracts have been tested for antiviral activity. In-

terestingly, when the essential oil from the plant is used, it too seems to have an

antiviral effect, although the essential oil has a different chemistry than the aque-

ous extract. Therefore a good pointer is to study the published research on the

aqueous extracts.

An investigation supported by the National Institutes of Health showed an

aqueous extract of lemon balm (Melissa ofﬁcinalis) had antiviral properties

(Kucera & Herrmann 1967). The aqueous extract was tested on embryonic eggs

and in tissue culture infected with Semliki forest (a mouse brain disease), New-

castle disease, vaccinia, and herpes simplex. The results showed lemon balm pro-

tected the embryonic eggs against the lethal action of all viruses tested. It is

thought that the antiviral action was produced by the tannin-like polyphenol.

This activity is thought to be unrelated to that of tea tannins, although they are

known antivirals and effective on inﬂuenza A (Cohen et al 1964). Kucera and

Herrmann (1967) also explored the antiviral effects of the aqueous extract of

lemon balm against inﬂuenza A and B, mumps, and three different strains of

parainﬂuenza (1, 2, and 3). The results showed that lemon balm had an antiviral

effect on mumps and the three parainﬂuenza strains, but had no effect on in-

ﬂuenza A and B. Extract of lemon balm is sold in commercial antiviral prepara-

tions in Germany (Foster & Duke 1960). I have found lemon balm essential oil

(5-25%) to be effective against herpes simplex 1 and 2.

Penoel (1991/1992) writes that essential oil of gully gum has strong viricidal

action and suggests the antiviral properties are due to 1,8-cineole (sometimes also

called eucalyptol). 1,8-cineole is found in several essential oils such as bay laurel

(Laurus nobilis), ravensara, spike lavender (Lavandula latifolia), rosemary, Span-

ish sage (Salvia lavendulaefolia), and cardamom (Elettaria cardamomum). Penoel

(1991/1992) suggests that limonene and ␣-pinene reinforce the antiviral action of

1,8-cineole, whereas alcohols strengthen its antiviral action. I have found gully

182 Section II Clinical Use of Aromatherapy

gum, ravensara, spike lavender, and rosemary all effective against both herpes and

the cold virus. I have not tested them against inﬂuenza.

Cariel and Jean (1990) tested cypress (Cupressus sempervirens) for viricidal

properties and then applied for a patent. Lemon gum was found to be an effec-

tive antiviral by Mendes et al (1990). This eucalyptus was also studied for its anti-

HIV activities, together with eight other medicinal plants from Zaire (Muanza et

al 1995). May and Willuhn (1978) found eucalyptus had antiviral properties. This

is of particular interest to patients with HIV/AIDS as eucalyptus is also known

to enhance the activity of streptomycin, isoniazid, and sulfetrone in TB, a com-

mon opportunistic infection among those with AIDS (Kufferath & Mundualgo

1954). Extract of eucalyptus was also found effective against herpes simplex I

(Takechi & Tanaka 1985). Extract of sweet marjoram was found to work as an

antiviral in a study by Kucera and Herrmann (1967). Sweet marjoram is a safe es-

sential oil to use on the skin.

Duke (1985) writes that ceylon cinnamon (Cinnamomum verum) and clove

(Syzygium aromaticum) have antiviral properties. Takechi and Tanaka (1981) sug-

gest the actual antiviral substance from the bud is eugeniin. Clove bud oil, which

is used in baking, perfumes, lipsticks, soaps, and dentistry, has caused hand der-

matitis (Lovell 1993), although clove bud essential oil is thought to be safe for use

at up to 5% dilution (Opdyke 1979).

Cinnamon produces two essential oils: one from the leaf and one from the

bark. The leaf essential oil contains less than 7% cinnamic aldehyde (a known skin

irritant), but the essential oil obtained from the bark contains up to 90% cinnamic

aldehyde (Lovell 1993). The latter is therefore contraindicated for topical appli-

cations, as even at such low dilutions as 0.01%, positive reactions have been found

in patch testing (Mathias 1980).

May and Willuhn (1979) tested 178 species of medicinal plants belonging

to 69 families for their virustatic properties. In total, 75 aqueous extracts ap-

peared to have antiviral properties. These were tested against polio, inﬂuenza,

and herpes viruses. Bay laurel, oregano, rosemary, and sage were the most effec-

tive of the Lamiaceae family against all three viruses. Juniper also showed sub-

stantial antiviral action against herpes and inﬂuenza. Bay laurel should perhaps

be avoided because it can cause contact dermatitis, although the Research Insti-

tute for Fragrance Materials (RIFM) monographs report in three separate tests

there were no reactions on human volunteers (Tisserand & Balacs 1995).

Oregano is high in phenols and known as a skin irritant so is best avoided

(Opdyke 1979). However, oregano can be used in aromatic medicine for acute

and chronic infections when taken by mouth, diluted in gelatin capsules. Please

see section of Chapter 7 on oral use. Juniper is a good choice for topical use be-

cause it contains mainly terpenes and has a very astringent action.

Essential oil of sandalwood was found to have antiviral activity in a study by

Benencia and Courreges (1999). Their study focused on herpes simplex 1 and 2

and was carried out on the kidney cells of monkeys. Sandalwood was most effec-

tive against herpes simplex 1. Benencia and Courreges speculated the antiviral

Chapter 9 Infection 183

effect could be due to sandalwood’s modulatory inﬂuence on cellular glutathione

S-transferase activity.

Isoborneol, a monoterpenic component of several essential oils, was found to

have viricidal activity against herpes simplex virus 1. Isoborneol inactivated the

virus within 30 minutes of exposure at a concentration of 0.06%, and completely

inhibited viral replication without affecting viral adsorption (Armaka et al 1999).

Isoborneol did not show signiﬁcant cytotoxicity when tested against human cell

lines at 0.16%. Therefore essential oils containing major proportions of isoborneol

might be useful in treating herpes.

A lesser-known essential oil, chameleon (Houttynia cordata), was tested

against herpes simplex, inﬂuenza, and HIV-1 in a Japanese study by Kyoko et al

(1994). This oil showed remarkable effects, although it was not effective against

the polio and coxsackie virus. The research showed that essential oils have the po-

tential to interfere with the virus envelope, which results in the loss of infectivity

of the virus, because the attachment to the cell surface must necessarily involve

viral-surface glycoproteins present in the envelope.

Garlic has been used against infections for centuries and is the subject of al-

most 1000 research papers. Recent research has shown garlic to be effective

against herpes virus types 1 and 2, parainﬂuenza virus type 3, vaccinia virus

(cowpox), and human rhinovirus type 2 (a common cold virus). The active in-

gredients, allicin and ajoene, are thought to attack the virus inside the cell, pos-

sibly in the cell membrane (Weber 1992). Although garlic essential oil is avail-

able, it is unlikely to be used in a clinical setting because of its strong, pervasive

odor.

Franchomme and Penoel (1990) list three chemotypes of Thymus vulgaris

(CT thymol, geraniol, and linalol) as antivirals. Sweet marjoram, lemon balm, cy-

press, eucalyptus, and juniper essential oil are all safe to use for treating herpes

simplex 1 and 2. Essential oils that contain a high 1,8-cineole content should be

used with caution in high dilutions on irritated mucous membrane, because they

may cause skin sensitivity. Essential oils that contain 1,8-cineole include gully

gum, bay laurel, ravensara, spike lavender, rosemary, Spanish sage, and cardamom.

Essential oil of eucalyptus is my ﬁrst choice against herpes simplex 1 and 2. Es-

sential oils can play an important role in the treatment of viral illness. For more

information about the treatment of herpes, including protocols, please see Chap-

ter 20 on immunology.

Fungal Infections

Some of the most deadly infections come from fungi in the air we breathe; when

a healthy immune system is in place, the fungi have no effect (Richardson 2000).

A fungus is a primitive organism classiﬁed as neither a plant nor an animal. Only

a few fungi are pathogenic to man, and most cause superﬁcial, mild lesions

(MacSween & Whaley 1992). Fungi are divided into three categories: superﬁcial,

subcutaneous, and systemic. All can be environmental in origin. Fungal infection

184 Section II Clinical Use of Aromatherapy

is caused by airborne allergens, elaborating toxins, or direct infection. A disease,

or infection, caused by fungi is called a mycosis (Parish 1991). With an airborne

allergen (such as tinea, or ringworm) the spores, or hyphae, of the fungus inﬁl-

trate the outer layers of the skin and cause destruction of the epidermis. With

mycetoma, a localized infection occurs that may slowly spread, although with can-

didiasis and cryptococcosis the infection can become systemic.

Cryptococcosis

Cryptococcosis is a yeast infection that is spread by bird droppings and begins as a

sporadic disease manifesting with lung infestation. From the lungs, yeast cells mi-

grate to the CNS. Techically there is a blood-brain barrier (BBB) but this barrier

is not 100% leakproof and under certain conditions, such as immune deﬁciency,

the BBB is compromised and CNS infection can occur. Standard treatments

are ﬂuconazole, itroconazole, or amphothericin B encapsulated in liposomes

(Cordonnier 1993). This treatment is still in use (Evans 2000). However, clinical

resistance occurs fairly quickly.

Aspergillosis

Spores of this Aspergillosis are present in the atmosphere, and many species are in-

fectious to man. The most common is Aspergillus fumigatus. Although the effect

of this fungus is not as rapid as that of Cryptococcus, the possible resulting

bronchial asthma can be debilitating. The fungus may colonize a bronchial cavity

and can result in necrotizing pneumonia. This tends to occur only in immuno-

compromised patients.

Candida albicans

Candida is normally present in the mouth, intestinal tract, vagina, and on moist

skin and does not pose a problem. However, in certain circumstances, the fun-

gus begins a mucocutaneous, or systemic, invasion. The mucosal infection occurs

when an alteration in the pH of the body tissue produces an alkaline medium

that allows the yeast fungus to proliferate. From the mucosa, Candida can invade

surrounding surfaces such as nail beds, producing chronic, granulomatous in-

ﬂammation of the underlying tissue. It can also spread throughout the body, in-

vading the heart valves, lungs, liver, and kidneys with multiple, small abscesses

containing the fungus (MacSween & Whaley 1992). The symptoms of mucosal

infestation are severe itching, with creamy, curd-like deposits. Candida is the ma-

jor fungal pathogen of immunocompromised patients (Kwon-Chung & Bennett

1992) but is also common in diabetes, pregnancy, antibiotic therapy, and after ra-

diation and chemotherapy. Recently, Candida has become resistant to many con-

ventional drugs and metabolic inhibitors that have no commonality (Goldway et

al 1995).

The incidence of Candida overgrowth has increased dramatically during the

preceding few years and is thought to be related to immune supression, the use of

the contraceptive pill, and the overuse of antibiotics (Zarno 1994).

Chapter 9 Infection 185

Synthetic Antifungals

It is more difﬁcult to treat fungal infections than bacterial infections, because

many fungal infections occur in tissues with poor (if any) blood supply. Examples

of infection sites are the nails, hair, and skin. However, fungal infections are

thought to be less difﬁcult to treat than viral diseases by orthodox medicine. The

drug of choice for fungal infections is ﬂuconazole (Diﬂucan) or mycostatin

(Nyastatin). Although topical application may keep the fungal infection at bay,

systemic treatment is often given to reduce the incidence of recurrence following

multiple infections. Fluconazole can affect kidney function. Of the other drugs

used to treat fungal infection, many cause nausea and induce skin rashes, and a

few can cause liver damage (Parish 1991). More recently developed antifungals

like itraconazole or Lamasil do cause liver damage (Newsham 2002).

Antifungal Properties of Essential Oils

Essential oils appear to have an antisporulating and respiration-inhibitory effect

on fungi (Inouye et al 1998). In 1927 Myers published some of the earliest re-

search on the antifungal properties of essential oils. He was prompted to investi-

gate the fungicidal properties of essential oils following successful treatment of a

lesion with a diluted solution of cinnamon oil, which caused immediate relief of

symptoms and rapid healing. He observed that thymol, carvacrol, and oil of

lemon destroyed yeast in less than a minute. His research involved nine yeast-like

organisms, which were isolated from infections in humans, including two lung in-

fections, two tongue infections, one infection involving a nail lesion, and various

other cutaneous ulcerations. Each infection rapidly became yeast-negative and

was resolved with no recurrence. Laboratory work has shown that volatile oils ex-

hibit antifungal activity at very low concentrations in growth medium. One ex-

ample is 1 to 10 ␮L

-1

of marjoram reduced the growth of ﬁlamentous fungiby up

to 89% (Deans & Svoboda 1990). Electrical or battery-operated diffusers and

nebulizers are the most effective ways of getting essential oils into the lungs.

Nebulizers are a very suitable method of treatment for lung infestations by yeast,

fungi, or bacteria as they ﬁll the air with an extremely ﬁne mist of micromolecules

of essential oil. Nebulizers can be programmed to come on and off at speciﬁc

times.

Cryptococcosis

Viollon and Chaumont (1994) tested the susceptibility of a strain of Cryptococcus

neoformans isolated from the blood of a patient with AIDS to 25 essential oils and

17 separate chemical constituents found in essential oils. Many of the essential

oils used showed good fungistatic action. The best effects were from palma rosa,

geranium, savory, sandalwood, thyme, marjoram, and lavender. Pattnaik et al

(1996) reported that lemongrass, eucalyptus, palma rosa, and peppermint were

the most effective essential oils tested against Cryptococcus. Basil and thyme were

186 Section II Clinical Use of Aromatherapy

not included in this study. (Lemongrass in low dilutions was effective not only

against Cryptococcus but against all 11 other fungi tested.) MIC for each of the

four essential oils against Cryptococcus was 5 ␮L

-1

In another paper, Pattnaik et al (1997a) found complete essential oils were

more effective against Cryptococcus than their isolated, active components.

Lemongrass was the exception. The effectiveness of lemongrass was equal to the

isolated parts of citral and geranial. Larrondo and Calvo (1991) compared the

topical and inhaled action of citral against the systemic effects of clotrimazole.

Although the actual way essential oils work as fungicides is not completely clear,

it seems metabolism and growth of the fungus is inhibited, often with a break-

down in the lipid part of the membrane, resulting in increased permeability or

rupture (Larrondoet al 1995).

Soliman et al (1994) found rosemary and Mehrotra and Rawat (1993) found

Artemisia parviﬂora (a member of the Indian tarragon family) to be effective

against Cryptococcus. Although this Artemsia is not in common use, rosemary is

used topically for muscle tension and is inhaled for its antispasmodic effect on

coughs (Price & Price 1995). Viollon and Chaumont (1994) suggest geranium,

palma rosa, savory, and thyme might also be good choices for Cryptococcus. If

the rosemary is a ketone chemotype, avoid using it for extended periods of time

(Tisserand & Balacs 1995).

Aspergillosis

Onawunmi (1989) found West Indian lemongrass (Cymbopogon citratus) and

Garg and Dengre (1988) found cumin (Cuminum cyminum) effective against as-

pergillosis. Tisserand & Balacs (1995) suggest that because cumin has a strong

photosensitizing action, it should not be used topically on patients who will

be exposed to ultraviolet light within 12 hours, and dilutions should be kept to

0.04%. Other effective essential oils include tarragon (Artemisia dracunculus)

(Mehrotra & Rawat 1993) and lemon gum (Hmamouchi et al 1990). Of these,

perhaps lemongrass and lemon gum are most commonly used. Neither of these

essential oils has any known adverse reactions at dilutions of 1% to 5 % (Opdyke

1976). Inoye et al (2000) found that just the vapor of lavender and tea tree

stopped the apical growth of hyphae of Aspergillus in closed containers.

West Indian lemongrass was found effective against Aspergillus fumigatus,

various isolates of Candida, and Trichophyton mentagrophytes by Onawunmi

(1989). The most active component of lemongrass is citral (70% to 80%), which

is thought to be responsible for the antifungal activity of this plant. In another

study, lemongrass was found to be effective against 15 fungi, including Aspergillus

terreus, A. ﬂavus, A. ochraceus, A. parasiticus, A. fumigatus, A. ustus, A. niger, Peni-

cillin nigricans, P. melin, P. chrysogenum, P. brevicompactum, Fusarium moniliforme,

and F. oxysporum (Agarwal et al 1980). Other plants with a high citral content are

lemon grass, citronella, lemon verbena, and lemon gum. Pattnaik (1999) con-

ﬁrmed the antifungal acitivty of most Cymbopogon spp. Camphor (Cinnamomum

camphora) was found to be as effective as Ceresan, copper oxychloride, and

Chapter 9 Infection 187

Thiovit (all synthetic, commonly used antifungal agents) against Aspergillus

ﬂavus, a common spoiler of stored food. However, essential oils of both brown

and yellow camphor are contraindicated in human use because they contain saf-

role, which is thought to be carcinogenic.

Candida albicans

Speciﬁc essential oils effective against Candida include tea tree (Belaiche 1985),

lemon grass (Larrondo & Calvo 1991), and lemon gum (Hmamouchi et al 1990).

Much has been reported about the antifungal effects of tea tree from Aus-

tralia (Belaiche 1985a; Shemesh 1991), and certainly this is one of the safest and

most effective essential oils to use, particularly in the vagina. However, many

other essential oils have antifungal properties. Caraway, clove, geranium, lavender,

lemon, lemongrass, neroli, peppermint, petitgrain, spearmint, coriander, and

sweet orange leaf are all effective to varying degrees (Galal et al 1973). Coriander

is one of the ﬂavorants of the liqueurs Chartreuse and Benedictine (Lawless

1992). Cuong (1994) found cajuput (Melaleuca cajuputi) effective against Candida

albicans. The cajuput tree grows to a height of 45 feet, and its resilience has made

it something of an unwanted visitor in some parts of the Far East, where it ap-

pears to resist burning and cutting. The principal constituent of the oil is 1,8-

cineole. Traditionally, cajuput has been used in Vietnamese medicine to treat skin

diseases, lice, and ﬂeas (Guenther 1952).

Research from India shows that many Indian essential oils have antifungal

properties (Satinder & Sinha 1991). Although not in common use, these essential

oils can be specially ordered from some of the leading essential-oil distributors.

Some of the Indian essential oils mentioned by Guenther (1952) are as follows:

Long pepper (Piper longum) is a climbing shrub with heart-shaped leaves and

berries that fuse together to form spike-like cylindrical cones. The es-

sential oil is pale green with an odor somewhere between that of black

pepper and ginger. It is effective against Candida albicans.

Holy basil (Ocimum sanctum) has a strong odor of cloves and contains 71%

eugenol, which has antifungal properties.

Ajowan (Trachyspermum ammi), which resembles the parsley plant although

it has a totally different smell, is used in India to treat intestinal prob-

lems. The essential oil has a high thymol content and is used in Indian

medicine to treat cholera as well as fungal infections

Deans and Svoboda (1990) found sweet marjoram effective against As-

pergillus niger and, to a lesser extent, against A. ﬂavus, A. ochraceus, A. parasiticus,

and Trichoderma viride. Candida albicans was also inhibited by 21 different Euca-

lyptus species in a study by Faouzia et al (1993).

Lippia alba, which grows widely in Central and South America, has been shown

to have strong antifungal activity against Trichophyton mentagrophytes var. interdigi-

tale and Candida albicans. Several chemotypes of the plant exist, so the essential oil

from Aruba was thought to be most suitable because it contains 64% citral (Fun &

Svendsen 1990). Lemon verbena (Lippia citriodora) contains 30% to 35% citral.

188 Section II Clinical Use of Aromatherapy

Tea tree has been shown to be extremely effective in the treatment of C. al-

bicans (Belaiche 1985a) in deep nail infections. These infections, which are usu-

ally notoriously difﬁcult to treat, responded well to tea tree. In all eight patients

treated, mycosic degeneration stopped. In two of the cases, the infected nail fell

off but the regrowth was healthy. In the other six cases the nail changed color.

This effect disappeared as the regrowth progressed. Belaiche noted that this has

not been observed with any other antifungal agents. Another important facet of

the study was that the treatment was pain free, and the skin appeared to be very

tolerant of this method.

Tea tree mouthwashes were effective against oral thrush in a young man who

had a bone-marrow transplant. He had a patch of white and green with some yel-

low on his tongue and had been treated for several months with Nystatin with no

success. However, after just 4 days of using a mouthwash with 2% tee tree, his

tongue was clear (Ogden 2001).

Clove (Eugenia caryophyllata) was shown to have fungicidal action at 0.4%

dilution against C. albicans in a study published by Briozzo et al (1989). Dube et

al (1989) found 22 species of fungi, including Aspergillus, were inhibited by the

essential oil of basil (Ocimum basilicum). Larrondo et al (1991) found lemon balm

to be 100% effective against C. albicans. Lemon balm contains 30% citral and 39%

citronella (Wagner 1984). Celery (Apium graveolens) and cumin used together

were effective in inhibiting the growth of 29 fungi tested, including A. ﬂavus and

A. parasiticus. Nenoff et al (1996) reported on the antifungal activity of a compo-

nent of tea tree, y terpinene. Jedlickova et al (1992) found terpinene-4-ol en-

hanced antibiotic (ticarcillin) effects against P. aeruginosa. Terpinene-4-ol is also

an effective antifungal agent. The functional groups of alcohol and terpene are

safe to use on the mucous membrane.

These are just a few examples of the hundreds of research studies (most of

them conducted in vitro) carried out over the last few years indicating the anti-

fungal properties of essential oils. Many of these essential oils are currently being

used only for stress management, not for their antifungal properties, because their

antifungal properties are not appreciated.

Plant oils are also being investigated for agricultural use. The New York Times

reported in 1999 that benzaldehyde, the compound that gives peaches their

aroma, also kills Fusarium oxysporum, Rhizoctania solani, Pythium aphaniderma-

tum, and Sclerotinia minor,which are all common fungi found in soil. Benzalde-

hyde could be a potential replacement for methyl bromide, a widely used pesti-

cide that is toxic to people and also damages the planet’s protective ozone layer

(Cushman 1999).

Parasites

A mainly temperate country such as the United States does not have as much of

a problem with parasites as do countries farther south, where bilharzia and

malaria can be endemic. However, with international travel, West Nile virus has

Chapter 9 Infection 189

arrived in the United States and epidemiologists theorize it is only a question of

time before malaria and yellow fever follow. Bilharzia may not be common in the

United States but scabies, Trichomonas vaginalis, lice, ticks, and ﬂeas are common

parasites, and infestations by hookworm and roundworm can be found.

Synthetic Antiparasites

The antiparasitic drug market is worth $3 billion worldwide. The ﬁrst modern

anthelmintic (after mercury and arsenic), Thiabendazole, was developed in 1960.

Since then pentamidine (Diamidine) and nitroheterocyclic antiprotozoal drugs

such as metronidazole have been developed. The major problem with treating

parasites with drugs is that the patient may become infected again almost imme-

diately. Many parasites, including malaria-carrying mosquitoes, are becoming

drug resistant, particularly in Africa and Asia where there are no effective drugs

left. The World Health Organization suggests that meﬂoquine should only be

used for treating the most difﬁcult, drug-resistant cases of malaria. Currently,

there are no effective drugs for Cryptosporidia, which infects the lining of the gut

and causes diarrhea, or Pneumocystis, which infects the lungs.

Antiparasitic Properties of Essential Oils

Malaria

There are approximately 300 to 500 million cases of malaria a year, resulting in

1.75 to 2.5 million deaths (Kayser et al 2002). The reemergence of malaria as

a major health problem, particularly in Africa, is due to the resistance of the

plasmodium-bearing mosquito to quinine, chloroquine, pyrimethamine, cy-

cloguanil, and meﬂoquine.

Essential oils from plants such as lemon grass, Palma rosa, and citronella (Cym-

bopogon nardus) have a long history of repelling mosquitoes (Ansari & Razdan

1995) and are as effective as the chemical insect repellent N,N-diethyl-meta-

toluamide (DEET) (Rutledge et al 1983). Neem (Azadirachta indica) and tumeric

are also effective (Ansari & Razdan 1995). Watanabe et al (1993) found Eucalyptus

camaldulensis effective, Chokechaijaroenporn et al (1994) found basil effective, and

Mwaiko (1992) found lemon and orange peel oils effective. Studies my students

and I carried out have conﬁrmed the ability of basil, palma rosa, and eucalyptus es-

sential oils to deter mosquitos in human subjects.

Massoud and Labib (2000) studied the effect of extract of myrrh (Com-

miphora molmol) against mosquito larvae. Microscopic examination showed great

pathologic effect on mosquitos’ fat, muscle, gut, and nervous tissue. Currently,

clinical trials are being completed on Artemisia annua ( Juteau et al 2002). In vitro

trials using isolated, biologically active substances (artemisinin and quinghaosu)

obtained from this species of Artemisia, have shown it to have pronounced anti-

190 Section II Clinical Use of Aromatherapy

malarial properties (Klayman et al 1985; Cubukcu et al 1990; Liu et al 1992;

Chalchat et al 1994). Artemisinin and quinghaosu are not found in the essential

oil but may be the precursors, similar to matricin and chamazulene.

Scabies

Scabies (Sarcoptes scabii) produces a papular, intensely itchy rash with burrows in

the ﬁnger clefts (Hope et al 1993). Larvae, nymphal instars, and adult mites were

all were killed within 3 hours after applying 5% tea tree in vitro (Walton et al

2000).

Bilharziasis

Bilharziasis is endemic in 76 countries and affects approximately 200 million peo-

ple worldwide (Marston & Hostettmann 1991). It is spread by larvae, which pen-

etrate the host skin and are carried by the blood to the liver. In the liver they ma-

ture, mate, and relocate to the veins around the small intestine where they lay

eggs. Conventional medication is Praziquantel, which kills the worms in situ. Un-

fortunately the dead worms may still be carried back to the liver and cause intense

inﬂammation. By interrupting the infectious process at the level of the interme-

diate host, this is avoided. Lahlou and Berrada (2001) tested 28 essential oils from

Moroccan aromatic plants against the molluscan intermediate host of the urinary

parasite Bulinus truncatus, which causes bilharziasis. Of the essential oils tested,

75% had molluscicidal acitvity. The most effective were Citrus aurantium L. var.

valencia and Origanum compactum. These were effective within 24 hours and at

low concentrations (0.21 to 0.38 parts per million). Fringed rue (Ruta chalepen-

sis), wormseed (Chenopodium ambrosioides), and Roman chamomile were also ef-

fective.

Other Parasites

Trichomonas vaginalis is a ﬂagellate parasite that causes vaginitis, and there are

other amoebas that cause dysentery-like symptoms. Perhaps more common in the

West are infestations by worms (both roundworms and tapeworms), lice, ticks,

and ﬂeas. Although several aromatherapy books suggest that various essential oils

have anthelmintic properties (which would make them suitable for removing in-

testinal worms), very little research data are available. To treat the gastrointestinal

tract, essential oils need to be taken orally. Parasites that live on or just under the

skin can be effectively treated with topically applied essential oils. Several of my

students in Florida have used essential oils topically to kill sea-lice and remove

the itching and erythema that accompany infestations of this kind. The essential

oil they used was true lavender, either undiluted or at 5% dilution. The effect was

“almost instant.”

Lemon gum has been found to be antiparasitic both for amoeba and for

worms (Gilbert & Mors 1972; De Blasi & Debrot 1990). Eucalyptus has also

been found effective against certain amoeba.

Chapter 9 Infection 191

American wormseed (Chenopodium ambrosioides L. var. anthelminticum) has a

long history of use by North American Indians, who used it to dispel worms and

parasites from the intestine. (They take the herb orally.) Sometimes called

Jerusalem oak, the seeds from this plant produce an essential oil that has been

used for hundreds of years that appears to be safe enough for children (Erichsen-

Brown 1979). Grieve (1931) found this variety of Chenopodium an effective rem-

edy for hookworm and roundworm, and it was listed in the ofﬁcial American

Pharmacopoeia. However, there is often confusion between the herbs Chenopodium

ambrosioides L. var. anthelminticum and Chenopodium botrys L., which contains a

much higher percentage of ascaridole and can cause fatalities.

Wormseed lavant (Artemisia cina) also has a long history of use dating back

to Dioscorides. Its anthelmintic action is thought to be caused by santonin, which

accumulates in the ﬂower heads. It is an effective agent against roundworms and,

to a lesser extent, against threadworms but has no effect on tapeworms. However

the side effects include vision disturbances that add a yellow tinge to everything

the patient sees. Santonin is not found in the essential oil but may be in the CO

extract. There are three wormwoods (common, sea, and Roman), which belong to

the genus Artemisia, which also includes tarragon, thought to be an anthelmintic

itself (Lawless 1992). All three herbs (Artemisia absinthium, Artemisia maritima,

and Artemisia pontica) possess anthelmintic properties.

Indian Pinkroot (Spigelia marilandica) is another North American plant that

has been used as a vermifuge by the American Indians (Lewis & Elvin-Lewis

1977). However, Duke (1995) suggests that if used, its extract should be followed

by a saline aperient because the herb is toxic and has effects similar to those of

strychnine. It is used homeopathically for mania and strabismus.

Tea tree and lavender (either Lavandula latifolia or L. angustifolia) are com-

mon essential oils used to treat lice, ticks, and fleas. L. angustifolia can also be

safely used on children and animals. Grosjean (1992) suggests geranium, sage,

or lavender for lice. Marigold (Tagetes minuta) was reported to have an-

thelmintic properties by Lawless (1992). Tisserand (1989) suggests the use of

bergamot, chamomile, camphor, eucalyptus, fennel, hyssop, lavender, lemon

balm, or peppermint. Valnet (1990) suggests all of these, plus cajuput, caraway,

cinnamon, clove, lemon, niaouli, savory, tarragon, and thyme. For the treatment

of ticks, Lawless (1992) suggests sweet marjoram, and for lice she suggests cin-

namon, eucalyptus (blue gum), geranium, spike lavender, Scotch pine, rosemary,

or thyme.

Although some of these essential oils are difﬁcult to obtain and their use may

be controversial, essential oils or CO

extracts appear to have potential as an-

tiparasitic agents. In the tropics or developing countries where orthodox drugs are

expensive and difﬁcult to obtain, essential oils might make economic sense. How-

ever, although the information provided here suggests that the essential oils dis-

cussed could have antiparasitic effects, there is no guarantee. Clinical trials are

needed.

192 Section II Clinical Use of Aromatherapy

Cross-Infection

No discussion of infection is complete without mentioning cross-infection. Al-

though this might come under the heading of hospital-acquired infections, cross-

infection can occur anywhere outside a hospital. It can become rampant in insti-

tutions or buildings, especially those that have a closed air-conditioning system.

Cross-infection includes bacterial, viral, fungal, or protozoan infections.

Bardeau (1976) investigated which essential oils can purify and deodorize the

air. Vaporized essential oils were tested for their capacity to destroy bacteria such

as Proteus, Staphylococcus aureus, and Streptococcus pyogenes. Within 3 hours, 90%

of microbes were destroyed. The oils found to be most effective were clove, laven-

der, lemon, marjoram, mint, niaouli, pine, rosemary, and thyme. Kazarinova et al

(2001) published an abstract of their research on using essential oils to “clear” a

hospital surgical unit of unspeciﬁed bacteria. The surgical rooms were routinely

irradiated with UV light from 5

PM to 9 AM, after surgery hours. Essential oils of

Organum vulgare and Origanum tyttanthum (two types of oregano) were sprayed

inside the rooms at 2

PM, the time at which the maximum number of microbes

was observed. The antimicrobial effect of the Organum vulgare and Origanum tyt-

tanthum diffused in the air lasted 1 to 4 hours. As a result of this study, the Russ-

ian Federation is conﬁrming a patent.

Benouda et al (1988) tested six essential oils, including tarragon, Coridothy-

mus capitatus, and eucalyptus, against 16 drug-resistant bacteria, with excellent re-

sults.

Research is ongoing as more and more pathogens become resistant to con-

ventional drugs. Hammer et al (1999) tested 52 plant oils and extracts against

Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aerugi-

nosa, Salmonella enterica subsp. enterica serotype typhimurium, Serratia marcescens,

and Staphylococcus aureus using an agar dilution method. Lemon grass, bay, and

oregano inhibited all oganisms at concentrations of less than or equal to 2%.

Twenty of the oils were effective against Candida. Vetiver was effective against

Staphylococcus aureus at 0.008%. The authors concluded that essential oils “have a

role as pharmaceuticals.” Essential oils could be important for maintaining anti-

sepsis in operating theaters and for protecting health-care professionals. They are

simple to use, considerably less expensive than conventional drugs, have thou-

sands of years of use, have been tested for toxicologic effect, have far fewer side

effects than conventional drugs, and they smell great!

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200 Section II Clinical Use of Aromatherapy

201

Insomnia

One sees clearly only with the heart, everything essential is invisible to the eyes.

Antoine De Saint-Exupery

The Little Prince

Insomnia

Today’s society is fast-moving and achievement-oriented in which thousands of

people travel daily, often across time zones. Regularity and sleep patterns are con-

stantly disturbed as new sounds and unfamiliar surroundings compound the sense

of timelessness caused by continuous movement. Sleep has become a commodity

to be bought and sold.

Patients in hospitals are separated from everything that makes them relaxed

and sleepy. They are in a strange bed, with a strange routine, and often have a

sense of fear. It is hardly surprising that sleeping pills are almost de rigueur. Aro-

matherapy offers another alternative, especially in the case of patients in the hos-

pital for a long stay who take sleeping tablets regularly.

Sleepless nights can affect us all at some time in our lives. Trauma, worries,

and jet lag can all cause insomnia. However, repeated sleepless nights result in a

poor attention span and, ultimately, in poor health, both physical and mental.

Sleep is deﬁned by Manley (1993) as an “altered state of consciousness from

which a person can be aroused by stimuli of sufﬁcient magnitude.” Why sleep is nec-

essary is unclear, but this period of “opting out” is essential for healthy living. Going

without sleep produces varying degrees of symptoms, ranging from feeling irritable

to psychosis. For a patient in the hospital, sleep deprivation is just one more stressor.

Sleep occurs in two modes: rapid eye movement (REM) sleep, when dream-

ing occurs, and orthodox sleep. Both types of sleep are important. Sleep is

thought to be controlled by a natural chemical called melatonin, which is secreted

by the pineal gland. It is possible to buy this compound over the counter as a sup-

plement, although it has recently been banned in the United Kingdom.

Insomnia is usually transitory, and after the trauma causing the insomnia has

passed, normal sleep rhythms return. However, chronic insomnia threatens to de-

stroy normal functioning. This kind of sleep problem can occur in two forms: fail-

ure to drift off to sleep or waking up after a short period. Both occur in a hospital,

where strange noises and smells permeate through dreams or prevent sleep from

occurring. A bedtime routine is also very difﬁcult to maintain in the hospital.

Sleeping Tablets

Orthodox treatment of insomnia involves two types of drugs, sedatives (anxiolyt-

ics) and sedative-hypnotics. The most common sleeping tablet is a benzodi-

azepine, which is both sedative-hypnotic and anxiolytic, such as diazepam (Val-

ium), lorazepam (Ativan), or nitrazepam (Mogadon). Dependency can occur

within weeks.

Benzodiazepines

Benzodiazepines have the basic structure of a benzene ring coupled to a seven-

membered, heterocyclic structure containing two nitrogen atoms (diazepine) at

positions 1 and 4 (Dailey 1994). This molecule binds to speciﬁc macromolecules

within the central nervous system (CNS) at receptors closely associated with ␥-

aminobutyric acid (GABA) transmission. GABA is the main inhibitory neuro-

transmitter in the brain. Research has indicated that benzodiazepines potentiate

GABA transmission.

Benzodiazepines depress the CNS and in low dosages produce a feeling of

calm. As the dose is increased, a feeling of drowsiness is followed by hypnosis and

muscle relaxation. The interval between feeling drowsy and potential death by

overdose is a large one. Because these drugs have a large therapeutic index they

are extremely useful for many patients, although their long-term use can be prob-

lematic. Benzodiazepines have almost entirely replaced the previous favorite

sleeping pill, the barbiturate.

Barbiturates

Barbiturates are used to treat intractable insomnia and are increasingly rarely pre-

scribed. They, too, bind to receptors associated with GABA transmission. How-

ever, this class of drug prolongs, rather than intensiﬁes, the GABA effect. Public

awareness of the dangers of barbiturate dependence was heightened in the 1970s

by novels like Valley of the Dolls, by Jacqueline Susann. Barbiturates have signiﬁ-

cant drug interactions. Several of the drugs they react with are in common use,

for example, the contraceptive pill, digoxin, beta-blockers, and anticoagulants.

Barbiturates accelerate the metabolism of these drugs, necessitating an increased

dosage. In addition, if the patient is on anticoagulant therapy, when barbiturates

202 Section II Clinical Use of Aromatherapy

are discontinued a dangerous reaction resulting in severe hemorrhage can occur

(Dailey 1994). This type of reaction can also occur with other drugs because the

induction of GABA metabolism has stopped.

Essential Oils with Sedative Effects

“Lavender Beats Benzodiazepines” was a 1988 headline in the International Jour-

nal of Aromatherapy (Tisserand 1988). In this article, the use of essential oils as

sedatives in a hospital setting was outlined. Of particular note were lavender, mar-

joram, geranium, mandarin, and cardamom.

Helen Passant, possibly the most holistic nurse after Florence Nightingale, in-

troduced aromatherapy into the Churchill Hospital, in Oxford, England, where she

was in charge of a ward for the elderly. Remarkably, Passant reduced her original

drug bill by one third by gradually replacing analgesia and night sedation with es-

sential oils. She found her patients seemed to “get off to sleep just as easily, if not bet-

ter, with oils of lavender or marjoram, either vaporized or applied by massage” (Tis-

serand 1988). In the same article another hospital was mentioned. The Radcliffe

Inﬁrmary, also in Oxford, introduced aromatherapy into Beeson Ward at about the

same time. Patients were given the option of aromatherapy instead of night sedation

or analgesics. Nearly all of the patients chose aromatherapy (Tisserand 1988).

Traditionally, true lavender (Lavandula angustifolia) has been used in aro-

matherapy to promote sleep and relaxation and to relieve anxiety. In Bulgaria,

Atanassova-Shopova et al (1973) found that linalol and terpineol were the active

components of lavender and had a depressing effect on the CNS. Oral doses

of linalool were found to be hypnotic and anticonvulsant in mice in a study by

Elisabetsky et al (1995). Elisabetsky et al (1995a) also established that linalol inhib-

ited glutamate binding in rat cortex in a way similar to phenobarbital. The glutamate

binding involved all receptor subtypes investigated. A Japanese study (Yamada et al

1994) concurred that inhaled lavender had anticonvulsant effects in mice.

In France, Guillemain et al (1989) agreed that oral doses of lavender (diluted

at 1:60 in olive oil) had marked sedative effects on mice and enhanced barbitu-

rate sleep time. In Germany, Buchbauer et al (1991) in Germany found that true

lavender had a sedative effect when inhaled by mice. Interestingly, the more agi-

tated the animal (as a result of the injection of caffeine), the more effective the

calming effect of true lavender. Jager et al (1992) established that lavender diluted

in peanut oil was absorbed through the skin.

Henry et al (1994) carried out a study on human subjects at Newholme Hos-

pital in Bakewell, England. The effects of nighttime diffusion of lavender in a

ward of dementia patients was monitored. The trial ran for 7 weeks and showed

that lavender had a statistically signiﬁcant sedative effect when inhaled. Hudson

(1995) also found lavender was effective for elderly patients in a long-term unit.

Eight of the nine patients in the study had improved sleep at night and improved

alertness during the day. Lavender straw (the byproduct of distillation) was itself

found to reduce stress of pigs in transit in a study by Bradsaw et al (1998).

Chapter 10 Insomnia 203

Jager et al (1992a) found that neroli had a sedative effect on mice. In this

study, the sedative effects were observed during the ﬁrst 30 minutes of exposure

to the aroma. Citronellal and phenylethyl acetate (components of essential oils)

were also found to have sedative properties. Citronellal is found in citronella

(Cymbopogon nardus), lemon gum (Eucalyptus citriodora), narrow-leaved pepper-

mint (Eucalyptus radiata), lemon, rose, melissa, lemongrass, basil, and geranium.

Phenylethyl acetate is found only in neroli, but phenylethyl alcohol is also found

in geranium (bourbon) and rose (Sheppard-Hangar 1995).

Buchbauer et al (1992) found essential oils of passionﬂower (Passiﬂora incar-

nata) and lime blossom (Tilia cordata) had sedative effects. Lime blossom and its

major component, benzyl alcohol, decreased the motility of animals in both nor-

mal and induced-agitation states. Interestingly, passionﬂower and its main com-

ponents, maltol and 2-phenylethanol, only reduced motility when the animals

were in an agitated state. This underscores the feeling amongt herbalists and aro-

matherapists that essential oils are adaptogens.

Khanna et al (1993) found black cumin (Nigella sativa) essential oil had a

sedative effect more powerful than the drug chlorpromazine (Largactil) and was

also an analgesic. The study suggested black cumin contained an opioid-like com-

ponent. West and Brockman (1994) reported on how aromatherapy helped de-

mentia patients with disturbed sleep and compulsive daytime activity. Several es-

sential oils were used.

Weihbrecht (1999) investigated the effect of inhaled true lavender on 10

adults (3 men and 7 women) who had a history of chronic insomnia. Subjects

took baseline measurements for the ﬁrst 14 days and recorded difﬁculty getting

to sleep, naps taken during the day, difﬁculty returning to sleep, and feeling rested

in the morning. A visual analog scale of 1 to 10 was used (1 ⫽ very difﬁcult,

10 ⫽ no difﬁculty). Subjects were asked not to change what they normally did

and to continue their sleep medication. For days 15 to 29 of the study, 2 drops of

true lavender were placed on the patients’ pillows or on a tissue kept nearby at

bedtime. Subjects mailed back a sleep questionnaire, and a telephone interview

was completed with each of them following completion of the study. One partic-

ipant pulled out of the study because she did not like the smell of lavender. Eight

participants had improved sleep in 1 of the 4 areas measured, and 8 reported less

difﬁculty in getting to sleep. One person reported that his difﬁculty was neither

improved nor worsened by the use of lavender, but he had the ﬂu during the ex-

perimental stage. Of all participants, 8 reported feeling more rested in the morn-

ing. The sleep aids normally used by the participants did not change.

King (2001) tested the effect of Roman chamomile (Chamomelum nobile) and

sweet marjoram (Origanum majorana) on insomnia. Ten women between the ages

of 36 and 59 with sleep problems took part in the study. One client had an allergy

to ragweed so a patch test was completed before the study began to make sure she

was not allergic to chamomile. Each subject was given a bottle containing a mix-

ture of Roman chamomile and sweet marjoram in a ratio of 1:2. For the ﬁrst 7

days, baselines were established. The second week the subjects used the aro-

204 Section II Clinical Use of Aromatherapy

matherapy mixture; the third week was a washout week with no aromatherapy;

and the fourth week was a repeat of the second week. During week 2 and week 4

(the aromatherapy weeks), 2 drops of essential oils were put on a cotton ball and

placed in the pillowcases of the subjects at bedtime. Subjects recorded time to fall

asleep, number of times waking, how long it took to fall back to sleep, span of

time from bedtime to getting up, and whether they felt rested in the morning.

The data were entered on in spreadsheet software program so results could be

compared.

Two subjects withdrew from the study because they reacted negatively to the

mixture. Neither of them liked the aroma. One subject experienced nausea and

headache, and the other had a severe headache. These two subjects were not en-

tered into the analysis. The results indicated a small improvement in almost every

category. Five women experienced an improvement in the time it took to go to

sleep. One subject took 240 minutes to fall asleep one night because of a death in

her family. The outcomes of the study were not changed to accommodate that. Six

women showed a reduction in the number of times they woke up during the night.

Only three women showed a reduction in the time taken to fall back to sleep. Five

women felt more rested after a night’s sleep with the aromatherapy mixture.

Most people enjoy the smell of roses. Rose is perhaps the most popular

aroma in the world. Despite the fact that essential oil of rose is expensive, the cost

may be justiﬁed where chronic insomnia is concerned. To date, there have been

no clinical studies to show that rose is effective in promoting sleep in humans.

However, Nacht and Ting (1921) and Rovesti and Columbo (1973) showed that

rose (Rosa damascena) essential oil has sedative effects. Certainly my personal ex-

perience, as well as that of my students and patients, suggests that rose is a strong

contender and certainly an essential oil to try for insomnia.

Finally, while conducting routine toxicity investigations of Tastromine (␤-

dimethylaminoethyl thymol ether), it was observed that the animals used in the

study became sedated (Ashford et al 1993). Further investigation revealed that

signiﬁcant CNS depressant activity appeared when the basic ethers involved were

derived from thymol. Isomers of thymol, namely carvacrol and isothymol, were

relatively inactive. The structural requirements of morphinelike analgesics were

similar to the structure of thymol ether.

REFERENCES

Ashford A, Sharpe C, Stephens F. 1993. Thymol basic ethers and related compounds:

central nervous system depressant action. Nature. 4871(197) 969-971.

Atanassova-Shopova S, Roussinov K, Boycheva I. 1973. On certain central neurotropic

effects of lavender essential oils. II. Communications: studies on the effects of linalol

and of terpineol. Bulletin of the Institute of Physiology. 55:149-156.

Bradsaw R, Marchant J, Meredith M et al. 1998. Effects of lavender straw on stress and

travel sickness in pigs. Journal of Alternative and Complementary Medicine. 4(3)

271-275.

Chapter 10 Insomnia 205

Buchbauer G, Jirovetz L, Jager W. 1991. Aromatherapy: Evidence for sedative effects of

the essential oil of lavender after inhalation. Zeitschrift fur Naturforschung 46

(11⫺12) 1067-1072.

Buchbauer G, Jirovetz L, Jager W. 1992. Kurzmitteilungen: Passiﬂora and lime-

blossoms—Motility effects after inhalation of the essential oils and of some of the

main constituents in animal experiments. Archiv der Pharmazie (Weinheim). 325(4)

247-248.

Dailey J. 1994. Sedative-hypnotic and anxiolytic drugs. In Craig C, Sitzel R (eds.),

Modern Pharmacology, 4th ed. Boston: Little Brown & Co., 369-377.

Elisabetsky E, de Souza G, Dos Santos M et al. 1995. Sedative properties of linalool. Fi-

toterapia. 66(5) 407-415.

Elisabetsky E, Marschner J, Souza D. 1995a. Effects of linalool on glutamatergic system

in the rat cerebral cortex. Neurochem Res. 20(4) 461-465.

Guillemain J, Rousseau A, Delaveau P. 1989. Effects neurodepresseurs de l’huile essen-

tielle de Lavandula angustifolia. Annales Pharmaceutiques Francaises. 47(6) 337-343.

Henry J, Rusius C, Davies M et al. 1994. Lavender for night sedation of people with de-

mentia. International Journal of Aromatherapy. 6(2) 28-30.

Hudson R. 1996. The value of lavender for rest and activity in the elderly patient. Com-

plementary Therapies in Medicine. 4(1) 52-57.

Jager W, Buchbauer G, Jirovetz L, et al. 1992. Percutaneous absorption of lavender oil

from a massage oil. Journal of the Society of Cosmetic Chemists. 43(1) 49-54.

Jager W, Buchbauer G, Jirovetz L. 1992a. Evidence of the sedative effect of neroli oil,

citronella and phenylethyl acetate on mice. Journal of Essential Oil Research. 4(4)

387-394.

Khanna T, Zaidi F, Dandiya P. 1993. CNS and analgesic studies on Nigella sativa. Fi-

toterapia. 64(5) 407-410.

King P. 2001. An insomnia study using Origanum majorana and Chamomelum nobile. Un-

published dissertation. R J Buckle Associates, Hunter, NY.

Macht D, Ting G. 19211921. Sedative properties of some aromatic drugs and fumes.

Journal of Pharmacology and Experimental Therapeutics. 18:361-372.

Manley K. 1993. Care of the acutely ill. In Hinchcliff S, Norman S, Schober J (eds.),

Nursing Practice and Health Care, 2nd ed. London: Edward Arnold, 1067-1072.

Rovesti P, Columbo E. 1973. Aromatherapy and aerosols. Soap, Perfumery & Cosmetics.

46:475-477.

Sheppard-Hangar S. 1995. Aromatherapy Practitioner Reference Manual, Vol. II.

Tampa, FL: Atlantic School of Aromatherapy.

Tisserand R. 1988. Lavender beats benzodiazepines. International Journal of Aro-

matherapy. 1(1) 1-2.

Weihbrecht L. 1999. A comparative study on the use of Lavandula angustifolia and its

effect on insomnia. Unpublished dissertation. R J Buckle Associates, Hunter, NY.

West B, Brockman S. 1994. The calming power of aromatherapy. Journal of Dementia

Care. March/April, 20-22.

Yamada K, Mimaki Y, Sashida Y et al. 1994. Anticonvulsant effects of inhaling lavender

oil vapor. Biological & Pharmaceutical Bulletin. 17(2) 359-360.

206 Section II Clinical Use of Aromatherapy

207

Nausea and Vomiting

As aromatic plants bestow

No spicy fragrance while they grow;

But crushed or trodden to the ground,

Diffuse their balmy sweets around.

Oliver Goldsmith

The Captivity, Act 1.

ausea and vomiting are symptoms that should be addressed separately,

because nausea does not always lead to actual vomiting. However,

the causes of nausea are similar to those of vomiting. Aromatherapy

has recently been recommended by an internet-based medical consultancy,

www.mdconsult.com, as being useful in nausea related to pregnancy. Vomiting is

activated by the vomiting center in the brain, which triggers nerves supplying the

stomach and chest muscles. Vomiting can have numerous causes.

Gastrointestinal Causes

Gastrointestinal causes of vomiting include the following:

Stomach or intestinal irritation, gastroenteritis

Appendicitis

Obstruction

Hypertrophic pyloric stenosis

Central Nervous System Causes

Central nervous system (CNS) causes of vomiting include the following:

Loss of sense of balance resulting from middle or inner ear trauma, labyrinthitis

Sensory responses in the brain activated by smell, sight, or emotion

Raised pressure in the brain (caused by tumors, hemorrhage, meningitis)

Head injury

Migraine

Psychiatric disorder

Chemoreceptor trigger areas that respond to either chemicals produced by the

body (e.g., kidney and pancreas) or to motion sickness

Metabolic Causes

Metabolic causes of vomiting include the following:

Pregnancy

Uremia

Alcohol

Chemoreceptor trigger areas responding to drugs absorbed by the body (Hope et

al 1993)

Conventional Approaches to Treating Vomiting

There are seven basic categories of antiemetic agents used in conventional medi-

cine: antihistamines, anticholinergics, corticosteroids, cannabinoids, benzodi-

azepines, dopamine antagonists, and serotonin antagonists.

Antihistamines (dramamine, diphenhydramine, hydroxyzine) affect the or-

gan of balance as well as the vomiting center of the brain. These drugs also have

an effect on the chemoreceptor trigger zone (CTZ), and they block the histamine

and dopamine receptors. In addition, they inhibit acetylcholine. Antihistamines

work by reducing the sensitivity of the vomiting center to input from the inner

ear, although they do not directly affect the inner ear.

Because the vomiting center of the brain is stimulated by the neurotransmitter

acetylcholine, one of the most direct ways of inhibiting vomiting is to use anti-

cholinergic drugs (atropine, scopolamine, hyoscyamine). Transdermal scopolamine

provides up to 72 hours of antiemetic treatment. However, long-term use of anti-

cholinergic drugs can cause side effects such as poor digestion, dry mouth, blurred

vision, and constipation. Corticosteroids (dexamethasone, prednisone) can help to

reduce nausea associated with chemotherapy but can cause side effects such as ma-

nia, insomnia, and gastric irritation. Cannabinoids (dronabinol) have been used to

treat nausea and vomiting in patients with end-stage illness, but they have limited

effectiveness resulting from irregular absorption rates. Cannabinoids often take sev-

eral days to weeks to reach therapeutic blood levels and have the side effect of un-

comfortable dizziness or euphoria. Benzodiazepines such as lorazepam have been

used to treat nausea. These drugs often cause dry mouth and drowsiness.

The neurochemical that stimulates the CTZ is dopamine. Dopamine ago-

nists (e.g., prochlorperazine, chlorpromazine, haloperidol) work by blocking

dopamine-mediated transmission, thereby relieving nausea. Dopamine agonists

have common side effects of extrapyramidal symptoms, which limit their use.

208 Section II Clinical Use of Aromatherapy

The new serotonin agonists (e.g., ondansetron) are safe and effective in con-

trolling nausea and are frequently considered ﬁrst-line antiemetic agents. How-

ever, these drugs are often prohibitively expensive.

Aromatherapy Approaches

Although conventional approaches are often very effective in managing nausea

and vomiting, some patients are intolerant of the drugs’ side effects or are unable

to afford them. In some cases, aromatherapy can be used both as adjunctive ther-

apy and alternative therapy for the control of nausea. Alexander (2001) suggests

that dopamine and serotonin can “cross talk,” and believes that essential oils af-

fect nausea in this manner.

Speciﬁc Essential Oils with Antiemetic Properties

Cardamom

Cardamom (Elettaria cardamomum) is listed in the Indian Materia Medica as

checking vomiting and nausea (Nadkarni 1992); it is one of the oldest essential

oils known (Arctander 1994). Tisserand (1989) also suggests it can relieve nau-

sea. Cardamom contains 50% ␣-terpinyl acetate and 1,8-cineole, with small

amounts of borneol, ␣-terpineol, and limonene. Borneol was shown to be an ef-

fective antagonist of acetylcholine in a study by Cabo et al (1986), and perhaps

this compound imbues cardamom with its antiemetic property.

Peppermint

Peppermint (Mentha piperita) has been a classic choice for the treatment of

nausea for hundreds of years. However, too much peppermint can cause nausea,

so only a few drops are needed. Used primarily to treat nausea, rather than actual

vomiting, peppermint has carminative effects both in vitro and in vivo. Pepper-

mint also has recognized antispasmodic effects; in a study of endos-

copy spasm, peppermint was found to relieve colonic spasm within 30 seconds

(Leicester & Hunt 1982).

In another study, patients were given peppermint following colostomies.

Among these patients, 18 of 20 individuals displayed reduced postoperative colic

and nausea (McKensie & Gallacher 1989). Valnet (1980) states that peppermint

is useful for the treatment of nervous vomiting. Franchomme (1980) also states

that peppermint is an antiemetic. Peppermint ﬂoral water is one of the active in-

gredients of babies’ gripe water, a traditional remedy recommended by hospitals

in the United Kingdom.

The effect of peppermint was audited in a study with 10 patients at the on-

cology center of St. Luke’s Hospital in New Bedford, Massachusetts, and found

to be effective in reducing the nausea of patients undergoing chemotherapy when

used instead of the drugs Zofran and Compazine (Figuenick 1998). Zofran is

very expensive. Peppermint proved so effective that those in the control group

Chapter 11 Nausea and Vomiting 209

demanded the peppermint, and the control part of the study collapsed! Of pa-

tients in this study, 84% stated that essential oil of peppermint relieved their nau-

sea, and 71% found it enhanced their standard antiemetic medication. One pa-

tient found it enhanced the ability to eat. Aromatherapy is now routinely offered

in many chemotherapy units in the United States and United Kingdom.

Tate (1997) carried out a controlled study of postoperative nausea on 18 pa-

tients who underwent major gynecologic surgery. Group 1 received no treatment,

group 2 received peppermint essence, and group 3 received peppermint essential

oil. Participants in group 3 were asked to inhale directly from the bottle when

they were nauseated. Measurement was made on a ﬁve-point scale ranging from

0 (no nausea) to 4 (about to vomit). The amount of antiemetic drugs (metoclo-

pramide [Maxolon], prochlorperazine [Stemetil], and ondansetron [Zofran])

used was measured. Participants in the experimental group needed 50% fewer

antiemetics. The Kruskal-Wallis test was used to establish signiﬁcance, P ⫽

0.0487. The cost per treatment was approximately 75 cents (48 pence).

Spearmint is thought to also have an antiemetic effect and, according to

Lawrence (2001), may prove effective for longer periods than peppermint. Several

US hospitals are conducting clinical trials on peppermint and spearmint as this text

is being written.

Ginger

Ginger (Zingiber ofﬁcinale) was introduced in Europe during the Middle

Ages. The essential oil, which does not smell anything like the dried root or can-

died ginger, contains zingiberene. In China, ginger root is classically given to new

mothers following the birth of their children. Although it is often used topically

in the treatment of chronic pain, inhaled essential oil of ginger is a very effective

remedy for nausea and is particularly suitable for pregnancy. Vutyavanich et al

(1997) studied 70 expectant mothers over a period of 5 months in a double-

masked, placebo-controlled trial. They found baseline nausea and vomiting de-

creased signiﬁcantly in the group using ginger. Ginger had no adverse effects on

the mothers’ pregnancy outcomes. However, ginger may not be as effective for

nausea associated with CNS disturbances. Visalyaputra et al (1998) found that

2 gr ginger powder taken orally was ineffective at reducing the incidence of post-

operative nausea and vomiting the day after gynecologic laparoscopy. This could

be because many people ﬁnd it difﬁcult to take anything orally when nauseated.

Lavender

Everson (2000) carried out a small project with lavandin (Lavandula inter-

media CT Super) to treat postoperative nausea. She became intrigued with the

antiemetic properties of lavender while undergoing chemotherapy herself. Dur-

ing the 26 weeks Everson received chemotherapy, she never vomited and only

used six of the prescribed antiemetic pills. All of the women in her cancer sup-

port group were nauseated, and all used most of their antiemetic pills. Ten pa-

tients were included in the exploratory postoperative study, which was not ran-

210 Section II Clinical Use of Aromatherapy

domized or controlled. Consent was given by the hospital and each patient signed

an informed consent. After inhaling lavender, only two patients required an

antiemetic postoperatively, a much lower than usual incidence. Although no con-

clusions can be reached from this study, this chemotype of lavandin might be

worth pursuing for treatment of postoperative nausea alongside spearmint, pep-

permint, cardamom, and ginger.

Clove (Eugenia caryophyllata) is listed in Potter’s New Cyclopaedia of Botanical

Drugs and Preparations as an antiemetic (Wren 1988). Pharmacognosy books

suggest that cardamom, which has an antispasmodic action on the gastrointesti-

nal tract, and peppermint are both suitable as carminatives (Evans 1994). Fennel

(Foeniculum vulgare) and aniseed (Anethum graveolens) are also mentioned, but

more as carminatives than as antinausea essential oils.

Other Anticholinergic Essential Oils

In a study investigating the activity of major components of various essential oils

of aromatic plants from Granada, borneol and myrcene were found to be active

against acetylcholine. In this instance, borneol and myrcene were from essential

oils of thyme (Thymus granatensis) and Spanish sage (Salvia lavendulaefolia). The

experiment was carried out with isolated duodenum. However, if borneol and

myrcene do display anticholinergic activity, it would be logical to try other essen-

tial oils that contain these compounds to provide relief from nausea and to inhibit

vomiting. Myrcene and borneol are found in many essential oils. Gas chromatog-

raphy linked to mass spectrometry indicates how much myrcene or borneol is

present in an essential oil.

Importance of Individual Preference in Choice of Essential Oil

Several of my students have completed case studies on nausea using ginger and

peppermint and found that patients tended to prefer one essential oil over an-

other. The essential oil patients preferred was more effective against their nausea

than one they did not like. This highlights the importance of learned memory and

of involving patients in choosing their oils. The method of choice is usually in-

halation. However, a gentle abdominal rub can be very beneﬁcial to a child or

anxious patient who is sick with worry, rather than nauseated for physical reasons.

REFERENCES

Alexander M. 2001. How Aromatherapy Works, Vol 1. Odessa, FL: Whole Spectrum

Books.

Arctander S. 1994. Perfume and Flavor Materials of Natural Origin. Carol Stream, IL:

Allured Publishing.

Cabo J, Crespo M, Jimenez J et al. 1986. The spasmolytic activity of various aromatic

plants from the province of Granada. The activity of the major components of their

essential oils. Plantes Medicinales et Phytotherapie. 20(3) 213-218.

Evans W. 1994. Trease & Evan’s Pharmacognosy, 13th ed. London: Bailliere Tindall.

Chapter 11 Nausea and Vomiting 211

Everson C. 2000. Lavandula intermedia (DT Super) as a post-operative anti-emetic. Un-

published dissertation. R J Buckle Associates, Hunter, NY.

Figuenick R. 1998. Essential oil of peppermint: A 3-part audit on nausea. Unpublished

dissertation. R J Buckle Associates, Hunter, NY.

Franchomme P, Penoel D. 1980. L’aromatherapie Exactement. Jollois, Limoge, France.

Hope R, Longmore J, Hodgetts T et al. 1993. Oxford Handbook of Clinical Medicine,

3rd ed. Oxford, UK: Oxford University Press.

Leicester R, Hunt R. 1982. Peppermint oil to reduce colonic spasm during endoscopy.

Lancet. 2(8305) 989-990.

Lawrence B•. 2001. Personal communication in September 2001.

McKenzie J, Gallacher M. 1989. A sweet-smelling success: Use of peppermint oil in

helping patients accept their colostomies. Nursing Times. 85(27) 48-49.

Nadkarni K. 1992. Indian Materia Medica, Vol. 1. Prakashan, India: Bombay Popular.

Tate S. 1997. Peppermint oil: A treatment for postoperative nausea. Journal of Advanced

Nursing. 26(3) 543-549.

Tisserand R. 1989. The Art of Aromatherapy. Saffron Walden, UK: CW Daniels.

Valnet J. 1990. The Practice of Aromatherapy. Saffron Walden, UK: CW Daniels.

Visalyaputra S, Petcchpaisit N, Somcharoen K et al. 1998. The efﬁcacy of ginger root in

the prevention of postoperative nausea and vomiting after outpatient gynaecological

laparoscopy. Anaesthesia. 53(5) 506-510.

Vutyavanich T, Kraisarin T, Ruangsri R. 1997. Ginger for nausea and vomiting in preg-

nancy: randomized, double-masked, placebo controlled trial. Obstetrics and Gynecol-

ogy. 97(4) 577-582.

Wren R. 1988. Potter’s New Cyclopaedia of Botanical Drugs and Preparations. London:

Churchill Livingstone.

212 Section II Clinical Use of Aromatherapy

213

Pain and Inﬂammation

How did the rose ever open its heart and give to this world all its beauty?

It felt the encouragement of light against its being,

otherwise we all remain too frightened.

Haﬁz

The Gift

Pain

Pain is an unpleasant sensation localized to part of the body (Fields 1997). Al-

though there are physical dimensions that reﬂect a commonality of pain in hu-

mans, the experience of pain is unique to the individual. People who live with

pain on a daily basis have what is to them a clear way of describing what they feel.

If the pain changes, they know it. However, describing pain to someone who does

not experience it is very subjective and can be problematic. Descriptions of pain

vary greatly. Apart from the site of the pain (for example, abdominal), one of the

most important aspects to consider is the onset of pain. The onset clariﬁes which

kind of pain is involved: acute or chronic.

Chronic pain costs the United States approximately $70 billion per year and

affects approximately 80 million Americans (Berman & Swyers 1997). Pain is one

of the most commonly addressed symptoms in a clinical setting.

Physiology of Pain

Pain is a complex neurophysiological phenomenon (Alavi et al 1997) and can be de-

scribed as somatic, neuropathic, or visceral. Somatic pain is well localized, persistent,

and is often described as sharp or stabbing. Neuropathic pain is usually described as

burning, numbing, or shooting and originates from compression or stimulation of a

nerve. Visceral pain tends to be poorly localized, dull, and aching and involves an A-

C ﬁber ratio of 1:10 in visceral afferents. In normal adults the ability to detect pain

is completely removed when A and C axons are blocked (Fields 1997). When pain

triggers the nociceptors (pain receptors), it is translated or transduced into electrical

activity. The electrical impulse is then transmitted to the spinal cord via the dorsal

root and relayed to the thalamus via the afferent pathways.

Pain is often divided into acute and chronic. Acute pain is short lasting and

has a well-deﬁned pattern of onset. Chronic pain persists beyond the expected pe-

riod of healing (Casey 2002) and is associated with a degenerative or chronic

pathological process such as arthritis. However, sometimes the cause of the pain

is elusive.

The thalamus is involved in pain perception and interpretation (Alavi et al

1997) and is, of course, part of the limbic system, which analyzes smell; therefore

there is an implicit suggestion that smell may affect the perception of pain. Pri-

mary afferent nociceptors activate spinal pain-transmission cells through two

neurotransmitters: glutamate (an amine) and substance P (a peptide) that are

present in C ﬁbers (Fields 1997). Greer (1995) noted substance P immunoreac-

tive processes throughout the laminae of the olfactory bulb. A variety of chemi-

cal agents can activate the primary afferent nociceptors. These include serotonin

and potassium. If the tissue is damaged or inﬂamed, the sensitivity of the noci-

ceptors is heightened. The whole process results in a subjective, sensory, and emo-

tional experience of pain.

Visceral pain is usually blocked by opioids (Sofaer & Foord 1993). Actually,

the body itself produces enkephalin, an opioid-like peptide that occurs in two

forms, Met-enkephalin and Leu-enkephalin.

Etiology of Pain

There are many possible causes of pain: a simple headache can have a dozen pre-

disposing factors including low blood sugar, hormonal imbalance, or a brain tu-

mor. Pain is an emotional issue because it is so intensely personal. Pain is closely

linked to feelings. Pain sufferers frequently feel guilty or that somehow they

should be able to bear their pain better, and many patients with chronic pain talk

of feeling helpless or vulnerable. Goleman (1996) writes “humanity is most evi-

dent in our feelings.” Feelings such as despair and anxiety are known to heighten

pain, and pleasure and relaxation appear to decrease pain. It is difﬁcult to relax

and feel pleasure unaided when in pain, and it is all too easy to feel despair and

anxiety. Changing perception of pain can be difﬁcult when tackled alone.

Orthodox Approach to Pain

In January 2001, the Joint Commission on Accreditation of Healthcare Organiza-

tions ( JCAHO), which accredits the majority of the United States’ medical facili-

ties, developed a new mandatory standard for the assessment and treatment of pain.

It was the ﬁrst time JCAHO, or any other accrediting body, had issued standards

focusing on pain. Institutions began to scramble to work out how they were going

214 Section II Clinical Use of Aromatherapy

to meet the new standards and what they needed to do to deal properly with a pa-

tient in pain. As part of the standards, medical institutions are required to inform

patients of their right to appropriate pain assessment and treatment. The assess-

ment includes documenting the level and characteristics of each person’s pain using

a numeric scale of 0-10 or pictures of expressive faces (www.JCAHO.org). No pa-

tient should score his or her pain above a four. Institutions are required to develop

protocols for pain management and to educate their staff on pain management.

Orthodox Pain Relief

Analgesics (pain relievers) are divided into opioids (narcotics) and nonopioids.

The use of opioids is strictly controlled. Originally narcotics were opioid deriva-

tives and came from the plant Papaver somniferum. Recent advances in pharma-

cology have resulted in the development of several synthetic analgesics that work

on the opioid receptors in the brain.

Narcotic/Opioid Drugs

Morphine is possibly the most common analgesic in this category. Derived

from the opium poppy, morphine works by depressing the cerebral cortex, resulting

in reduced powers of concentration as well as reduced pain. However, the respira-

tory and cough centers are also depressed by morphine, as is the neurotransmitter

acetylcholine. Cananga odorata var. genuina (ylang ylang) has mild, opioid-like

properties and can sometimes enhance the effect of opioid drugs. Codeine is a com-

mon but milder narcotic also derived from the opium poppy (Martin 1994).

Codeine is used to suppress dry coughs as well as for the relief of general pain. Mor-

phine, codeine, and opioid-like drugs are addictive, although they are less likely to

be addictive for someone in severe or chronic pain. Such a patient’s chances of ad-

diction then fall to 1 in 3000 (Carter 1996). Another side effect of opioids is con-

stipation. Narcotics have an extremely important role to play in health care.

Common Nonopioid/Nonnarcotic Drugs

The two most important drugs in this category are aspirin and acetamin-

ophen. Aspirin (acetylsalicylic acid), as well as having antiinﬂammatory effects, is

a well-recognized analgesic. Originally this analgesic was derived from salacin, a

glycoside found in willow tree bark. Aspirin blocks prostaglandin synthesis in the

central nervous system (CNS) and peripheral nervous system. Acetaminophen

(Tylenol) is a painkiller that has no antiinﬂammatory effects because it blocks

prostaglandin synthesis only in the CNS (Parish 1991). A list of undesirable side

effects of antiinﬂammatory drugs can be found in many textbooks (Goodman-

Gilma et al 1985). They are outlined in the following sections and are divided into

the two main categories: nonsteroidal and steroidal.

Nonsteroidal Antiinﬂammatory Drugs

Aspirin is the most common nonsteroidal antiinﬂammatory drug (NSAID)

and has a long history of use. Yin et al (1998) found aspirin inhibited transcrip-

Chapter 12 Pain and Inﬂammation 215

tion factors that coded the production of prostaglandin sythase enzymes. Lyss et

al (1997) discovered helenalin, a lactone found in arnica, also inhibits the same

transcription factor but in a different way. However, blocking prostaglandin syn-

thesis can give rise to speciﬁc side effects. All NSAIDs, including aspirin (sali-

cylic acid)-based antiinﬂammatories, can increase gastric bleeding in patients

with gastric ulcers due to the inhibition of prostaglandin PGE2, which suppresses

gastric acid secretion. NSAIDs can also prolong bleeding as they inhibit produc-

tion of thromboxane (Ward 1993), upset the ﬂuid balance by decreasing excretion

due to inhibition of renal blood ﬂow, cause bronchospasm and nasal polyposis in

susceptible individuals, and delay the onset of labor due to loss of contractile ef-

fects of prostaglandins on the uterine muscles (Kvam 1994). Indomethacin is of-

ten used when salicylates are not tolerated. However, in arthritic patients, in-

domethacin can lead to a high incidence of CNS effects if the dose is high.

Phenylbutazone-like drugs can also cause gastrointestinal irritation, hepati-

tis, vertigo, and headaches. With prolonged usage, they can also depress the bone

marrow, leading to leukemia and aplastic anemia (Craig & Stitzel 1994).

Steroid-Based Antiinﬂammatory Drugs

Despite being superior in effect to NSAIDs (and affecting the inﬂammatory

process at each level), steroidal antiinﬂammatory drugs have many side effects.

These include hyperglycemia leading to diabetes, myopathy, increased intraocular

pressure with the potential for glaucoma, electrolyte imbalance leading to hyper-

tension, thinning of the skin with an increased tendency for poor healing and skin

breakdown, hirsutism, insomnia, depression, and psychosis (Craig & Stitzel

1994). These drugs are usually avoided in long-term treatment. However,

steroidal antiinﬂammatory drugs have provided relief for chronic inﬂammatory

conditions and will continue to be used until other drugs with fewer side effects

are found.

Disadvantages of Orthodox Treatments

Despite advances in pain medication, many patients suffer chronic, and some-

times severe, pain before they die. Articles published in the New England Journal

of Medicine and the Journal of the American Medical Association disclosed that chil-

dren as well as adults suffered unnecessarily from pain. Carter (1996) suggests the

poor pain-control in the studies could be because narcotics are often so tightly

controlled in hospitals that staff cannot get them when their patients most need

them. He suggests patient-controlled analgesia as the answer.

The barriers to pain management are patients’ fear of addiction and their re-

luctance to report pain, plus their concerns about the side effects of medication

and their fear their pain will not be controlled. These barriers have been com-

pounded by inadequate reimbursement, poor administrative support, the high

cost of technology, lack of continuity of care, and the lack of accountability for

poor pain management. Muddying the whole issue of pain control are drug con-

216 Section II Clinical Use of Aromatherapy

troversies such as that surrounding Oxycontin: a drug as potent as morphine that

was heavily marketed to physicians without warning them of its addictive poten-

tial, which has had devastating consequences (Meier & Petersen 2001). However,

things are changing for the better. As of January 2, 2002, pain management was

recognized and reimbursed by Medicare, along with nutrition therapy (Pear

2002), and it is hoped that many health-insurance companies will follow suit.

Chronic Pain Syndrome

Chronic pain syndrome has been described as a complex dysfunction and is ex-

tremely difﬁcult to treat successfully. Allopathic medicine treats CPS with a mix-

ture of opioid and nonopioid drugs backed with tricyclic or Valium-type drugs

that are not antidepressants, although they are used for that purpose in this

instance.

Aromatherapy in Chronic Pain Management

Touch, relaxation, and pleasure each play an important part in how individuals

perceives the world around them, and how they feel about themselves. This in-

cludes the perception of pain (Beck & Beck 1987). Aromatherapy works on the

sensory system and appears to enhance the parasympathetic response, which is

closely linked with endorphins (Weil 1996). The intensity and depth of pain is

inﬂuenced by external factors such as previous experience, attitude, and culture.

Pain can be “put on hold” by strong emotions such as anger, fear, or elation. Con-

versely, fear can make pain feel worse. Pain is a warning system. By deadening it,

the warning system is dulled. A headache pill does not make the cause of the

headache go away; it just allows the person to carry on functioning.

Aromatherapy using touch is very gentle and can be helpful in alleviating

chronic pain. An application of diluted essential oils with either massage or se-

quenced movements (the “m” technique) is very relaxing. The odor of the essential

oils is pleasurable. Even ignoring the possibility that essential oils might have phar-

macologically active components or the possible pharmacokinetic enhancement of

orthodox drugs by essential oils, there is still a potential role for aromatherapy as part

of an integrated, multidisciplinary approach to pain management.

Aromatherapy enhances the parasympathetic response through the effects of

touch and smell, encouraging relaxation at a deep level. Relaxation has been

shown to alter perceptions of pain. Aromatherapy also enables patients to get “in

touch with” feelings of relaxation and pleasure through smell and touch. These al-

low patients to “let go,” often for the ﬁrst time. A compress or gentle massage can

draw attention either to the site of the pain, or away from it, depending on what

will most meet the patient’s psychological needs. Diffusing a relaxing essential oil

can alter perceptions of pain (Buckle 1999).

The analgesic effects of aromatherapy can be traced to several factors:

1. A complex mixture of volatile chemicals reaching the pleasure memory sites

within the brain;

Chapter 12 Pain and Inﬂammation 217

2. Certain analgesic components within the essential oil, which may or may not

be known, affecting the neurotransmitters dopamine, serotonin, and nora-

drenaline at receptor sites in the brain;

3 The interaction of touch with sensory ﬁbers in the skin, which could possibly

affect the transmission of referred pain;

4. The rubefacient effect of baths or friction on the skin.

Two thousand years ago, man used the plants Salix (willow) and Populus

(poplar) to alleviate pain (Lewis & Elvin-Lewis 1977). Gattefosse (1937) states

“almost all essential oils have analgesic properties,” but some are more effective

than others. Tables 12-1 and 12-2 list essential oils that are particularly suited to

the treatment of chronic pain.

218 Section II Clinical Use of Aromatherapy

Table 12-1 h Essential Oils Suitable for Chronic Pain

Common Name Botanical Name Application

Black pepper Piper nigrum Topical

Clove bud

a, b

Syzygium aromaticum Topical

Frankincense Boswellia carteri Inhaled, topical

Ginger

Zingiber ofﬁcinale Topical

Juniper Juniperus communis Topical

Lavender (Spike)

Lavandula latifolia Topical

Lavender (True ) Lavandula angustifolia Inhaled, topical

Lemongrass

Cymbopogon citrates Inhaled, topical

Marjoram (Sweet) Origanum majorana Inhaled, topical

Myrrh Commiphora molmol Topical

Peppermint Mentha piperita Topical

Rose Rosa damascene Topical

Rosemary

Rosmarinus ofﬁcinalis Inhaled, topical

Verbena Aloysia triphylla Inhaled, topical

Ylang ylang Cananga odorata Inhaled

a  Clove bud is safer than clove leaf. Phenols can be harsh on the skin.

b  Best avoid regular use of clove with patients on anticoagulant therapy.

c  The CO

extraction contains gingerol thought to have analgesic action.

d  Spike lavender can be a stimulant; best avoid regular use in hypertension.

e  Lemongrass contains aldehydes; avoid in high concentrations on sensitive skin.

f  Rosemary is a stimulant; best avoid regular use in hypertension or epilepsy.

Animal Studies

Lorenzetti et al (1991) found myrcene, a terpene found in up to 20% in

lemongrass (Cymbopogon citratus), had a direct analgesic effect on rats. The effect

lasted 3 hours and was similar to that of peripheral-acting opioids, but did not af-

fect the CNS, which was remarkable as the essential oil was administered orally.

The analgesic effects did not lead to tolerance during a period of 5 days (which

would have occurred with a narcotic). This is interesting as Seth et al (1976) had

previously investigated the effect of lemongrass on pain and found it enhanced

the effect of morphine in rats. However, Seth also investigated Cymbopogon nar-

dus (East Indian lemongrass) and found it to be less effective as an analgesic.

Cymbopogon nardus contains considerably less myrcene than Cymbopogon citratus

(Boelens 1994). Lorenzetti et al (1991) conclude their paper with the suggestion

that terpenes should be investigated with the “possibility of developing a new

class of analgesic with myrcene as the prototype.” Myrcene is found in small

amounts in a number of essential oils, including rosemary, frankincense, juniper,

rose, ginger, and verbena (Sheppard-Hangar 1995), all of which have traditional

analgesic qualities. The analgesic effects of lemongrass in mice was the subject of

another paper by Viana et al (2000) who concluded the essential oil worked at

both central and peripheral levels when given by oral and intraperitoneal routes.

Artemisia caerulescens was found to have an analgesic effect on rats in a study by

Moran et al (1989). Nepetalactone, a lactone found in Nepeta caesarea, was found to

have analgesic properties in a controlled, comparative study with morphine on mice

and hailed the “new opioid” (Aydin et al 1998). The essential oil was given by in-

traperitoneal injection. The lactone appeared to affect mechanical, not thermal, al-

gesic receptors, which “suggests speciﬁcity for speciﬁc opioid receptor subtypes ex-

cluding mu-opioid receptors.” Because the lactone is the main component of Nepeta

caesarea (92%-95%) it was thought to have speciﬁc, opioid-receptor-subtype ago-

nistic activity. The essential oil also had marked sedative effects. Aydin et al (1996)

had previously studied Origanum onites and found it too had analgesic activity.

Chapter 12 Pain and Inﬂammation 219

Table 12-2 h Essential Oils Particularly Suitable for Children

Common Name Botanical Name Application

Chamomile (Roman) Chamaemelum nobile Inhaled, topical

Geranium Pelargonium graveolens Inhaled, topical

Mandarin Citrus reticulate Inhaled, topical

Neroli Citrus aurantium Inhaled, topical

Palma rosa Cymbopogon martini var. motia Inhaled, topical

Sandalwood Santalum album Inhaled, topical

Inhaled: 2 drops on cotton ball inhaled for 5-10 minutes

Topical: 2-5 drops diluted in a compress or in a vegetable cream/gel/oil

Lavandula angustifolia was found to have a local anesthetic effect in rabbits

by Ghelardini et al (1999).

Human Studies

The analgesic effect of essential oils also occurred in human studies as re-

ported by Woolfson and Hewitt (1992) who found a 50% pain reduction in 100

patients nursed in a critical care unit. Thirty-six patients were randomly allocated

into three groups of 12: one group received massage plus lavender, one group re-

ceived massage without lavender, and a control group received no massage but

were left to “rest curtained off ” from the remainder of the unit. Treatment con-

sisted of 20 minutes of foot massage twice a week for 5 weeks. This was an in-

teresting study as 50% of the patients were artiﬁcially ventilated, and therefore the

effects of the essential oil could not be from inhalation. The most striking differ-

ence between the group receiving massage with lavender (Group A) and without

lavender (Group B) was in the effect upon heart rate. Ninety percent of Group A

showed a reduction of between 11 and 15 beats per minute whereas only 58% of

Group B showed any reduction, and it was consistently less. Only 41% of the con-

trol group showed any reduction. The study gives no formal statistics or analysis.

Wilkinson (1995) investigated the effects of 1% Roman chamomile (Chamo-

melum nobile) on 51 patients with cancer in a randomized study. The participants

ranged in age from 26 to 84 years. Ninety-four percent of the participants were fe-

male, and 6% were male. Forty-one percent had been referred for pain control.

During the study, 45% of the participants were receiving morphine, with the re-

mainder on weak opioids, nonopioids, or nothing. Seventy-six percent of the par-

ticipants had metastases. Mann-Whitney U tests on all independent variables re-

vealed no signiﬁcant differences between conditions in the pretest scores for the

Rotterdam Symptom Checklist on physical or psychological symptoms, activities,

and top 10 symptoms. The data were analyzed using the Statistical Package for the

Social Sciences (Nie et al 1975) and nonparametric tests were employed for all sta-

tistical analysis. State Trait Anxiety Inventory (STAI) scores fell by an average of

16 points in the aromatherapy massage group but only 10 points in the plain mas-

sage or standard group (p  0.005), and pain was reduced statistically (p  0.003).

One patient is quoted as saying “I know now, almost deﬁnitely, that it (aro-

matherapy) has helped me in my quest for pain relief. I have told Dr. R at the pain

clinic how pain free I was while having regular (aromatherapy) treatment”

(Wilkinson 1995).

Gobel et al (1991) studied the effect of peppermint on headaches. Pain was

induced in healthy humans using pressure, thermal, and ischemic stimuli. The in-

tensity of the pain, neurophysiology, performance-related activity, and mood

states were monitored. Peppermint diluted in ethanol and applied topically pro-

duced a signiﬁcant analgesic effect. Perez-Raya et al (1990) found Mentha rotun-

difolia and Mentha longifolia (both types of peppermint) had analgesic properties

in mice and rats. Peana et al (1999) found essential oil of clary sage to have an an-

tiinﬂammatory and analgesic action at a local level. Extracts of myrrh (Com-

220 Section II Clinical Use of Aromatherapy

miphora momol) were found to have a strong local anesthetic effect in a study by

Dolara et al (2000). The anesthetic action blocked the sodium current of excitable

mammalian membranes. Local anesthetic activity on nerve cells was measured by

incubating hippocampal brain slices, freshly dissected with a tissue chopper, from

the brain of one of the experimental male rats. The slices were stimulated with a

positive electrical current applied though electrodes.

Krall and Krause (1993) conducted an open, randomized study of 100 patients

to evaluate the effects of a topically applied gel containing peppermint oil (30%) on

periarticular pain. Effects of the peppermint gel were measured in acute (n  49) and

subacute (n  51) conditions compared to the standard treatment of 10% hydrox-

yethyl salicylate gel. Different aspects of pain (intensity on pressure and spontaneous

and movement pain) were examined using visual analog scales (0  no symptom to

100  severe symptom) for a period of 20 days. No statistical details were given. In

78% of cases both the physician and patient considered the results with the mint

therapy to be highly effective, as opposed to 50% and 34 % respectively with the

standard gel. There were 10 instances of side effects from the hydroxyethyl salicylate

gel (three of erythema and seven of itching) and only one (smell of peppermint in

the nose) from the mint oil. At the end of the study, 19% of the mint-oil patients

were still suffering from pain, as were 36% of the aspirin gel group. The results of

this comparative study were dependent on the severity of the symptoms.

Hot-pepper cream containing capsaicin has been found useful for arthritis

and shingles and also appears to relieve postsurgical pain in cancer patients. Pa-

tients who used a cream containing 0.075% capsaicin around the incision site for

8 weeks following surgery experienced a 53% reduction in pain, compared with a

17% reduction for those using a placebo cream. Side effects included redness and

burning of the skin, but those effects diminished with time. Capsaicin also ap-

pears to inhibit substance P.

Ginger (Zingiber ofﬁcinale) can also have an analgesic and deeply warming

action, but the topical analgesic gingerol (a phenol) only occurs in the CO

ex-

tract, not in the essential oil (Wren 1988). Oleum spica was traditionally used as a

topical analgesic. Oleum spica contains one part spike lavender to four parts tur-

pentine. It is thought the analgesic effect of turpentine is enhanced by the pres-

ence of spike lavender (Von Frohilche 1968).

Benzoin, camphor, clove, coriander, ginger, hops, lemongrass, marjoram,

black pepper, pine, savory, and ylang ylang have analgesic properties (Rose 1992).

Other suggestions include white birch, chamomile, frankincense, wintergreen,

clove, lavender, and mint. Lawless (1994) writes that during the pre-Christian

era, myrrh was added to wine to provide pain relief to those about to be cruciﬁed.

Myrrh contains terpenes, esters, and a phenol called eugenol, all of which are re-

puted to be analgesics (Franchomme & Penoel 1991). Eugenol (and myrcene) are

found in West Indian Bay (Pimenta racemosa) and in clove (Syzygium aromaticum).

Use clove-bud oil (which also contains esters) not the leaf or stem oil that is

higher in phenols. Diluted clove oil is useful to use prior to venipuncture as it

make the veins more prominent and gives some local-anesthetic effect. Borneol

Chapter 12 Pain and Inﬂammation 221

(an alcohol) and myrcene (a terpene) were found to be effective antagonists of

acetylcholine in a study by Cabo et al (1986). This study was conducted on iso-

lated duodenum to counter contractile tissue. Acetylcholine is a central and pe-

ripheral nervous system transmitter (Craig 1994).

Muscle Spasm and Pain

Some pain is caused by muscle spasm. Several essential oils have antispasmodic

effects, particularly those high in esters. The greater the number of different es-

ters in an essential oil, the greater is thought to be the antispasmodic effect. Ro-

man chamomile has more esters than any other essential oil and is also a recog-

nized analgesic (Wren 1988). Lis-Balchin (1997) found clary sage, dill, fennel,

frankincense, nutmeg, and lavender reduced the “twitch response to nerve stimu-

lation; in isolated rat tissue.” Historically the essential oils listed in Table 12-3

have been used for their antispasmodic effect.

Enteric-coated peppermint-oil capsules were used in the treatment of irrita-

ble bowel syndrome symptoms (Kline et al 2001). Fifty children took part in the

controlled, multicentered study. The gelatin capsules did not release the oil until

they were in the small intestine (an environment of pH 6.8 or higher). Between

one capsule (187 mg) and two capsules were given three times a day. During the

study eight children withdrew for various reasons. However, 76% of the pepper-

mint group showed signiﬁcant reduction in symptoms compared to the placebo

group (43%). No side effects were reported and no change in stool consistency.

Inﬂammation

Sometimes pain is caused by inﬂammation. Inﬂammation is a fundamentally pro-

tective mechanism (Betts 1993) and has been called “the most important of the

222 Section II Clinical Use of Aromatherapy

Table 12-3 h Some Antispasmodic Essential Oils

Common Name Botanical Name Reference

Roman chamomile Chamaemelum nobile Franchomme & Penoel 1991

Petitgrain Citrus amara Reiter & Brandt 1985

Dill Anethum graveolens Lis-Balchin 1997

Clary sage Salvia sclarea Lis-Balchin 1997

Fennel Foeniculum vulgare Lis-Balchin 1997

Frankincense Boswellia carteri Lis-Balchin 1997

Lavender Lavandula angustifolia Lis-Balchin 1997

Sage Salvia ofﬁcinalis Taddei et al 1988;

Giachetti et al 1988

body’s defense mechanisms” (MacSween & Whaley 1992). Derived from the

Latin inﬂammare, meaning “to burn,” the function of inﬂammation is to restore the

body to normal functioning as quickly as possible. The symptoms of inﬂammation

are redness, swelling, heat, and pain—through history listed as rubor, tumor, calor,

and dolor (Mills 1991)— and a loss of function (Craig & Stitzel 1994).

Antiinﬂammatory Essential Oils

Essential oils have some of their most poignant antiinﬂammatory effects on the

dermis and epidermis (Bowles 2000). Mascolo et al (1987) screened 75 species of

plants (chosen from medicinal folklore) and their extracts for antiinﬂammatory

activity. The experiments were performed on rats with carrageenan-induced foot

edema. The control drug was indomethacin. Herbal extracts (not essential oils)

from the plants were administered orally. However, many of the plants selected

also produce essential oils used for antiinﬂammatory purposes in aromatherapy.

Coriandrum sativum (coriander), Foeniculum vulgare (fennel), and Juniperus com-

munis (juniper) all produced 45% reduction of inﬂammation, comparable with the

control. However, if the essential oils had been applied topically, the response

might have been greater. Essential oils are absorbed through the skin, with 70%

of the oil being absorbed within 24 hours (Bronaugh et al 1990).

Rossi et al (1988) investigated Roman chamomile (Anthemis nobilis) in a

comparative, controlled study on rats with carrageenan-induced edema. The con-

trol was indomethacin. Three essential oils of chamomile were used. White-

headed, double-ﬂowered chamomile ﬂowers showed a greater antiinﬂammatory

action than the yellow-ﬂowered variety. Nevertheless, all three essential oils of

Roman chamomile produced signiﬁcant antiinﬂammatory effects. In this study

the chamomile was given subcutaneously into the peritoneal cavity. Jakovlev et al

(1979) demonstrated the antiinﬂammatory effect of German chamomile and sug-

gested the antiphlogistic effects were due to bisabolol and bisabolol oxides.

Tubaro et al (1984) found when German chamomile (Matricaria recutita) was ap-

plied topically to mouse ears, with hydrocortisone as the control, the chamomile

showed an antiinﬂammatory action, although the effect was only half as strong as

that of the steroid.

Nutmeg (Myristica fragrans) may have been the inspiration for Nostradamus’

prophecies, but it also has antiinﬂammatory activities. Benet et al (1988), attrib-

uted nutmeg’s antiinﬂammatory action to eugenol. They found the greatest effect

was observed after 4 hours and was comparable to the effects of phenylbutazone

and indomethacin. However, most essential oils of nutmeg contain very small

amounts of eugenol (Lawrence 1995).

Wagner et al (1986) screened various essential oils traditionally used for their

antiinﬂammatory action. They concluded eugenol, eugenyl acetate, thymol, cap-

saicin, curcumin, and carvacrol were present in most of the essential oils screened,

and the antiphlogistic effects were closely linked to the vascular reaction of early

inﬂammation. In herbal medicine this is called the counterirritant effect. Clove

and cinnamon had the strongest effect, Dwarf pine (Pinus mugo var. pumilo) and

Chapter 12 Pain and Inﬂammation 223

eucalyptus (Eucalyptus globulus) had a mild effect and Chamomelum nobile had a

weak antiinﬂammatory effect.

Where there is topical inﬂammation, essential oils should be applied topi-

cally. Essential oils are absorbed into and through the skin, and they can en-

hance the penetration of other medication. Godwin and Michniak (1999) found

terpenen-4-ol and a-terpineol enhanced the penetration of a hydrocortisome

cream on mouse skin by between three and ﬁve times. Sesquiterpenenes and

sesquiterpenoids (found in many antiinﬂammatory essential oils) caused a 20%

increase in penetration of 5-ﬂuorouracil, and this effect lasts for 4 days (Cornwall

& Barry 1994).

Sometimes, in cases of arthritic pain, heat can help. If this is the case, essen-

tial oils that have rubefacient effects, such as Piper nigrum (black pepper), Syzy-

gium aromaticum (clove), or Zingiber ofﬁcinale (ginger) can be useful, as CO

ex-

tracts. Sometimes cooling will help and an essential oil like Mentha piperita

(peppermint) can be added to the topical-application mix.

It is important patients be allowed to smell the mixture before it is applied;

they will have to live with it, after all! Be gentle and slow. Allowing someone to

touch a painful area takes courage, and that courage needs to be rewarded with

respect. All the essential oils mentioned are safe to use for relief of pain. While a

1-5% solution is usually adequate, much higher concentrations can be used. In

some circumstances, and depending on the essential oils selected, 100% solutions

can be used. Lavender and tea tree are good examples of oils that can be used at

full strength.

Plant flavonoids have measurable effects on the CNS (Paladini et al 1999).

Some semisynthetic derivatives of plant favonoids were found to have an anxi-

olytic effect 30 times that of diazepam. Both natural and synthetic flavonoids

are a part of Western living and are ingested by millions of people on a daily

basis.

Finally, the pain experienced by patients with sickle cell anemia, an inherited

disease, may be helped with herbal medicine. Fakim and Sewaj (1992) found an

aqueous extract of Pelargonium graveolens (geranium) successfully reverted sickled

cells in vitro. Fennel has also been shown to reverse sickling (Fakim et al 1990).

The extract used was aqueous, and therefore not found in the essential oil, but

there could be a similar response using the CO

extract.

There is no suggestion that essential oils should replace conventional analge-

sia. However, topical or inhaled, applications of essential oils appears to enhance

orthodox analgesia either through the placebo response, the effect of touch and

smell on the parasympathetic nervous system, or because of pharmacologically ac-

tive ingredients within the essential oils that may have an analgesic effect. There

have been few published clinical trials, but there is growing anecdotal evidence to

suggest essential oils could have an important role in augmenting conventional

analgesia. Finally, anethole, methyl salicilate, and camphor are all analgesic com-

ponents found in essential oils, and they are all found in root beer!

224 Section II Clinical Use of Aromatherapy

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Chapter 12 Pain and Inﬂammation 227

228

Stress Management

History is ﬁlled with examples that demonstrate how human contact acts as one of

nature’s most powerful antidotes to stress.

James Lynch (1979)

atients’ stress levels will directly impact the rate of their recovery. However,

it is sometimes easy for health professionals to forget patients (and those

who care for them) are under stress as all attention is ﬁxed on their symp-

toms or their disease. The reliability of previously used tools to measure stress is

now questioned, and there are moves to create different tools more sensitive to

psychological stress. Frazier et al (2002) found reliance on the top recognized

anxiety indicators in health care: agitation, increased blood pressure, increased

heart rate, patients’ verbalization of anxiety, and restlessness, produced an inaccu-

rate and incomplete anxiety evaluation of vulnerable patients. Frazier et al (2002)

wrote that reliance on these indicators could lead to “serious underestimation of

the extent of anxiety because anxiety is an uncomfortable, subjective phenomenon

that precedes the development of the most objectively detectable signs and be-

haviors.” O’Brien et al (2001) found no correlation of rating of stress between

coronary care patients and their attending health-care professionals. Van der

Does (1989) found a similar mismatch between patients and their caregivers in a

burn unit.

Despite these problems, health professionals now recognize stress has serious

consequences, and procedures are in place to help reduce stress when possible.

Redd and Manne (1995) investigated the effect of using aroma to reduce distress

during magnetic resonance imaging and found that a pleasant smell reduced the

stress and enhanced the coping ability of patients who had undergone traumatic

experiences. Fifty-seven participants received either heliotropin (a vanilla-like

scent) or plain air via a small tube inserted into their nostrils. Patients who re-

ceived the heliotropin reported 64% less anxiety than patients who had plain air.

However, their respiration and heart rate were not affected. Aromatherapy ap-

pears to be a quick, economical, and effective way of relieving, avoiding, and re-

moving stress, not just for patients, but also for staff and relatives.

Deﬁnitions of Stress

There are many deﬁnitions and types of stress, but it is generally agreed that Hans

Selye of McGill University conceived of the idea of stress in 1935. He was carry-

ing out research on rats and discovered those that had been injected with various

hormonal extracts developed enlarged adrenal glands, shrunken lymphatic glands,

and bleeding gastrointestinal ulcers. He called this “the stress syndrome” (Anthony

& Thibodeau 1983).

Rahe (1975), a psychiatrist at the University of Washington School of Med-

icine, found the more stress a person experienced, the more likely he or she

would fall ill. He interviewed more than 5000 people and devised what was to

become a classic, systematized method for correlating the events in people’s lives

with their illnesses (Pelletier 1992). Until that time it had been assumed only ad-

verse stress would have a signiﬁcant effect. However the survey indicated any

change in the normal pattern of life, even good stress, was found to produce

symptoms.

Today, the word stress is used to describe the cause of all ills that cannot be

explained in any other way, even though the meaning of the word is unclear. A

1991 article in the British Medical Journal called stress a “chimera – an unreliable

word to be used sparingly” (Wilkinson 1991). However, there is such a thing as

good stress, which everyone feels occasionally and which galvanizes action.

A major conference held in Arizona in the 1980s brought together leading

psychologists, immunologists, and physicians to discuss stress and try to deﬁne it.

After heated debate, it was agreed there was no absolute deﬁnition of stress but

that “things” outside people caused stress. These “things” were labeled stressors. It

was suggested that people react and adapt to stressors differently. Some individ-

uals seem to be able to cope, while others do not, and there is no way of telling

who will cope and who will not.

The conference delegates agreed that stressors had measurable psychological

and physiological effects. This was borne out by Cohen et al’s later research on

stress and human susceptibility to the common cold (Cohen et al 1991), which

showed an individual under stress was more likely to “catch” a cold than someone

not under stress.

Anthony and Thibodeau (1983) wrote of the ancient Chinese custom using

anticipated physiological effects of stress. Individuals suspected of lying were

forced to chew rice powder and then spit it out. The Chinese believed the stress

of lying would render a person incapable of salivation. Indeed, perhaps this is the

origin of the saying “the dry mouth of fear.”

Chapter 13 Stress Management 229

Indicators of Stress

Selye’s List of Common Stressors (Anthony & Thibodeau 1983)

Extreme stimuli includes too much of almost anything. Consider a patient

in a hospital, perhaps in a high-dependency unit. It is obvious the pa-

tient is receiving continuous extreme stimuli in the form of bright lights

and loud or sudden noises.

Extreme deﬁciency including social deﬁciency incurred during solitary con-

ﬁnement, blindness, deafness, etc. This is called sensory deprivation, but

some patients are physically isolated for either their own protection or that

of others. Others can be made to feel outsiders to society because of their

illness, such as those with AIDS, HIV, hepatitis, or the physically handi-

capped. Perhaps a semiconscious patient would also ﬁt into this category.

Stressors are often injurious, unpleasant, or painful. Hospital personnel do

not set out to injure their patients in the accepted sense of the word.

However, many medical procedures are unpleasant or painful.

Stressors are things an individual perceives to be a threat, whether real or

imaginary. Many hospital and nursing procedures are perceived to be

threatening, such as injections or lumbar punctures.

Stress is an intangible phenomenon. It cannot be tasted, heard, smelled, or

measured directly.

Stressors are individual. What is stressful today may not be tomorrow, and

what is stressful to one patient may not be to another.

Some indicators of stress can be easily measured, such as blood pressure rise,

tachycardia, pupil dilation, etc. But often stress cannot be measured in this way

and a psychological tool such as the stress and self-esteem questionaire developed

by Dr. Edward O’Brien (www.marywood.edu) needs to be used. Stress can be di-

vided into that which is necessary for survival and that which will eventually lead

to break down. Selye divided the physiological response to stressors into three

stages: alarm, resistance, and exhaustion. The alarm response can be life-saving—

the ﬁght or ﬂight phenomenon. During the alarm response, physiological changes

produced by receptors in the brain increase heartbeat and respiration rates. Un-

necessary metabolism, such as digestion, is curbed, while blood and oxygen are

swiftly redirected to the more vital centers of the body. When the danger is over,

the body quickly returns to its original state. Sweaty, clammy hands and cold feet

become warm and dry again. Respiration and pulse slow down to a normal level,

and digestion recommences.

Nixon (1976), a British cardiologist, found that when stress continued, a per-

son reached a point of no return. Fig. 13-1 indicates the point at which a person

under chronic stress would break down. Nixon thought if that person was isolated

and encouraged to rest, the mind, body, and spirit would be able to mend. Many

cardiac patients were treated successfully in this way when working with Nixon

in the 1970s.

230 Section II Clinical Use of Aromatherapy

In chronic stress, the “arousal state” of a person is never completely amelio-

rated. The measurable levels of stress in the body do not return to normal, and cor-

tisol levels remain above average. Throughout a period of time, small but damag-

ing physiological changes occur: blood sugar and pressure are raised, hormonal

functions change, and digestion and elimination are affected. Psychological stres-

sors are the most common cause of chronic stress. Pitts (1969) found lactate con-

centrations in the blood increased in patients with high levels of psychological

stress, producing anxiety neurosis. Barasch (1993) wrote prolonged stress could

create “ﬁbrin cocoons” that prevented T cells from attacking cancerous metastases.

Stress is now recognized as one of the most serious health issues of the 20th

century. In 2002, the workforce still continues to push itself to the limit. It is al-

most as though being stressed is the acceptable face of modern life. No one seems

to consider changing his or her lifestyle. However if stress remains relentless,

change is often forced through breakdown.

If a person is unable to “switch off,” either physically or mentally, he or she

will eventually break down. It may be slow in coming, but break down they will

because the body cannot maintain that level of stress. Wilde McCormick (1992),

a British psychologist, wrote in her book on breakdown, “if we start to break down

in our bodies with symptoms that don’t seem to have an organic cause, it is a mes-

sage to us from the unconscious that we need to be taken into areas we have not

yet explored or made conscious.”

Occasionally, some individuals who have undergone stringent training in the

handling of potentially stressful situations (such as army personnel, ﬁreﬁghters, or

Chapter 13 Stress Management 231

Figure 13-1 The human function curve: a performance arousal curve used as a model for

a systems or biopsychosocial approach to a clinical problem.

Reproduced from: Nixon P.

1976. The human function curve. Practitioner. 217(76) 769, 935-944, with kind permission of the

author.

paramedics) will only show signs of stress when the situation is over, almost as if

their body is allowing them to “let go” when it is safe. Only then do they experi-

ence the palpitations and interrupted sleep patterns their colleagues experienced

while in the stress situation. Survivors of the 9/11 terrorist attacks in the United

States have written and spoken of this phenomenon.

Pelletier (1992a) quotes Sir William Osler: “the care of tuberculosis depends

more on what the patient has in his head than what he has in his chest.” In other

words how a patient feels will affect how he recovers. This is very relevant to the

way a patient is cared for in the hospital. Perhaps the word treat should be re-

assessed.

Stressors can be divided into several categories: physical, emotional, behav-

ioral, environmental, cultural, and political. A patient in the hospital could be ex-

periencing physical, emotional, behavioral, and environmental stress simultane-

ously. Physiological stress is usually accompanied by some psychological stress.

Psychological stress produces measurable physical changes. Even though psy-

chophysiology has found a wide range of physiological responses to psychologi-

cal stress, very little is done to address the psychological stress of patients in hos-

pitals (Anthony & Thibodeau 1983).

Physical responses to stress are governed by the hypothalamus, which is po-

sitioned next to the pituitary gland for easy hormone control (Clark & Montague

1993). The hypothalamus controls the autonomic nervous system and forms part

of the limbic system, so it is immediately apparent that stress will have a direct ef-

fect on almost all bodily functions, from temperature to hormone balance. Any-

thing that affects the sensory systems, like an odor, has a direct pathway to the

limbic system, in particular to the amygdala. LeDoux (1996) suggests this path-

way “does not allow for cortical processing and may be responsible for emotional

responses a person does not understand.”

The secretion of almost every hormone is altered in response to stress, and

the altered chemical signals immediately affect the immune system. The immune

system governs the ability to repair and heal (Linn et al 1988). Therefore the sug-

gestion that aromas might affect a response to stress is a very important one.

Common Measurable Physical Responses

Measurable physical responses to stress include the following:

Increased concentrations of adrenaline/noradrenaline in the blood and urine;

Increase in the rate and force of the heartbeat;

Rise in systolic blood pressure;

Dilation of the pupils;

Decrease in the number of white blood cells;

Increase in the level of blood adrenocorticoids;

Increase in the level of lactate in the blood;

Increase in the level of urinary adrenocorticoids.

An increase in eosinophils and lymphocytes during times of stress will lead to im-

munosuppression and decreased resistance to infection. An increase in aldosterone,

232 Section II Clinical Use of Aromatherapy

thyroxine, and glucagon will increase the level of blood glucocorticoids. An in-

crease in cortisol levels will affect carbohydrate, lipid, and protein metabolism.

This can lead to muscle wasting, thinning of the skin, and depression of immune

responses, as well as raised blood-cholesterol levels and a reduction in vitamin D

levels and calcium absorption resulting in osteoporosis.

The effect of stress is determined by whether a person becomes angry or

frightened. Proportions of adrenaline and noradrenaline are directly related to the

emotion displayed (Clark & Montague 1993). Predatory animals produce more

noradrenaline, while domestic animals produce more adrenaline. Patients in the

hospital tend to become frightened rather than angry. It would be interesting to

measure the levels of adrenaline and noradrenaline in patients to determine which

is higher and therefore what their stress response might be.

Psychological stress negatively impacts the skin and blocks the cutaneous

permeability barrier function. Coadministration of tranquilizers blocks this

stress-induced deterioration in barrier function (Garg et al 2001). This is why so

many skin diseases appear to be precipitated and exacerbated by stress. Walsh

(1996) reports on the case study of a 57-year-old mother of four who had expe-

rienced psoriasis for 30 years. Severe plaque psoriasis affected both her knees and

elbows. She had tried many orthodox treatments unsuccessfully. Bergamot, jas-

mine, sandalwood, and lavender in sweet almond oil were applied (2%) and im-

provement “beyond the normal” for prescribed medication was experienced. The

dry, ﬂaky skin and red “scabs” disappeared, and she was able to wear a short-

sleeved blouse and knee-length skirt for the ﬁrst time in years without embar-

rassment. While the psoriasis did not clear up completely, there was a great im-

provement. It is unclear whether the essential oils reduced her stress thus

impacting her psoriasis, or if the essential oils directly impacted the psoriasis.

Rimmer (1998) wrote about using aromatherapy to reduce stress in a patient

with terminal cancer. By using pleasant-smelling essential oils to reduce stress, the

patient was able to relax deeply, began to sleep better, and was better able to cope

with her pain.

Symptoms of Stress (Wilson-Barnett & Carrigy 1978)

Physical

Clenched jaw, leading to bruxism and referred neck pain

Hostility, depression, introspection, overemotionalism, nervous twitches,

nail-biting

Sweating for no obvious reason

Inability to sit still

Frequent crying or wish to cry

Lack of appetite or unnatural craving for food

Dyspepsia, indigestion/heartburn, constipation, diarrhea

Constant tiredness

Insomnia, vivid dreams, sleep disturbances

Headaches, migraines

Chapter 13 Stress Management 233

Breathlessness without exertion, palpitations, tachycardia

Dry mouth, dysphagia

Hypertension

Infertility, impotence

Mental

Constant irritability

Loss of sense of humor

Difﬁculty in concentrating

Lack of interest in life

Feeling unable to cope

Depression, being unable to show feelings

Dreading the future

Fear of being alone

Illnesses

Eczema, psoriasis, acne, skin disorders

Asthma

Dysmenorrea, premenstrual syndrome, hormonal imbalance, alopecia

Pruritus

Diabetes mellitus

Overactive thyroid

Colitis, irritable bowel syndrome

Pitt (1969), in Scientiﬁc American, made a list of 26 symptoms that are a result of

prolonged stress. The list is as follows:

1. Tires easily 14. Insomnia

2. Breathlessness 15. Unhappiness

3. Nervousness 16. Shakiness

4. Chest pain 17. Fatigued all the time

5. Sighing 18. Sweating

6. Dizziness 19. Fear of death

7. Faintness 20. Smothering

8. Apprehensiveness 21. Syncope

9. Headache 22. Nervous chill

10. Paresis 23. Urinary frequency

11. Weakness 24. Vomiting and diarrhea

12. Trembling 25. Anorexia

13. Breath unsatisfactory 26. Palpitations

Stress and Immunology

The immunological effects of stress are not always clear because each person deals

with them in his or her own way and because the effects are cumulative. How-

ever, there is a growing body of published evidence (both scientiﬁc and anecdo-

234 Section II Clinical Use of Aromatherapy

tal) to show that speciﬁc stressors are linked to depressed immune function. A

decrease in immunoglobulin A was measured in a study of dental students during

their ﬁrst year (Ng et al 2002; Klecolt-Glaser & Glaser 1993). A similar study of

medical students prior to and during the ﬁrst day of their ﬁnal examinations re-

peated those ﬁndings; the students’ ability to produce interferon was drastically

reduced. Pelletier (1992a) discussed Bartrop’s study on bereavement, which

showed a lower lymphocyte function during the ﬁrst 8 weeks following bereave-

ment. Quinn (1993) used this knowledge for her research on bereavement, which

looked at lowered immunological function and the effects of therapeutic touch.

Pert (1997), a molecular biologist and research scientist, described immunol-

ogy as a network of information with the mind ﬂowing along it. Karl Pibram

(1976), who carried out neurophysiological research at Stanford University for

many years, describes the brain as a hologram storing information available to all

its different parts. In this case, could it be that when a person becomes stressed,

this hologram is affected and communication between neuropeptides (the net-

work of information) becomes blocked? Certain types of people appear to be pro-

tected from feelings of chronic stress. Jeanne Achterberg, an American psycholo-

gist, noted that at two institutions for the criminally insane, inmates who had

carried out horrendous crimes had been unusually protected from life-threaten-

ing diseases such as cancer, despite poor health habits such as heavy smoking.

Further studies showed mentally handicapped people were less likely to die from

cancer. On the basis of these studies it was suggested that a higher level of intel-

ligence could be linked to a higher incidence of chronic diseases such as cancer

(Barasch 1993). Do intelligent people tend to suppress their feelings, which then

suppress their immunological systems?

Stress and Patients

Arguably, one of the most stressful situations in anyone’s life is to be institution-

alized. To many people a hospital can seem like a prison. This attitude is well doc-

umented ( Jamison et al 1987). In a hospital is it all too easy for patients to lose

their sense of identity. Patients often feel anonymous. This feeling of anonymity

is compounded by Western medicine, which treats the medical condition rather

than the patient. An appendix is removed or a cancer is irradiated with little re-

gard for the gender, age, or weight of the person. Yet human beings are all unique,

so how can such a blanket treatment be right?

Patients in hospital are encouraged to conform. Questioning procedures of-

ten labels a patient as “difﬁcult”. The medical profession is trained to diagnose,

not to discuss. Responsibility and choice of treatment are often removed from the

patient in the current medical model. Patients are rarely asked how they feel about

their treatment, or given a choice in it.

One of the most stressful things in life is to feel a loss of control. Being a hos-

pital patient means exactly that. This is not just the loss of control produced by

an alien environment (being unable to choose when to sleep or eat) but also the

Chapter 13 Stress Management 235

loss of control of intimate bodily functions. The more seriously ill the patient, the

more severe the loss of control and the ensuing stress. Compounding this sense

of loss is the feeling of invasion. Privacy, personal space, and the body itself are

invaded.

Of all surgery, perhaps heart surgery is the most feared, and a high percent-

age of patients experience psychological disturbances following open-heart

surgery (Layne & Yudofsky 1971). This may be due to the bypass machinery, but

it may have a closer connection to being in an intensive care unit and the relent-

less stressors found there: total loss of privacy, loss of sleep, bright lights, and con-

tinuous noise (Roberts 1991). It is ironic that the stress induced by a high-

dependency unit may impact the psyche of a patient to such an extent that he or

she may not survive the miracle of modern medicine.

Aromatherapy and Stress

Familiar smells associated with happy memories can help reestablish feelings of

happiness. To be happy is to be unstressed. Most essential oils from plants and

ﬂowers have the potential to reduce stress. Certain essential oils, such as lavender,

rose, neroli, and petitgrain, are well known for this ability.

Each hospital department, whether oncology or dermatology, carries its

own particular brand of stress and fear. One of the most common, but least life-

threatening, stresses in oncology is a patient’s fear of hair loss. For women espe-

cially, this may produce profound anxiety. The simple act of a gentle head mas-

sage with a diluted essential oil such as lavender (Lavandula angustifolia ) can do

a tremendous amount to “touch the spot” and help reassure the patient that their

hair will grow back. In a randomized, controlled study, hair loss due to alopecia

responded well to topically applied essential oils (Hay et al 1998).

Organ transplant brings with it intense relief but also feelings of guilt and

anger. Sometimes these two emotions are not fully addressed, despite counseling.

For the patient receiving the transplant, it may not be the fact that another human

being has had to suffer, or die, but that a part of their own body has been “thrown

away” (Sylvia & Novak 1997). In the case of heart transplants, when patients have

literally “lost their hearts,” aromatherapy can introduce smell and touch to help re-

lease these feelings of grief and pain. Essential oils such as frankincense, ylang

ylang, angelica, and neroli can be useful tools in the healing process.

Outpatient departments are associated with long waits, dark corridors,

fraught staff, and physicians who rarely have time to look up from their notes.

Aromatherapy can help reduce the stress of waiting. Lehrner et al (2000) con-

ducted a randomized, controlled study with 72 participants and found Citrus

sinensis (sweet orange) had a calming and relaxing effect on patients waiting in a

dentist’s ofﬁce.

Schulz et al (1998) conducted two multiple-crossover studies, each involving

12 female subjects and electroencephalograms to screen for acute sedating effect

of eight different plant extracts. Lavandula angustifolia (1200 mg) was given in

236 Section II Clinical Use of Aromatherapy

capsule form (orally), and 140 minutes later 100 mg of caffeine was given orally

in tablet form. Conventional medications decreased theta frequency but increased

beta in these studies. However, several plant extracts increased theta but had no

effect on beta. Theta and beta are brain waves generated by the thalamus

(http://brain.web-us.com/brainwavesfunction.htm).

Tasev et al (1969) and Sugano and Sato (1991) found rose was gently uplift-

ing. Muruzzella and Sicurella (1960) found eucalyptus was antibacterial. So, a va-

porizer containing rose (Rosa damascena) or eucalyptus (Eucalyptus globulus) could

gently uplift patients and staff and reduce the possibility of cross-infection.

Stress and Hospital Staff

Stress in hospitals is not conﬁned to patients. The nursing staff is under tremen-

dous stress; their numbers have been cut even though their workload has re-

mained just as heavy, and morale is very low. Hospital managers show signs of

stress as they attempt to keep hospitals functioning. Physicians, too, are often de-

pressed and stressed. They have been forced into the “role of God” by the public,

and are then pilloried if they get it wrong. Healthcare is not healthy.

From the interns, many of whom still work 80-hour weeks, to consultant

surgeons who dash between operating rooms, there is no way these people could

avoid stress. Few physicians ﬁnd it easy to linger over a meal or to resist answer-

ing the telephone by the second ring. Stress is something accepted as part of the

job in medicine. Alcoholism, drug abuse, and suicide were the downsides of work-

ing in medicine in the 1980s (Bennett 1987), and little has changed.

Health professionals ﬁnd it hard to look after themselves. Since September

11, 2001, it has become more acceptable to acknowledge a sense of vulnerability

but it is still not OK for a health professional to admit being overwhelmed. The

pressure may be more manageable if some aromatherapy is used. Mandarin (Cit-

rus reticulata), lavender (Lavandula angustifolia), or chamomile (Chamaemelum no-

bile) inhaled for 5 minutes to help relaxation, or a few drops of peppermint (Men-

tha piperita), black pepper (Piper nigrum), or rosemary (Rosmarinus ofﬁcinalis) oil

on a tissue, to revive and stimulate, might make long nights more tolerable.

Health professionals experience many emotional and disturbing scenes. This

is always distressing. Often there is no way of ameliorating emotions until the

next break, and frequently there are no breaks. However, a 2-minute hand “m”

technique with some neroli (Citrus aurantium var. amara) could be a quick, effec-

tive, and therapeutic pick-me-up (Penson 1991). Just inhaling angelica, petit-

grain, or rose could also be helpful. Touch and smell may be as old as the hills, but

they can be deeply comforting.

Stress and Visitors

Visiting a sick relative is stressful. What to say? What to do? Where to sit? Fre-

quently, the patient has insufﬁcient energy to carry on a conversation, and the si-

lences become longer and longer.The sicker the patient, the more stressed the vis-

itors, and yet they come, sometimes long distances, if only for a few moments, to

Chapter 13 Stress Management 237

show that they care. Learning a simple hand or face “m” technique and using fa-

miliar smells can empower a visitor and make the patient feel wanted and cared

for. No words are necessary; touch can say it all.

It does not matter how ill patients are, they still need this kind of compas-

sion, especially from their loved ones. Research indicates the sicker the patients,

the less likely they are to be touched by their relatives, who are frequently afraid

to upset the complicated equipment around the patients. Research has also shown

patients with the poorest prognosis, or who are the most acutely ill, are often

touched least by the hospital staff (Ashworth 1984), although one of the most ba-

sic human, emotional needs is to feel physical contact (Weiss 1979).

Nurses, physicians, physical therapists, and others represent a large reservoir of

professionals who touch other people throughout life—from pediatrics to the care

of the elderly. For nurses in particular, aromatherapy offers a simple and acceptable

way of care. Children can learn how to give a gentle aromatherapy “m” technique to

elderly relatives, such as grandparents, in long-term care. Often a child visitor is

restless and awkward. This kind of structured touch is easy for a child to learn. It is

a simple and loving thing to do and costs little in terms of money, time, or energy,

but it communicates a great deal. Learning the “m” technique can be empowering.

It is the little things in life that are important, and in sickness the little things be-

come more signiﬁcant, including fresh air, natural light, plants, peace and quiet,

kindly touch, and pleasant smells. Few of these occur in a hospital. Perhaps this is

what Florence Nightingale meant when she said the “least fortunate were those

who found themselves nearest to a hospital” (Landsdown 1994).

Relaxation

Relaxation is not just the opposite of stress, it is the answer to stress, and is im-

portant to our quality of life and to our survival. However, sometimes it is difﬁ-

cult to “switch off,” especially in a strange environment. The harder a person tries,

the more elusive relaxation seems to become. Modern life is geared to doing, not

being. What do you do? What do you want to do? These are the questions we use,

not Who are you? or Who do you want to be? When people become sick, the

ability to do is replaced with an enforced “being.” This alone is stressful to people

who have spent most of their lives in a doing mode. Dossey (1993) writes, “The

most effective way to reverse illness is sometimes to focus primarily on being.”

Health professionals frequently ask the impossible. “Just relax,” nurses mur-

mur before plunging hypodermic needles deep into the upper, outer quadrant.

“Just relax,” physicians suggest before probing the rectum with a ﬁnger. “Just

breathe naturally,” the voice murmurs as a gowned, masked man inserts a cardiac

catheter into the femoral artery, aimed at the heart. What do health profession-

als actually do to help patients relax?

Relaxation brings with it manifold beneﬁts both for patients and health pro-

fessionals. Benson (1975) suggested many years ago that a relaxation break should

replace a coffee break. Despite this, stress management is not emphasized enough

238 Section II Clinical Use of Aromatherapy

in nurses’ or physicians’ training. However, there are programs developing to ad-

dress this issue.

In a discussion of massage and aromatherapy as supportive therapies in

health care, Sheena Hildebrand (1994) quotes from Wang Wei, who wrote in the

8th century, “Look in the perfumes of ﬂowers and of nature for peace of mind and

joy of life.” Drury (1989) also wrote:

Caring, loving, touching,

Absence of connection to stress factors,

Being a part of reality but

Being centered in caring

for the whole person, Functioning with a positive

conﬁdent, loving presence.

Touch and relaxation

Many people ﬁnd it pleasant and soothing to be stroked gently with something

that smells pleasant. In The Caring Touch (1981), reference is made to Sidney

Simon, who wrote of “skin hunger” and said “every human being comes into the

world needing to be touched, and the need for skin contact persists until death,

despite society’s efforts to make us believe otherwise”(Pratt & Mason 1981). He

also pointed out that “touch is quite distinct from sexual contact” and called for

“touch nourishment strategies.”

Touch presents a large body of reference that indicates a relaxation response.

In Palliative Care for Patients with Cancer, Victor Brewer, a patient with advanced

cancer, is quoted as describing the effects of touch as follows: “You unwind with

the gentleness of the human touch. It would be marvelous if nurses could do it in

hospital....With touch, as soon as the hands go on, you know she’s there, she’s

calm, she has time for you” (Penson 1991). The type of touch used in the “m”

technique is different from regular massage. It is much lighter and slower and is

not intended to address muscle tone, but to address soul tone. Please see the sec-

tion in Chapter 8 on the “m” technique.

Relaxation and Pain Relief

Touch aids the release of endorphins. Some endorphins can block the release of

substance P, one of the neurotransmitters involved in the sensation of pain. Some

pain can also be alleviated by rubbing the skin. In the gate theory, rubbing the

skin stimulates large-diameter afferent sensory ﬁbers that excite interneurons,

causing enkephalin release (Turk & Nash 1993). Enkephalin release inhibits the

release of substance P from activated unmyelinated C ﬁbers. This prevents T cell

activation and closes the pain gate (Fields 1997). The pain most often relieved by

massage is chronic pain that is poorly localized (Sofaer & Foord 1993). This type

of pain can be associated with many chronic conditions and with postoperative

recovery, although not with immediate postoperative care. Although deep massage

is contraindicated following recent surgery, the gentleness of the “m” technique

Chapter 13 Stress Management 239

around the affected area is highly appropriate and is a very useful adjunct to pain

control.

Some fragrances have deeply relaxing effects. Japanese research has shown

contingent negative variation (CNV), namely the upward shift in the brain waves

recorded by electrodes attached to the scalp, occurs in situations in which subjects

are expecting something to happen. CNV alters in response to odor. Following ex-

periments with diazepam and caffeine that produced central nervous system

(CNS) depression or stimulation, Torii et al (1988) found lavender had a depress-

ing effect and jasmine had a stimulating effect on the CNS. Further investigation

revealed that although odor had an effect on the brain, it did not appear to affect

physiological functions. Even in individuals who have no sense of smell (anosmia),

a chemical reaction to odors occurs in the brain if the olfactory nerve is intact.

In conclusion, touch and smell are two powerful relaxation tools available to

health professionals. It would be a shame not to use them.

Stress, Relaxation, and Psychoneuroimmunology

The American physicians Bernie Siegal and Larry Dossey have done much to

raise awareness of the importance of psychoneuroimmunology (PNI). The term

ﬁrst became popular in 1986 with the publication of Siegal’s book, Love, Medicine

and Miracles (1986). In the book he wrote of patients who had survived cancer.

He calls them “exceptional cancer patients.” In one famous address to eminent,

orthodox physicians (many of whom were openly hostile to his views), he read

aloud from the novel Lady Chatterley’s Lover. He read for some time, until the

conservatively dressed men in front of him were ﬁdgeting and red-faced. Then he

paused, closed the book, and said quietly “Now then, gentlemen, don’t tell me that

your mind has not affected your body!”

PNI is a medical subspeciality that involves the study of the connection be-

tween the mind (psycho), the brain (neuro), and the body’s ability to defend itself

against disease (immune). Humans do have the ability to affect their wellness or

disease-susceptibility through the power of thought. This ﬁnding has not been

accepted readily within orthodox medicine. Indeed, Siegal quotes from Dosto-

evsky at the beginning of his book: “A new philosophy, a way of life, is not given

for nothing. It has to be paid for dearly and is only acquired with much patience

and great effort.” Perhaps this quote is as relevant to aromatherapy as it is to PNI.

Norman Cousins, a patient, decided to apply the principle of PNI to himself.

Diagnosed with ankylosing spondylitis, he was told his spinal connective tissue

was dissolving (Cousins 1979). A regimen of medication consisting of 26 aspirin

and 12 phenylbutazone tablets daily resulted in hives all over his body but no pain

relief. Appalled by his hospital treatment (one day he had to give four separate

samples of blood for the same test because the pathology laboratory was in

chaos), he checked out of the hospital and into a hotel. Cousins knew pain could

be affected by attitude, and he instinctively chose to try laughter instead of

medication.

240 Section II Clinical Use of Aromatherapy

It was a brave and desperate move, but one that showed him 10 minutes of

genuine belly laughter had an anesthetic effect and gave him 2 hours of pain-free

sleep. Wanting “real” proof, Cousins took blood tests that conﬁrmed his erythro-

cyte sedimentation rate fell by at least ﬁve points following laughter therapy. Bet-

ter still, the effect was cumulative. It seems laughter was stimulating the produc-

tion of endorphins, which resulted in a profound reduction of his joint

inﬂammation. Bolstered by this discovery, he refused to let his friends see him un-

less they could bring a new joke, cartoon, or ﬁlm to make him laugh. Cousins un-

derstood how he felt affected how he was, and that included his illness.

It would be interesting to see if laughter could become a commodity provided

by hospitals. True, some get-well cards can be slightly amusing, but laughter ther-

apy, although effective, is not an approach easily incorporated into either a West-

ern medical model or the Western temperament. Illness is serious business, and

in the private sector, serious illness means serious money and long faces. No one

wants to be seen laughing! However Wilde McCormick (1990), in her book on

changing one’s life through self-help psychotherapy, advises “Make sure you laugh

every day.”

The relationship between an emotional reaction brought on by an illness and

the survival rate of a patient is highlighted by Fiore (1979), a patient with cancer.

Health professionals are in a unique position to encourage PNI, because “care

givers have the power to be dispiriting or inspiring to their patients” (Young

1990). Yet how many health professionals actually use this power to encourage

patients to draw on their own self-healing abilities?

Aromatherapy and PNI

Aromatherapy is a perfect way of utilizing PNI. Many patients ﬁnd them-

selves lulled by repeated stroking movements, which encourage a series of endor-

phins into play. The pleasant smell of an essential oil will enhance this effect. To-

gether, smell and touch can produce a synergy of social, physical, psychological,

and neurological interactions in the patient. The most common comment made by

patients is how relaxing they ﬁnd the treatment and how the feeling of relaxation

remains for several days. This may be highly relevant. Although it is recognized

that smell is instant, the effect of smell wears off very quickly as olfactory neurons

become inured to the odor. Perhaps by administering the “smell” transdermally, a

slow-release smell that produces a longer-lasting effect could be achieved.

Antoni et al (1990) wrote relaxation “may inﬂuence the immune function of

those patients with HIV, and retard disease progression among early HIV-1

seropositive individuals.” Supportive personal relationships improved the immune

function of women with breast cancer (Kiecolt-Glaser & Glaser 1993). Dean

Ornish’s study on reversing heart disease was based on diet, exercise, and stress

management. He wrote he was “increasingly convinced that the root of chronic

stress is a sense of isolation—from oneself, from others, and from something spir-

itual” (Ornish 1991).

Chapter 13 Stress Management 241

Farrow (1990) used massage in an acute medical ward. She found it reduced

anxiety in patients receiving morphine-pump therapy for pain during the period

when the pump was being changed, and it enabled a teenager to cope better with

her disﬁguring postoperative ileostomy tubes and drains. Tisserand and Balacs

(1988) wrote about the “emotionally uplifting and comforting oils” that can be used

with cancer patients. King (1993) wrote about the ability of odor impressions to

“produce effects partly through mood changes” and concludes “fragrance provides a

useful adjunct for relaxation and has considerable potential for future development.”

Birchall (1990), writing for the New Scientist, asked whether aromatherapy

matches the potency of Valium and Librium, two drugs often used for stress, stat-

ing many of aromatherapy’s claims are now being validated by research. In fact,

as early as May 1988, the International Journal of Aromatherapy bore the headline

“Lavender beats benzodiazepines”(Tisserand 1988).

Reed and Norfolk (1993) found 36 of 38 patients experienced a feeling of re-

laxation following aromatherapy. This British study was carried out by two mid-

wives who were investigating whether lavender might reduce pain during child-

birth. Patients took baths with ﬁve drops of lavender during labor. There was no

control to this study. However, the results suggested aromatherapy did alter pain

perception in 30 women, and 36 women felt their ability to relax during labor was

enhanced. Stevenson (1992) concluded 100% of patients found the effects of a

foot massage with essential oil relaxing. She was investigating the effects of neroli

(Citrus aurantium ﬂos) on 100 patients in London’s Middlesex Hospital cardiac

intensive-care unit following open-heart surgery. This was a controlled, random-

ized study using a modiﬁed Spielberger State Trait Anxiety Inventory for Adults

State Evaluation Questionnaire to measure pain, anxiety, tension, calmness, rest,

and relaxation. Physiological measurement showed a decrease in respiration, sug-

gesting an increased parasympathetic response. This conclusion was supported by

the psychological measurements. Stevenson showed patients who received a

neroli foot massage felt their anxiety decreased more than the patients who re-

ceived a foot massage without neroli essential oil.

Woolfson and Hewitt (1992) found 91% of patients experienced a reduction in

their heart rate of between 11 and 15 beats per minute following aromatherapy

massage. This study was carried out in the intensive-care unit of Royal Sussex

County Hospital in the United Kingdom. A total of 36 patients were allocated to

one of three groups: those massaged with essential oils, those massaged without es-

sential oils, and a control group who just rested. The results of this study appear to

agree with Stevenson’s ﬁndings that massage with an essential oil, in this case laven-

der, was more effective in reducing stress than massage without an essential oil.

Dunn et al (1995) found 122 patients felt anxiety reduction following aro-

matherapy massage with lavender in an intensive-care unit. Dunn led one of the

ﬁrst formal trials to be conducted in a hospital, which paved the way for further

trials. Burns and Blamey (1994) studied 585 women in labor to determine

whether aromatherapy with any of 10 essential oils could reduce anxiety, increase

contractions, and reduce pain. The oils used were lavender, clary sage, pepper-

242 Section II Clinical Use of Aromatherapy

mint, eucalyptus, mandarin, chamomile, jasmine, rose, frankincense, and lemon.

The study was set up when the two investigators discovered aromatherapy was

part of the curriculum and examination syllabus for all student midwives in Ger-

many. Their results showed much satisfaction expressed by the mothers and the

delivery team concerning the reduction of stress with all of the essential oils used.

The study was not randomized or controlled but was an important investigation

and has led the way for the use of aromatherapy in other maternity units. A fur-

ther analysis of 8058 mothers who had received aromatherapy between 1990 and

1998 indicated more than 50% of mothers found it helpful for relaxation (Burns

et al 2000).

More than 10 years ago Wise (1989) wrote, “Aromatherapy helps to take the

anxiety out of being in hospital and quickens the patient’s return to self-care.”

Whether patients choose drops of essential oil on a pillow or an aromatic “m”

technique, there is no doubt that aromatherapy as a method of stress therapy is a

valid and important part of health care.

Spontaneous Remission

Finally, no chapter that refers to PNI would be complete without a mention

of spontaneous remission. The Institute of Noetic Sciences was founded in 1973

by astronaut Edgar D. Mitchell, following his experience of walking on the moon.

It is a research foundation and educational institution and has 30,000 members

worldwide. The word noetic comes from the Greek word nous, meaning mind, in-

telligence, and transcendental knowing.

In 1993, the Institute of Noetic Sciences and the Fetzer Institute published a

book documenting the results of a 10-year research program on the healing response.

Their program was “based on the belief that the ability of the physician to promote

health and to heal the sick in the future may be as dependent on the deeper under-

standing of the mind-body relationship as on the development of new technologies.”

Their study revealed a large body of evidence of extraordinary healing, in-

cluding regression of normally fatal tumors, with no currently available scientiﬁc

explanation (O’Regan & Hirschberg 1993). This discovery was not new to med-

icine. Nearly a century earlier Handley (1909) wrote in the British Medical Jour-

nal that “the recorded cases of natural repair of cancer, far from being anomalous

and exceptional, merely illustrate more strikingly than usual the natural laws

which govern every case of the disease.” The study carried out by the Institute of

Noetic Sciences was the largest investigation of spontaneous remission to date. It

concluded, “The evidence suggests this kind of healing can be triggered by a va-

riety of stimuli, diverse in nature, including signals, suggestions and guidance

from the physical, mental and/or spiritual realm of every individual.”

Sadly, Brendan O’Regan, the visionary responsible for the program, died in

1992 before the study was completed. Although a great portion of the study was

completed in 1990, more than 300 additional references to spontaneous remission

from cancer and other diseases (which were published in medical journals be-

tween 1990 and 1992) have been collated subsequently.

Chapter 13 Stress Management 243

There is no suggestion that aromatherapy could result in spontaneous remis-

sion, but aromatherapy does have a profound impact on the mind-body link. It

would be interesting to measure immune levels before and after an aromatherapy

treatment. To quote the Institute of Noetic Sciences, “We are at the threshold of

a new ﬁeld of inquiry.” Ralph Waldo Emerson wrote that “thought is the blos-

som, language the bud, action the fruit behind it.” I hope this chapter will serve

as the bud to encourage a little fruit!

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246 Section II Clinical Use of Aromatherapy

247

Cardiology

Whatever the physiological problem with the heart, its function is affected by what

each individual asks of their heart in terms of effort. This is determined by the

person we are, by the way we live within our own body and by the relationship

we do or do not make with it.

Elizabeth McCormick (1997)

lterations in mental status are common among patients in a cardiac

intensive-care unit. These changes can be due to medication, brain

trauma, or metabolic function (Beauchamp et al 2000). However, contin-

uous stress, insomnia, sensory deprivation, and loss of privacy can also cause

changes in mental state. These all occur in an intensive-care unit. The heart is of-

ten described as the seat of emotion, and aromatherapy can play an important role

in assisting patients as they come to terms with feelings that may have been

blocked. Aromatherapy can also help them cope with a highly stressful situation.

While aromatherapy cannot replace a damaged valve or repair an atrial septal de-

fect, it can be useful for reducing the stress that surrounds a heart attack and may

reduce the period of recovery following a heart attack or surgery. Aromatherapy

is used in some medical and surgical cardiac units, and many of the essential oils

have a history of being supportive to the heart, as well as being generally relaxing.

Several cardiac conditions can beneﬁt from aromatherapy: borderline hyper-

tension, anxiety associated with myocardial infarction, and postpump depression

or delirium (PPD).

Borderline Hypertension

Hypertension and its complications affect an estimated 50 million Americans, 30%

of whom are unaware they have hypertension. Only 70% of those who are aware of

their condition receive treatment (Manger & Gifford 2001). Approximately 35,000

Americans die each year from conditions directly associated with hypertension.

Hypertension, an abnormal rise in blood pressure, occurs when the arterioles be-

come constricted, reducing the ability of the blood to ﬂow and making the heart

work harder. Ninety percent of all cases of hypertension are essential hypertension,

which means there is no apparent reason. However, there are some associated risk

factors: obesity, smoking, alcohol consumption, a diet high in fat or salt, gender

(men are more likely to have hypertension than women), race (African Americans

are more likely to develop hypertension than any other group), and genetics. Sec-

ondary hypertension is deﬁned as an elevation in blood pressure caused by a preex-

isting condition such as coarctation of the aorta, kidney disease, or thyroid mal-

function. However, Samuel Mann, a professor of clinical medicine at Cornell

University, believes emotion may play a major role in hypertension (Mann 1997).

An elevated blood-pressure reading is above 140/90. Antihypertensive drugs

appear to be effective at reducing mortality and morbidity in the elderly (Mulrow

et al 1997). However, the British National Health Service Center for Reviews and

Dissemination at the University of York (1999) reported all the main classes of an-

tihypertensive drugs are associated with adverse side effects, although the majority

of symptoms were mild, such as dizziness, headache, or rash. In addition, the report

continued, the older the patient, the more severe the side effects become, including

arrhythmias or renal dysfunction. Both the older types of beta-blocker and diuretic

drugs and the newer angiotensin-converting enzyme (ACE) inhibitors and calcium-

channel blockers had side effects. Instead, light exercise, change in diet, relaxation,

and meditation are often encouraged to reduce borderline blood pressure.

Aromatherapy can help as an adjunctive relaxing therapy, and some essential

oils are thought to help reduce borderline hypertension. Thymol isolated from es-

sential oil of Trachyspermum ammi reduced the blood pressure of anesthetized rats

(Aftab et al 1995). This herb has a history of being used in Pakistan to reduce hy-

pertension. However, in this study quite large amounts of thymol were given (1-

10 mg/kg) by intraperitoneal injection. The authors postulate the hypotensive ef-

fect of thymol was due to its calcium-channel-blocking ability. Thymol is also

found in Thymus vulgaris (common thyme), an inexpensive essential oil. Thymol

is a phenol and as such is not something that immediately comes to mind for hy-

pertension, as phenols are generally thought to be stimulating.

Tisserand and Balacs (1995) state “it is extremely unlikely that an essential oil

could exacerbate hypertension or hypotension.” Guba (2000), an Australian clinical

aromatherapist, completed an extensive search of the available literature and con-

cluded that an essential oil was unlikely to elevate high blood pressure and many aro-

matherapy cautions regarding essential oils and hypertension were based on myth.

A recent study carried out on human subjects did show inhaled rosemary in-

creased systolic and diastolic measurements, but the effects were transient, lasting

only a few minutes (Saeki & Shihora 2001). The same study found lavender re-

duced systolic pressure, again for a short period of time. Other essential oils such

as geranium and clary sage have shown measurable hypotensive effect in animal

248 Section II Clinical Use of Aromatherapy

studies. Essential oils, like herbs, appear to be adaptogenic; they balance the body

when it is out of balance. Adaptogens constitute a novel class of metabolic regu-

lators that can have different psychological and physiological effects depending

on the requirement of the host (Panossian et al 1999).

Despite a lack of evidence, many schools of aromatherapy suggest avoiding

stimulant essential oils such as Rosmarinus ofﬁcinalis (rosemary), Mentha piperita

(peppermint), or spike lavender(Lavandula latifolia) with any patient who has hy-

pertension. These essential oils will be discussed individually.

O’Brien (1997) reported on her experiences with the hypertensive effects of

rosemary in elderly, long-term-care patients suffering transient hypotension as a

side effect of antidepressants. Patients inhaled two drops of rosemary for 5 min-

utes before getting up from a seated position. Blood pressure was measured be-

fore and after getting up. A control group was given carrier oil with no known

pharmacological properties to smell. Blood pressures of all patients had been

recorded since their admission to the hospital, prior to beginning the antidepres-

sant medication. The number of instances in which a subject fell down immedi-

ately after rising from a sitting position (presumably as a result of hypotension)

was compared with falls within the same timeframe the previous year. The num-

ber of falls dropped by more than 50%. Rosemary did not appear to have any hy-

pertensive effect on normal blood pressure.

Rosemary was also found to have pharmacological stimulatory effects in

animals by Kovar et al (1987). However, rosemary was shown to have slight

anxiety-reducing effects in a study at the University of Wolverhampton. Unfor-

tunately, the botanical name and chemotype of the rosemary used were not stated

(Morris et al 1995).

Peppermint is traditionally considered to have stimulating properties.

Menthol-ﬂavored cigarettes and peppermint confections have both been responsi-

ble for atrial ﬁbrillation in cardiac patients prone to that condition who were previ-

ously stabilized on quinidine (Thomas 1962). l-menthol was found to dilate sys-

temic blood vessels when given intravenously (Agshikar & Abraham 1957). It is

extremely unlikely that inhaled peppermint would have any negative effect on pa-

tients with high blood pressure, and peppermint is very useful for nausea. However,

peppermint has a pervasive smell and is difﬁcult to tolerate for several hours. Perez-

Raya et al (1990) found two other mints, Mentha rotundifolia and Mentha longifo-

lia, which grow wild in Spain, enhanced sodium barbitone-induced sleep in rats.

Spike lavender (Lavandula latifolia) has a history of being an expectorant and

mycolytic and was found useful in upper respiratory-tract infection (Charron

1997). It is also thought to be a stimulant. Certainly a few drops of this

camphorous-smelling lavender is more likely to clear the sinuses than induce

sleep; however, there is no record of spike lavender increasing blood pressure.

Freund (1999) conducted a small pilot study on 13 patients with borderline

hypertension. The age range was 21-71 years, and the group included ﬁve males

and eight females. Eleven patients were more than 15 pounds overweight.

Baseline blood pressure was taken with each patient in a supine position. Patients

Chapter 14 Cardiology 249

rated their stress level based on a visual analog. Subjects were asked to inhale ﬁve

drops of ylang ylang essential oil for 15 minutes. Blood pressure was remeasured,

and the stress level recording was reassessed. The same group received a control

aroma (carrier oil with no pharmacological effect) at a different time. The ylang

ylang (Cananga odorata) group experienced a 50% greater drop in systolic and di-

astolic pressure than did the control group. The stress visual analog also indicated

the ylang ylang group felt a 50% greater reduction in stress. Ylang ylang has an

anecdotal history of being used to reduce blood pressure and is used by British

midwives to help reduce hypertension in pregnancy.

Essential oils that could help reduce hypertension are ylang ylang, Roman

chamomile, true lavender, and clary sage. Neroli, sandalwood, spikenard, and

sweet marjoram might also have advantageous effects. Whatever the choice of es-

sential oil, it is important to ask patients which aromas remind them of pleasant

memories and use those. Gentle touch is one of the most soothing actions that

can be offered another human being in distress. Holism is about being present for

the patient. Aromatherapy can put the heart back into health care.

Anxiety and Myocardial Infarction

Acute myocardial infarction (known more commonly as a heart attack) is the lead-

ing cause of death in the Western world with one million deaths each year (Rogers

et al 1994). It is also a leading reason for hospitalization in the United States (Hill

et al 1992). Approximately 90% of those who reach a hospital survive (Hill et al

1992). Twenty to 30% of the cost associated with acute myocardial infarction is re-

lated to the length of time a patient stays in the coronary-care unit (Sgura et al

2001). The main symptom of acute myocardial infarction is deﬁned by the World

Health Organization as intense, prolonged, or intolerable chest pain necessitating

hospitalization. Fifty percents of deaths caused by myocardial infarction occur

within 2 hours of the onset of symptoms (Hope et al 1993). In the United King-

dom, the number of deaths from heart attacks each year is equal to the number of

babies born (McCormick 1993). Standard treatment is primary reperfusion ther-

apy and the judicious use of aspirin, beta blockers, angiotensin-converting enzyme

(ACE) inhibitors, and glyoprotein antagonists. These have reduced the length of

time patients spend in a high-dependency unit (Sgura et al 2001).

Despite analgesics and sedatives, many patients are anxious when they arrive in

a coronary-care unit. Their arrival at the hospital is usually unexpected, so they come

unprepared. Unattended business meetings and unanswered e-mail are difﬁcult to

forget, and patients ﬁnd it a challenge to switch off their worries. Anxiety can extend

infarction areas or precipitate further arrhythmias (Summers Dunnington et al

1988). Anxious patients are more likely to experience severe or chronic psychologi-

cal distress. Rowe (1989) discovered patients’ anxieties tend to be focused on their

own illness. The severity of the infarction and how close to death patients perceive

themselves to be will inﬂuence the level of psychological distress they experience.

Vlay and Fricchione (1985) reported on heart-attack patients’ emotional distur-

250 Section II Clinical Use of Aromatherapy

bances, which are often expressed as depression, anger, frustration, and fear. Mood

has a powerful inﬂuence on prognosis after acute myocardial infarction (Petty 2000).

Aromatherapy attempts to alleviate these feelings and to reduce anxiety. Be-

cause these patients have constant monitoring and/or visitors, it is important to

select essential oils that will be acceptable to all those who will smell them. Aro-

mas of citrus and herbs are usually acceptable. Gould et al (1973) reported on the

relaxing cardiac effects of chamomile tea on a group of 12 hospitalized patients

who were undergoing cardiac catheterization. They found there was a small but

signiﬁcant rise in the group’s mean brachial-artery pressure, so there was some

hemodynamic change but essentially no cardiac effect. However, the scientists

were more struck that 10 of the 12 patients fell into a deep sleep within 10 min-

utes of drinking the tea. Sleeping is a rarity during cardiac catheterization. Pa-

tients had not been premedicated and received no other sedation during the pro-

cedure.

Yamada et al (1996) found chamomile essential oil reduced stress-induced

increases in plasma adrenocorticotropic-hormone levels in rats and concluded es-

sential oil of Roman chamomile might be useful against stress in humans. Finally,

Avollone et al (1996) studied an aqueous extract of German chamomile ﬂowers

and found it behaved as both central and peripheral benzodiazepine receptor lig-

ands, with anxiolytic effects. Viola et al (1995) identiﬁed the anxiolytic compound

as apigenin. German and Roman chamomile are different essential oils with dif-

ferent chemistries. Roman may be more conducive to use in a cardiac unit as it

has a more pleasant aroma. Table 14-1 lists essential oils used following myocar-

dial infarction along with the studies that have been done on their effects.

Chapter 14 Cardiology 251

Table 14-1

h Anxiolytic Essential Oils for Use Following

Myocardial Infarction

Common Name Botanical Name Reference

Melissa Melissa ofﬁcinalis Wagner & Sprinkmeyer 1973

Buchbauer et al 1993

Lavender Lavandula angustifolia Bauhbauer et al 1991,

Woolfson & Hewitt 1991

Roman chamomile Chamaemelum nobile Rossi et al 1988

Neroli Citrus aurantium ﬂos Jager et al 1992

Rosewood Aniba rosaeodora Nacht & Ting 1921

Marjoram Origanum majorana Nacht & Ting 1921

German chamomile Matricaria recutita Viola et al 1995

Rose Rosa damascena Nacht & Ting 1921,

Buchbauer et al 1994

Postpump Depression/Delirium

Alterations in mental status are common following bypass surgery (Beauchamp

et al 2000). Up to 75% of patients have deterioration in performance on neu-

ropsychiatric tests (Mahanna et al 1996), and up to 32% develop Postpump

depression/delirium (PPD) (Roach et al 1996). Glick et al (1996) suggest PPD is

often not recorded, so it is difﬁcult to analyze how many patients are affected. A

2001 article in the New York Times suggested depression is more common after

bypass surgery than other types of surgery (Epstein 2001) and occurs in 30%-75%

of patients. The article quotes Dr. R. Scott Mitchell, a cardiovascular surgeon at

Stanford, and Dr. Roy John, professor of psychiatry and director of the brain re-

search laboratories at New York University Medical Center. Dr. John suggests

atherosclerotic plaques in the aorta could become dislodged during surgery and

bombard the brain, or that the anesthesia and cooling used during the operation

could alter brain chemistry. A doctor at one British university suggests PPD

(delirium) could be caused by sensory imbalance or disorientation (Lidster 2001).

Danilowicz and Gabriel (2001) compared two matched groups of patients

from the National Heart Institute and found the incidence of PPD (delirium) was

higher among men than women and higher in those who were not able to com-

municate in English. The study emphasizes the importance of communication.

PPD is thought to play a major role in the development of sternal instability

(Bimmel et al 2001), which has a major inﬂuence on postoperative recovery after

bypass surgery.

Many patients arriving in a critical-care unit have undergone elective surgery,

so they have been prepared for the ordeal that awaits them. British psychologist

McCormick (1993) suggests “preparation by the feeling heart for the worker

heart’s surgery is essential.” Many surgeons, including Mehmet Oz, MD, at Co-

lumbia Presbyterian Medical Center in New York, believe she is right. Patients

who are prepared are better able to cope with their condition postoperatively

(Roberts 1991), as fear of surgery is a factor that can strongly inﬂuence a patient’s

emotional response to hospitalization (Wilson-Barnett & Carrigy 1978). Of all

the operations performed, open-heart surgery is possibly the most feared.

The symptoms of PPD are hyperventilation, tachycardia, auditory hallucina-

tions, disorientation, and paranoid delusions (Layne & Yudofsky 1971). The

symptoms are distressing for the patient, their relatives, and for those who care

for them. The Rancho Los Amigos Cognitive Scale lists eight different states of

consciousness (Herndon 1997). They range from no response, through confused-

inappropriate, to purposeful appropriate and could be a very good tool to use in

measuring PPD.

Although there are several theories concerning the pathogenesis of PPD,

nothing is clear. It is thought that older patients, those undergoing aortic valve re-

placement, and male patients are more at risk. However, Layne and Yudofsky

(1971) found a reduction in postoperative psychosis was achieved in 50% of pa-

tients by conducting a preoperative psychiatric interview. This interview allowed

252 Section II Clinical Use of Aromatherapy

and encouraged patients to ask questions about their disease and surgery and to

discuss openly any worries they had (Layne & Yudofsky 1971). Preoperative psy-

chological preparation is now recognized as being important not just for the pa-

tient, but also for the relatives who will be supporting the patient postoperatively

(Roberts 1991). Discussing current or potential marital or relationship problems

can help indicate which patients are more likely to succumb to PPD (Egerton &

Kay 1964). Any illness will force a relationship to change, and open-heart surgery

will certainly test the strength of every relationship.

Utilizing the preparation time, aromatherapy can set a safe, gentle pattern

which, when repeated postoperatively, could affect the patient positively through

learned memory. If patients feel relaxation and pleasure when they receive a foot,

hand, or face “m” technique with a favorite aroma preoperatively, chances are they

will feel the same relaxation and pleasure when the aromatherapy is repeated

postoperatively. Table 14-2 lists essential oils that have been used to prevent

and/or treat PPD, along with the studies undertaken to determine the possible

beneﬁts.

Chapter 14 Cardiology 253

Table 14-2 h Essential Oils for the Possible Reduction of PPD

Common Name Botanical Name Reference

Neroli Citrus aurantium ﬂos Jager et al 1992,

Stevensen 1994

Angelica Angelica archangelica (root) Franchomme & Penoel

1991

Lavender Lavandula angustifolia Dunn et al 1995

Rosewood Aniba rosaeodora Nacht & Ting 1921

Marjoram Origanum majorana Nacht & Ting 1921

Rose Rosa damascena Nacht & Ting 1921,

Rovesti & Columbo 1973

Lemon Citrus limon Komori et al 1995

Bergamot Citrus bergamia Komori et al 1995

Geranium Pelargonium graveolens Morris et al 1995

Roman chamomile Anthemis nobilis Rossi et al 1988, Moate

1995

Melissa Melissa ofﬁcinalis Wagner & Sprinkmeyer

1973

Sandalwood Santalum album Kikuchi et al 1995

Komori et al (1995) demonstrated the positive effects of lemon oil (Citrus

limon) mixed with bergamot, sweet orange, and cis-4-hexanol on depressed inpa-

tients who were exposed to the fragrance for 4 to 11 weeks while their antide-

pressant medication was systematically reduced. By the end of the period, nine of

the 12 patients no longer needed antidepressant medication. Their levels of uri-

nary cortisol and dopamine became lower and were normalized with the citrus

aroma. The authors posited that inappropriate use of antidepressants could

weaken immune function.

Moate (1995) wrote of a patient suffering from depression who was treated

with Largactil and Sertraline (a tricyclic) but found profound relief from aro-

matherapy massage using lavender and chamomile. In another study, Sano et al

(1998) showed essence of cedarwood produced sedative effects on rats and re-

duced the time needed to achieve deeper stages of sleep in napping humans.

Templeton (2002) carried out a small study to investigate the effects of berg-

amot as an antidepressant. Ten volunteers from a natural-health clinic responded

to an advertisement to take part in a study on depression. Each agreed to take six

aromatic baths and six baths with no aroma. Subjects were to remain in the bath

for 20 minutes. While the study was self-monitoring, several subjects commented

on how this simple technique had empowered them. One wrote, “I experienced

an overwhelming feeling of tranquility.”

Vogley (2002) used bergamot in her study on anxiety in a psychiatric unit for

the elderly. A psychiatric nurse assessed each patient each morning for 10 days

and scored their level of anxiety on a scale of zero to 10. Then, bergamot was dif-

fused and the patients were reassessed. There was a notable difference in many of

the patients, which presented as enhanced communication and the ability to sit

still. One participant was hospitalized for depression and had been taking Lib-

rium for 20 years. It was decided to withdraw her from the drug. She was having

great difﬁculty sleeping and was feeling generally anxious. Several drops of

bergamot were placed on a cotton ball and put inside her pillowcase. The follow-

ing morning she reported it was the ﬁrst good night’s sleep since she had stopped

taking Librium. She continued to use bergamot throughout her stay, and at dis-

charge she asked for and was given bergamot essential oil to take home with her,

along with instructions on how to use it.

A patient’s “pleasure memory” could have an effect even when the patient is

not fully conscious. Patients who have their chosen music played via headphones

during an operation need less medication postoperatively (Good et al 1999). Pa-

tients receiving aromatherapy using the “m” technique in a critical-care unit post-

operatively have experienced a decrease in their pain perception. Some patients

remember receiving the “m” technique when they recover consciousness. What

the patients probably remember is they received care in a manner they could rec-

ognize, even when they were not conscious. In today’s “managed care,” care seems

to be in danger of becoming marginalized simply because it is not on the reim-

bursement form. Ten years ago, when I was carrying out a pilot study on

254 Section II Clinical Use of Aromatherapy

post–open-heart surgery patients in an intensive-care unit in England, a patient

said, “You were the ﬁrst person who didn’t hurt me.” That made a deep impres-

sion on me that has remained to this day. Health professionals do not want to

hurt their patients, but much of the time they do.

Talk with patients about the smells they enjoyed in their childhood and

about the smells they did not like. Were they brought up in the country, near a

wood? Have they traveled to far-away places? What kind of perfumes do they en-

joy? The answers to all of these questions will provide guidelines as to which es-

sential oils to use. This is a situation where, apart from trying to reduce the pa-

tient’s anxiety, the focus is also on giving pleasure in circumstances in which

pleasure is not often experienced.

Patients frequently experience a “high” of survival immediately after open-

heart surgery. This is often followed by a “low” of exhaustion. Touch and smell

can help a patient accept this rite of passage. Post-open-heart surgery patients

need to feel celebrated, whole, and held. They have survived one of the greatest

miracles orthodox medicine has to offer. Now it is time to help them to heal,

through the comforts of gentle touch and familiar smell.

Other Cardiac Uses for Aromatherapy

Claudia Ogden, RN, (2001) used aromatherapy on a 19-year-old girl with an in-

sufﬁcient aortic valve as a result of a Streptococcus virus at the University of Michi-

gan’s Motts Children’s Hospital. The girl had had an initial repair at age 13. Dur-

ing open-heart surgery for this subsequent repair, she developed compartment

syndrome, which required fasciotomy. She was then required to be on bedrest, ﬂat

on her back, while the skin grafts had an opportunity to take hold. During this

time she experienced considerable amounts of pain, anxiety, and depression.

Compounding her discomfort was constipation, and she was experiencing con-

siderable pain, anxiety, and profuse perspiration while attempting to have a bowel

movement.

Ogden was called in to see if clinical aromatherapy could help. She used

neroli ﬂoral water as a spray to immediately ease anxiety and then a 1% mixture

of frankincense and rose on the patient’s abdomen in a clockwise movement us-

ing the “m” technique. The same 1% mixture was also used on the patient’s hands

using the “m” technique. The patient calmed down a great deal. She was able to

cooperate better with the staff and required less pain medication. She managed a

bowel movement. The nurse showed the patient’s mother how to apply the aro-

matherapy mixture to her daughter’s foot or hand using the “m” technique when-

ever her daughter felt anxious. The mother reported being able to use aromather-

apy, and stated that the “m” technique had both comforted her daughter and

empowered her. The skin on the patient’s feet had become red and sore from

pushing against the sheets. After only two days, the dilute essential oils had soft-

ened and smoothed the girl’s heels, and all redness disappeared.

Chapter 14 Cardiology 255

Coumarins in Aromatherapy

There is some confusion over the possible anticoagulant effects of coumarins. A

synthetic chemical called dicoumarol forms the basis of warfarin, an anticoagu-

lant drug (Seth et al 1976). Dicoumarol is created naturally by the breakdown of

sweet clover plant but is created synthetically for the drug companies (Budavari

1996). However, a careful look at the chemical drawing of warfarin will uncover

a coumarin group within it (Bowles 2000). This does not mean an essential oil

containing coumarin could or would cause bleeding. Coumarins are present in

small amounts, less than 6%, in a few essential oils used in aromatherapy, and it

is extremely unlikely they would affect anticoagulant therapy, especially using 1-

5% dilutions on the skin. To put things into perspective, wintergreen, a common

ﬂavoring in chewing gum and toothpaste, is also used in proprietary topical ap-

plications for sprains and strains. Wintergreen is almost all methyl salicylate and

as such is much more likely to increase the effect of anticoagulant therapy. De-

spite this, there are no warnings on chewing gum, so the risk must be extremely

small!

Unlike the commonly prescribed tranquilizer, droperidol, which caused fatal,

irregular heartbeats at far lower doses than expected (prompting the manufacturer

to enact a global withdrawal of the product), aromatherapy is a safe, gentle ther-

apy to use in cardiology that may well help a patient’s anxiety.

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Chapter 14 Cardiology 259

260

Care of the Elderly

The body it crumbles. Grace and vigor depart.

There is now a stone where I once had a heart.

But inside this old carcass, a young girl still dwells,

And now and again my battered heart swells.

I remember the pain, and I remember the joys,

And I’m living and loving all over again.

And I think of the years, all too few, gone too fast,

And accept the stark fact that nothing will last.

So open your eyes, nurse, open and see, not a crabbed old woman.

Look closer. See me.

Anonymous—found in a nursing home after the author’s death

(cited in Montagu 1986)

mproved diet and medical breakthroughs have allowed humans to survive

longer and longer. The oldest woman thus far, Jeanne Calment, lived to the

age of 121 years. Therefore it is hardly surprising that many older people will

need care and, in some instances, supervision. It is a sad part of Western culture

that age is not revered, and those who could impart so much information and life

experience to younger members of society are frequently isolated in residential

homes. This is not to denigrate such institutions, as they are obviously much

needed, but to question why civilized society either cannot, or does not want to,

look after its elderly own. Indian and Asian families who have moved to the

United States often choose to maintain their cultural choice of extended family

living.

However, for many Westerners, the world has become such a busy place there

appears to be no time to nurture or just “be” with those whose sense of time has

gone. Cases of dementia and Alzheimer’s disease appear to be increasing.

Whether this increase is because humans are living longer or because factors that

may contribute to dementia are becoming more widespread is difﬁcult to say.

Nearly 20% of those over 80 suffer from dementia. Nearly half of those over 85

suffer from Alzheimer’s disease. Some 4 million Americans are afﬂicted with

Alzheimer’s, and it is now the fourth leading cause of death among American

adults. The average amount of time from onset of symptoms until death ranges

from 3 to 20 years. Conventional treatment is with tacrine (Cognex) and

donepezil (Aricept): drugs that can temporarily improve the cognitive capabilities

but do not slow the progress of the disease (Weil 1997). Alzheimer’s disease is a

very difﬁcult condition for relatives to accept. Several years ago, a family-practice

physician in New Mexico who was investigating dementia among the Native

American population commented that there was no record of Alzheimer’s disease

among the Navaho because “it just did not occur.” She believed this was possibly

because of genetic or environmental factors.

Until recently friends of mine ran a beautiful home for the elderly in the New

Forest area of England. The average age of the residents was 88.4 years. However,

the 82-year-old mother of one of the owners regularly came in to help on week-

ends. She was a sprightly, immaculately dressed lady, and she was older than many

of the residents she cared for. This seems to indicate age often has little to do with

aging. That residential home used aromatherapy regularly, and the immediate im-

pression on walking into the lobby was of a beautiful, caring atmosphere.

Aromatherapy and the Elderly

There is no doubt the elderly become forgetful. Certain plants from the Labiatae

and Asteracae family have long histories of use as restoratives of lost or declining

cognitive functions (Wake et al 2000). Extracts from Melissa and three Salvia

species were screened for contents able to displace (3H)-(N)-nicotine and (3H0-

(N) scopolomine from nicotinic and muscarinic receptors of human cerebral-cell

membranes. Melissa ofﬁcinalis had the highest (3H)-(N)-nicotine displacement

value, and Salvia elegans had the highest (3H0-(N) scopolomine deplacement

value.

Helen Passant, a geriatric-nurse manager is recognized as one of the ﬁrst

nurses to use aromatherapy in care of the elderly (Passant 1990). Buckwalter

(1992) a geriatric nurse researcher described Passant’s work as “giving new mean-

ing to the term holistic care. She and her staff were able to restore harmony, to

bring body and mind together and to allow the spirit to shine through.” Pa-

padopoulos et al (1999) carried out a qualitative assessment of the use of aro-

matherapy for older patients in a hospital in Birmingham, England. Each of

the 10 participants (six clients and four caregivers) were interviewed using a

semistructured interview to explore which part of a session they liked best and

Chapter 15 Care of the Elderly 261

what they perceived as beneﬁts of essential oils of Lavandula angustifolia and

Chamaemelum nobile.

There are classic problems that can occur among elderly patients. These in-

clude sleep-pattern alteration, dementia, constipation, skin ulcers and poor heal-

ing, and osteoarthritis. Each condition can often be treated and improved with

aromatherapy.

Sleep Pattern Alteration and Insomnia

There have been a few published studies on aromatherapy and insomnia, and the

Lancet published a letter explaining one of the studies (Hardy et al 1995). Hardy

(1991) investigated the effects of lavender (Lavandula angustifolia) on four male

residents over a 6-week period and found all four men slept approximately the

same number of hours with lavender as they did with their previous conventional

sleep medication. The worst sleeper of the four men, who also presented noisy,

aggressive behavior during the day, appeared calmer. This could have been be-

cause of the lavender or the cessation of the sleep medication. Two of the other

men in the study no longer required naps during the day, presumably because they

were getting enough sleep at night. The lavender was cost effective: about

⁄

the

price of the sleep medication.

Hudson (1996) carried out a similar study on 51 patients using Lavandula

angustifolia for 14 days. Sleep pattern and daytime alertness were monitored.

During the ﬁrst week, baseline measurements were taken. During the second

week, two drops of lavender were put on the pillow of each participant; no other

changes were made. Findings were an improved sleep pattern and increased alert-

ness during the day with a 50% reduction in confusion.

Cannard (1994) investigated the effects of a “commercially pre-mixed blend

of essential oils” on 10 patients in a nursing-development unit. Eight of the pa-

tients were aged over 70. In this study inhalation and hand massage were used.

Baseline sleep patterns were established over 94 nights. Then inhaled lavender

plus hand massage were introduced for two nights. On the third day, night seda-

tion was discontinued and sleep patterns were recorded for a further 94 nights.

Some patients required no sedation at all during the second 94-night period; only

one person requested night sedation every night. Ninety-seven percent of patients

felt they had a good night’s sleep. Although the paper itself did not reveal what

was in the mixture, another source reported it contained Ocimum basilicum CT

linalool, Lavandula angustifolia, and Origanum majorana (Price & Price 1999).

Remember, the wrong lavender (Lavandula latifolia or Lavandula stoechas)

will not produce a sedative effect and too much of even the right lavender (La-

vandula angustifolia) can exacerbate a patient’s insomnia. There could also be a

problem with overdoing it if too much lavender is put in an electric nebulizer, and

it is kept on incessantly. For some elderly people, lavender can be a disliked smell,

associated with death.

The learned memory of lavender can trigger negative images of dying rela-

tives or friends, as years ago lavender was used to protect linen from moths and

262 Section II Clinical Use of Aromatherapy

mold and every linen cupboard was liberally stacked with lavender bags. In all

cases, but especially with care of the elderly, it is important to allow patients to

choose their own aromas when possible. Memories are very individual, and smell

memories can be easily triggered (Ehrlichman & Halpern 1988).

Usha Rani & Naidu (1998) discuss the use of Nardostachys jatamansi (spike-

nard) to produce tranquility and sedation in conditions of insomnia and restless-

ness and cite Arora (1965) who suggests the sedative effect of spikenard is due to

the sesquiterpene ketone, jatamansone. Gupta and Virmani’s double-blind clini-

cal study on children (1968) found isolated jatamansone caused signiﬁcant im-

provement in restlessness and aggressiveness in 28 hyperkinetic children com-

pared to amphetamine. This is interesting as jatamansone is identical in structure

to valeranone, the ketone in Valeriana ofﬁcinalis (Lawrence 1989) thought to pro-

duce valerian’s sedative effect. Essential oil of spikenard also was found to produce

marked relaxation of skeletal muscles and central nervous system depression by

Bose et al (1957).

Sanderson and Ruddle (1992) found lavender and sweet marjoram were of-

ten offered as alternatives to Temazepan in an Oxford, UK, nursing-development

unit. The comment was that although lavender was effective when inhaled, it was

much more effective when given in a massage.

Studies are not limited to olfaction only. In two multiple-crossover studies,

each involving 12 female subjects, Schulz et al (1998) demonstrated that extract

of Lavandula angustifolia when taken orally produced a sedative effect only

slightly less sedative than diazepam. Lavender drops have been taken orally for

their digestive and relaxing properties for hundreds of years in Europe. Frankin-

cense was found to enhance the effect of barbiturates in a study on rats by Menon

and Kar (1971). Injected frankincense also appeared to have a sedative action on

its own and in high doses (300 mg/kg) to have an action comparable to 7.5 mg/kg

chlorpromazine. Suggested essential oils for insomnia are listed in Table 15-1.

Dementia

Dementia is present in 20% of individuals over 80 years of age (Jobst et al

1994). People who suffer dementia have been identiﬁed as a special-needs group

(Kilstoff & Chenoweth 1998). Although there are more than 50 different causes

of dementia, some of which are reversible, the majority are progressive and lead

to premature death. The most common cause of dementia in the developed world

is Alzheimer’s disease. Although Alzheimer’s can affect patients as young as 35

years of age, the most recent view is that this disturbing disease is part of a patho-

logical cascade process linked with aging (Jobst et al 1994a). In total, 70% of pa-

tients older than 65 who have dementia will have Alzheimer’s disease. Currently

there is no cure.

Olfactory dysfunction is thought to be a marker for detecting early

Alzheimer’s disease (Burns 2000). While aromatherapy is not a cure for demen-

tia, smell and touch are powerful messengers, often penetrating the fog of amne-

sia in a way words do not. Knasko and Gilbert (1990) suggest patients normally

Chapter 15 Care of the Elderly 263

unable to communicate would ﬁnd it “refreshing to have a nonverbal interaction

with their environment.” Ho (1996) described the sensory-stimulation groups de-

veloped at Burton Hospital in Dudley, England. Odors were matched with col-

ors, such as lavender with shades of mauve and purple. Music associated with the

aroma was played, such as the nursery rhyme “Lavender Blue Dilly Dilly,” and pa-

tients had access to herbs and photographs connected with the aroma. In many

instances patients with dementia were able to make the correct connections.

Smith et al (1992) reported on ambient odor that elicited verbal memory in

a study of 47 college students with a mean age of 20.5 years (age range was 17-

25). The two odors used were jasmine incense and Lauren perfume. Superior

memory for the 24 words chosen was found when the odor present during the re-

learning session was the same as the odor present at the time of the initial learn-

ing, thereby demonstrating a context-dependent memory.

Flanagan (1995) reported on the use of a variety of essential oils to improve

atmosphere and behavior in institutionalized patients with Alzheimer’s. One pa-

tient, who was so combative he required sedation injections, changed dramatically

when a cotton ball with essential oil of lavender was pinned to his shirt lapel. Now,

he no longer needs medication if the cotton ball can be pinned to his shirt in time.

Kilstoff and Chenoweth (1998) reported on the effect of aromatherapy on patients

in a multicultural dementia day-care center in Australia for a period of 18 months.

They used a combination of lavender, mandarin, and geranium essential oils di-

264 Section II Clinical Use of Aromatherapy

Table 15-1 h Essential Oils for Insomnia

Common Name Botanical Name Reference

Neroli Citrus aurantium ﬂos Jager et al 1992

Mandarin Citrus reticulate Kilstoff & Chenoweth 1998

Melissa Melissa ofﬁcinalis Mitchell 1993

Angelica Angelica archangelica Franchomme 1991

Spikenard Nardostachys jaamansi Usah Rani 1998

Lemongrass Cymbopogon citrates Seth et al 1976

Lavender Lavandula angustifolia Flanagan 1995

Geranium Pelargonium graveolens Flanagan 1995

Mandarin Citrus reticulate Flanagan 1995

Roman chamomile Chamaemelum nobile Rossi et al 1988

Sandalwood Santalum album Kikuchi et al 1995

Rose Rosa damascene Brud & Szydlowska 1991

Sweet marjoram Origanum majorana Price & Price 1999

luted in a hand massage. Patients were thought to have become more alert and less

agitated, although it was unclear whether this was from the hand massage or the

essential oils. The use of aromathreapy appeared to have had a positive effect on

the staff and caregivers as well, possibly because of empowerment.

Smith (2000) studied the effects of inhaled lavender and sweet marjoram on

17 residents of the Northboro Senior Care Center in Northboro, Massachusetts.

Subjects who had memory-impaired agitation were chosen for the study, and

their relative or responsible party was approached for written consent. The most

frequent time for agitation was between 6 pm and 7:30 pm, and behavior ranged

from mild to severe agitation. The study took 9 weeks. During the ﬁrst week, a

baseline was taken, and it was noted how many times the alarm was set off. (This

is a safety alarm set off when patients who cannot stand on their own attempt to

get out of their seats unaided.) For the next 4 weeks, essential oil of Lavandula

angustifolia was diffused into the meeting room 15 minutes prior to each session.

As of the ﬁfth week, Origanum majorana (sweet marjoram) was diffused into the

meeting room 15 minutes prior each session. The whole residential-care team ob-

served subjects during the study to avoid bias. The team discussed the effects and

decided lavender had the best effect, as all subjects were able to remain engaged

with a marked decrease in agitation. No alarms went off during the lavender,

which was very unusual. Sweet marjoram appeared less effective.

MacMohan and Kermode (1998) found aromatherapy dramatically im-

proved motivational behavior in a 2-month study (n⫽1). However, not all stud-

ies have shown improvement in dementia. Brooker et al (1997) investigated the

effects of lavender inhalation and massage on four severely demented patients and

found two patients became severely agitated. The lavender may have evoked dis-

tressing memories, or perhaps they did not like being massaged.

In cases where patients cannot or will not remain stationary, walking along-

side them while simultaneously conducting a gentle, hand “m” technique can lead

to some positive changes in the patient, such as renewed eye contact and speech

coherence. In cases in which patients are conﬁned to bed and incapable of walk-

ing or are violently resistant to any form of touch, vaporizers and nebulizers can

be used. Even in instances such as these, when it seems the patient will be unable

to help with the selection of an aroma, offering a choice of two different smells

can elicit a response. Laraine Kyle, MSN, in Boulder, Colorado, has done much

to introduce aromatherapy into the geriatric setting in the United States. She

writes aromatherapy can help “transport Alzheimer patients to memories of their

past. Seeing facial expressions change from mask-like to animated smiles is feed-

back enough to know that something is happening” (Kyle 1996).

Mitchell (1993) used melissa and lavender in a randomized, controlled

crossover study of 12 patients with Alzheimer’s aged between 64 and 91 at a res-

idential and day-care unit. Six drops of lavender were added to the morning wash.

A 3% solution of melissa was applied to the patients’ chins at midday, and three

drops of lavender were applied to their pillows at night. Mild behavioral and ver-

bal improvements were observed.

Chapter 15 Care of the Elderly 265

Other suitable essential oils are those the patients might be familiar with ei-

ther from their childhood or from positive life experiences. For example,

Trumpers, possibly the oldest gentlemen’s hairdressers in London, has used es-

sential oil of geranium (Bourbon) in their pomade for more than 100 years (Free-

man 1996).

Rosmarinus ofﬁcinalis CT cineole or borneol (rosemary) will be remembered

by most elderly patients as a common ingredient in cooking and from gardening.

“There’s rosemary—that’s for remembrance” said Shakespeare’s Ophelia, and it is

a valid comment. Rosemary is traditionally thought to be helpful as a memory

aid. Suggestions for other aromas to try are listed in Table 15-2. There are in no

particular order. If a patient has lived in India or Asia, lemongrass, ginger, or ylang

ylang might be appealing and soothing.

Dales Occupational Therapy Service in Derbyshire, United Kingdom, used

aromatherapy to improve the quality of life of their Alzheimer’s patients. Essen-

tial oils they found useful include pine, eucalyptus, and peppermint to trigger

conversation and memory and lavender and geranium to trigger thoughts of

cooking and plants (Henry 1993).

266 Section II Clinical Use of Aromatherapy

Table 15-2 h Essential Oils for Dementia

Common Name Botanical Name

Geranium Pelargonium graveolens

Lavender Lavandula angustifolia

Sandalwood Santalum album

Patchouli Pogostemon patchouli

Clary sage Slavia sclarea

Rose Rosa damascene

Lavender Lavandula angustifolia

Mandarin Citrus reticulate

Geranium Pelargonium graveolens

Rosemary Rosmarinus ofﬁcinalis

Melissa Melissa ofﬁcinalis

Peppermint Mentha piperita

Eucalyptus Eucalyptus globules

Ginger Zingiber ofﬁcinalis

Ylang ylang Cananga odorata var. genuine

Constipation

The slowed-down passage of food through the large intestine may be a result of

reduced exercise or insufﬁcient roughage in the diet. The latter could be due to

poor appetite for various reasons ranging from ill-ﬁtting dentures to boredom

with institutional food. Another cause of constipation is regular use of night se-

dation.

One of the simplest and most gentle ways to ease constipation is through ab-

dominal massage using essential oils. This is effective for mild constipation. A

slight improvement was documented in a study by Klauser et al (1992), although

in that instance no essential oils were used. In the residential home owned by my

friends, this form of massage produced very good results and was used success-

fully for several years. See Table 15-3 for a list of essential oils Barker (1995) sug-

gests for treating constipation.

Use a 3% solution (three drops of essential oil/s in 5ccs of cold-pressed veg-

etable oil). Let the patient choose which oil to use from the selection in Table

15-3. Work slowly and rhythmically up the ascending colon, along the transverse

colon, and down the descending colon, paying attention to both hepatic and

splenic ﬂexures. This gentle massage only takes 5 minutes, but it can be really use-

ful. It is best repeated up to ﬁve times a day or until relief is obtained.

Skin Ulcers and Slow Healing

Aging slows down the body’s ability to heal. Skin becomes thinner and more frag-

ile, and the slightest knock can cause a deep bruise, especially if the person is tak-

ing steroids. Very gentle massage with cold-pressed vegetable oils, such as oil of

evening primrose, can aid the elasticity of aging skin, and certain essential oils can

enhance aging skin’s ability to heal. Alan Barker, a clinical aromatherapist em-

ployed by the British National Health Service, has used ﬂoral waters to irrigate

wounds (Barker 1994). Table 15-4 lists some ﬂoral waters used for this purpose.

Floral waters are the byproduct of steam distillation and can be obtained from

many essential-oil suppliers. Slightly acidic, they are refreshing to use, smell

lovely, and are excellent for skin care. (Floral waters are slightly acidic because

they contain parts of the essential oil that are most soluble.) When using ﬂoral

Chapter 15 Care of the Elderly 267

Table 15-3 h Essential Oils for Constipation

Common Name Botanical Name

Black pepper Piper nigrum

Ginger Zingiber ofﬁcinale

Fennel Foeniculum vulgare

Marjoram Origanum marjorana

Grapefruit Citrus paradisi

water, make sure the distributor can supply an analysis to prove the ﬂoral water is

not contaminated with bacteria or fungi.

After irrigating the wound, a compress soaked in diluted essential oils can be

applied to aid healing. The essential oils will also reduce the chance of infection.

Apply a fresh compress twice daily, or every 4 hours if the wound is infected. Ar-

eas immediately around the wound can be gently swabbed with oil of evening

primrose or Rosa rubiginosa. Another excellent oil to use around the wound would

be a macerated oil such as Hypericum perforatum (St John’s wort) or calendula

(Calendula ofﬁcinalis).

Glowania et al (1987) found Matricaria recutita (German chamomile) effec-

tive in a controlled, double-blind study of slow-healing wounds in 14 patients. A

further article, in the Journal of Tissue Viability in 1993, reported on two case stud-

ies using lavender and tea tree (Hitchin 1993). Thorne (1996) described the use of

3% oil of Lavandula angustifolia in a carrier oil of rosehip (Rosa rubiginosa) on a leg

ulcer measuring 1.5 cm by 1 cm. After one month of applying the lavender solu-

tion to the area around the wound (not the wound itself), the wound was smaller

(1cm by 1cm), and the whole area looked much healthier. It is not clear why the

mixture was not applied to the wound itself. However, after tea tree was added to

the dilution, the wound became inﬂamed, and a course of antibiotics was pre-

scribed. This may have been due to an allergy to the tea tree. There is no indica-

tion a patch test was taken. Two months later the wound had healed, but there is

no indication that this was due to the antibiotic rather than the essential oils.

Emeny (1994) reported on a 90-year-old woman with a diabetic foot ulcer

that had become gangrenous: amputation was scheduled. Undiluted tea tree was

applied to the ulcerated lesion between her toes in the form of soaks for 1 week.

Her pain level decreased, and there was marked physical improvement. Tea tree

was continued in a 10% solution, decreasing to 3% over the next 3 weeks. The

foot gradually became warmer. Continuing tea tree at 3% for 9 weeks, the wound

healed completely, and there was no evidence of gangrene. Belaiche (1985) a

French physician, used undiluted tea tree daily on intertrigo under the breasts and

in the groin and underarm with disappearance of all lesions within 2 months.

Ron Guba (1999) reported on the rapid healing of dermal wounds using his

own essential oil-based cream (See Table 15-5 for details.) on selected patients in

six nursing homes in Australia. Wounds were divided into two groups: skin tears

268 Section II Clinical Use of Aromatherapy

Table 15-4 h Floral Waters Used to Irrigate Wounds

Common Name Botanical Name

Niaouli Melaleuca viridiﬂora

Tea tree Melaleuca alternifolia

German chamomile Matricaria recutitia

Grapefruit Citrus paradisi

received once-a-day treatment, while pressure-area and venous ulcers received

treatment twice a day. Treatment consisted of putting the cream onto dry gauze

and taping it over the wound. Detailed accounts of seven patients (aged 58-93)

are given. All wounds healed, some within a week. This was remarkable as some

of the wounds had been in stasis for several months. Guba also conducted a

punch-biopsy, controlled study on ﬁve subjects who each sustained two wounds.

The wounds treated with Guba’s cream healed within an average of 12 weeks.

The control wounds took an average of 26 weeks.

My own clinical experience conﬁrms the excellence of Guba’s wound-

healing cream. I have also found frankincense very beneﬁcial to superﬁcial

wounds and scars, and palma rosa is good for deeper wounds.

Finally, essential oils that contain high percentages of ketones are thought to

be beneﬁcial in wounds and may help reduce cheloid scars. This process may be

accelerated if the carrier oil used is Rosa rubiginosa (rosehip).

Osteoarthritis

Degenerative joint pain is frequently part of the aging process, especially if there

is a family history of rheumatism. As secondary changes occur in the underlying

bone, pain and impaired function make life a misery for those who were once ag-

ile. This is particularly the case if one of the affected joints has been injured.

Chapter 15 Care of the Elderly 269

Table 15-5 h Guba’s Wound-Healing Cream (reprinted with permission)

Common Name Botanical Name Concentration

True lavender Lavandula angustifolia 40 mg/g

Mugwort Artemesia vulgaris 10 mg/g

Sage Salvia ofﬁcinalis 10 mg/g

Everlasting Helichrysum italicum 18 mg/g

German chamomile Matricaria recutita 12 mg/g

Calendula Calendula ofﬁcinalis 10 mg/g

Tamanu Calophyllum inophyllum vegetable oil 62.5 mg/g

Borage Borago ofﬁcinalis vegetable oil 62.5 mg/g

Flaxseed Linum usitatissimum vegetable oil 62.5 mg/g

Shea butter Butrospermum parkii vegetable oil 62.5 mg/g

Grapefruit seed Citrus paradisi (as preservative) 5.0 mg/g

Rosemary Rosmarinus ofﬁcinalis CT cineole CO

0.125 mg/g

(antioxidant)

Extract of ginger was found to be marginally effective in a randomized, con-

trolled crossover study by Bliddel et al (2000). While in the crossover period no

statistical difference could be demonstrated, during the ﬁrst explorative period gin-

ger was found to be better than the control. The extracts were taken orally, which

may have contributed to the poor results. Ginger foot baths and compresses are

very good for both feet and knees; use CO

extract that contains gingerol.

Cote (2002) investigated the effect of topically applied Piper nigrum (black

pepper) on 11 self-selected subjects (10 women and one man) who were members

of Panorama City Retirement Community in Lacy, Florida. Following baseline

measurement of pain using a visual analog, a 4% dilution of black pepper in 5 ml

of grapeseed oil was massaged into the painful joint of each subject (7 hands, one

knee, one shoulder, one ankle, one foot). After the massage, the subjects were

asked to rate their pain immediately, then again after 2 hours and after 4 hours.

There was a slight reduction in perception of pain for most participants. It is dif-

ﬁcult to assess whether the reduction was due to the massage or the essential oil.

Macdonald (1995) wrote about elderly patients and osteopathic pain. The

following essential oils were used in her study: eucalyptus, juniper, marjoram, and

rosemary. Unfortunately, no botanical names were given, so it is impossible to as-

sess which essential oils were actually used (there are 400 different types of Euca-

lyptus). Traditional essential oils for osteoarthritic pain are rubefacient ones that

will dilate the capillaries and give a peripheral warming effect. One such essential

oil is black pepper. An antiinﬂammatory essential oil such as German chamomile

or immortelle (Helicrysum italicum) can give relief, as can an analgesic essential oil

such as lavender or peppermint. For more information on antiinﬂammatory es-

sential oils, please see the section of Chapter 12 on inﬂammation. For more in-

formation on analgesic essential oils, please see the section of Chapter 12 on pain.

Franchomme and Penoel (1991) state that p-cymene has analgesic properties

and is particularly suited to osteoarthritis. Paracymene is present in cajeput

(6.8%), summer savory (7%), and Thymus vulgaris (21.9%) (Bowles 2000), al-

though at these low percentages it is dubious that the cymeme will have much

impact.

I have found Cymbopogon citratus (lemongrass) useful for alleviating os-

teoarthritic pain using a 5% compress. Lemongrass may be analgesic due to its

myrcene content (Lorenzetti et al 1991). Satureja hortensis (summer savory) is also

useful for pain, and it contains a small amount of myrcene.

Perhaps it would be pertinent to end this section with a mention of essential

oils for aging. Deans (1991) conducted substantial research into the properties of

polyunsaturated fatty acids (PUFAs) at Warwick University in England. PUFAs

form part of plant oils and are used by the human body to make cellular compo-

nents and steroid hormones. Aging is associated with a decline in PUFAs. In re-

search on aging rats, essential oils were found to restore PUFA levels almost to

the levels observed in young mice. Of the essential oils tested, red thyme and

clove appeared to give the most impressive results (Deans 1991).This research in-

volved feeding the rats essential oils by mouth. There is no suggestion we do the

270 Section II Clinical Use of Aromatherapy

same for our patients or ourselves, but the antiaging properties of essential oils

may turn out to be an exciting area. In the meantime, both West (1993) and Kyle

(1999) suggest aromatherapy can be integrated into care of the elderly very sim-

ply, and many health professionals are following her lead.

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Chapter 15 Care of the Elderly 273

274

Critical Care

We may need to be cured by ﬂowers.

Sharman Russell

Anatomy of a Rose

ritical care encompasses patients with grave, long-term medical condi-

tions, those with acute myocardial infarctions who will have shorter stays,

and patients who have had major surgery. The one common factor will be

the gravity of their condition. Patients in critical care experience one of the most

stressful times in their lives (Dunn et al 1995). Often unable to breathe unaided,

their survival depends on the experience and expertise of their professional care-

givers. Communication and trust play a large role in the patient-caregiver rela-

tionship. Ingham (1989) suggests communication should be “written in to a pa-

tient’s care-plan.” Touch is a communication skill that can enhance trust.

Ashworth (1984) wrote about the importance of teaching nonprocedural touch,

commenting “it was more difﬁcult to learn than deﬁbrillation and cardiopul-

monary resuscitation and at least as valuable.”

A critical-care nurse who experienced being intubated as a patient in a

critical-care unit described how “her worst nightmare came true.” She felt “aban-

doned and longed for someone to reassure her.” Following her experience she un-

derstood “why it was sometimes necessary to hold a patient’s hand” (Urden 1997).

It is greatly underestimated how important it is for intensive-care unit patients to

feel trust and conﬁdence in their caregivers. Nonprocedural touch and pleasant

aromas can do much to relive anxiety and give comfort in what is perceived by pa-

tients to be a “hostile environment” (Welsh 1997). Essential oils can be used in

many ways in a critical-care unit: from relieving the pain of intravenous insertions

to alleviating bronchial spasm to reducing anxiety (Buckle 1998).

Most of the published research has focused on physical parameters that can

be easily measured. These physical tools have not always conveyed what the pa-

tients have said if their perception of anxiety, pain, or stress have been relieved.

This could be because a more accurate tool, such as measuring blood or saliva cor-

tisol levels, has been too expensive for most nursing studies. However this would

be an excellent area of study for the future.

Aromatherapy in a Critical-Care Setting

Dunn et al (1995) reported on the effects of reducing stress using a gentle mas-

sage with of 1% lavender (Lavandula angustifolia) on 122 patients in an intensive-

care unit at Battle Hospital in Reading, United Kingdom. Patients were randomly

assigned to three groups: one with plain massage, one with massage plus 1%

lavender, and one with rest for 30 minutes. The areas of massage depended on the

areas available and lasted between 15 and 30 minutes (mean time 16.5 minutes).

The age of participants ranged from 2 years to 92 years. Physiological and psy-

chological measurements were taken before and after the treatment. Although

there appeared to be no difference between the group that received massage with

and without an essential oil, this could be because the percentage used was very

low. or it could be because when patients fell asleep during the aromatherapy

massage they were not awakened! (Dunn 1996). However, the comments indi-

cated all patients were very appreciative of the extra care they received. One pa-

tient who had received the aromatherapy massage commented, “Aromatherapy

made me feel clean and like a whole person.”

Woolfson and Hewitt (1992) used foot massage with 1% lavender in their

study of 36 patients in a medical and surgery critical-care unit at the Royal Sus-

sex County Hospital in the United Kingdom. Each patient was randomly as-

signed to three groups. The groups received either a 20-minute massage without

oil, 20-minute massage with oil, or a 20-minute rest. Two treatments per

week were given for 5 weeks. This means the majority of patients would have

been medical (as surgical patients tend not to stay that long). The massage-with-

lavender group showed the greatest beneﬁts with a consistent decrease in blood

pressure, heart rate, respiration, and anxiety. Patients in the lavender group per-

ceived their stress as being less than patients in the control group.

Stevensen (1994) reported on the effects of a 2.5% neroli (Citrus aurantium

ﬂos) foot massage on 100 patients in the critical-care unit at Middlesex Hospital

in London, England. In this study patients were randomly assigned to one of four

groups: massage with neroli, massage with plain oil (apricot kernel), a rest period,

or nothing. Results indicated the neroli group perceived they were less stressed,

although there were only small differences in physical measurements.

In my study (Buckle 1993) Lavandula x intermedia (lavandin) was used as a

control because at that time it was thought to have little therapeutic effect. The

study was to ﬁnd out if aromatherapy had an effect beyond that of massage.

Lavandula angustifolia was chosen for the experimental group. Two-percent

Chapter 16 Critical Care 275

solutions of Lavandula angustifolia and Lavandula x intermedia, (called Lavandula

burnati by Frachomme and Penoel 2000) were supplied by the Fragrant Earth

Co. Ltd. The company labeled the solutions Lavender A and Lavender B.

At 2% dilution it was impossible to tell which lavender was which, so the in-

vestigator was blind to the intervention, and so were the patients. Each patient

was randomly allocated to one of two groups. Following analysis, it did appear

one of the lavenders was more effective at reducing respiration rate than the other

one. When the identity of the experimental group lavender was revealed, it was

lavandin, and it appeared to be twice as effective as Lavandula angustifolia. The

results were rechecked as they appeared to contradict what was being taught

about lavandin. This also indicated the relaxation was not simply due to massage

as there was a difference between the two groups. One of the comments made was

“You were the ﬁrst person who didn’t hurt me.” Another was, “Why send ﬂowers

and cards if you can send this?” Others were, “I feel like you really cared about

me,” and “I felt like I was important, not just a number, and that you really would

take care of me,” and “Until you did that, I was really scared, but you made me

feel it would be OK to relax.”

Waldman et al (1993) suggested the following essential oils would be useful

in a critical-care setting: lavender, clary sage, jasmine, peppermint, rose, rosemary,

tea tree, and ylang ylang. The oils were used in a 2% massage solution and in elec-

tric burners. Others could include neroli, Roman chamomile, sandalwood, lemon,

lemongrass, and palma rosa. Mitchell (2002), a critical-care nurse, has used aro-

matherapy in her unit for several years. She suggests frankincense, geranium, pe-

titgrain, sweet marjoram, mandarin, juniper, and German chamomile.

Each patient is someone’s child, no matter how old he or she is. Most pa-

tients in an intensive-care unit are frightened, no matter how brave they try to ap-

pear. Each patient belongs, in some capacity, to another, and the others are also

in need of nurturing. Critical-care units can be very frightening for relatives, with

so many tubes and complicated machinery around the motionless body of a loved

one. Mitchell (2002) writes relatives are often stunned by the intensive-care unit,

and they are very appreciative when their loved ones receive the loving care aro-

matherapy provides.

I remember seeing my father in a critical-care unit many years ago, and more

recently my brother-in-law, and experiencing some of the feelings of helplessness

many relatives and visitors feel even though I had trained and worked in critical

care for many years. Often relatives feel there is nothing they can do except wait

and pray. Aromatherapy presents a wonderful opportunity to give the family a

sense of control and a simple way to contribute and promote comfort and quality

of care for their loved one.

The gentle, stroking movements of the “m” technique, which can be used to

apply dilute essential oils, are extremely simple both to teach and to learn. I taught

them to a 5-year-old granddaughter who spent almost an hour lovingly stroking

her grandfather’s hands. Her sad, cross little face softened as she sang gently

under her breath, moving her hands in time to her lullaby. Her parents watched

276 Section II Clinical Use of Aromatherapy

her as she worked, amazed at the transformation. This little girl knew she had

been given an important task, one that not only empowered her but was actually

of therapeutic value.

Teaching relatives to touch in this way does not take very long—probably

only 5 minutes. Everyone can ﬁnd that amount of time. Talking with relatives

about the aromas patients enjoyed before they came into hospital allows dialogue

on a safe subject, but one still linked to the patient. Finding an aroma relatives

feel could help their loved ones gives them something to think about and a way

of becoming involved. It is best to offer just a few aromas known to have relaxing

effects. The ﬂoral aromas are usually popular. The rose essential oil used on my

brother-in-law in Papworth Hospital in Cambridge, England, produced a smile

even though he was extremely ill and was appreciated by the staff who gravitated

toward the lovely smell.

Clinical aromatherapy has much to offer critical care as it reveals the softer,

more caring side of a hard, mechanistic world. In a place full of technical equip-

ment, aromatherapy allows patient and health provider a chance to get in touch

with their feelings, to trust, and to communicate. Human beings often forget how

to “be” as they are programmed to “do.” The transition from doing to being can

be a hard one to learn, but in the learning, both patient and health provider can

share in the healing process at a much deeper level. In critical care, patients have

to be. Aromatherapy enables patients to feel better as well as get better. That is

the essence of holistic care. Anxiety, pain, insomnia, and stress are major areas in

which aromatherapy could help in a critical-care setting. These have been covered

in-depth in other chapters of the book, so please refer to the index for more in-

formation. The remaining sections of this chapter address other specialized areas

of critical care where aromatherapy could be of use.

Extubation

Extubation is an alarming procedure for a patient who needs to be awake enough

to breathe without assistance, but sedated enough not to ﬁght the endotracheal

tube. Tremendous trust is needed. Aromatherapy using the “m” technique can help

produce a deep level of trust in a very short period of time. Just because a patient

is intubated does not mean aromatherapy will have no effect. Drugs such as fen-

tanyl, scopolamine, and clonidine are absorbed through the skin. Some compound

pharmacists for hospice care are even putting Ativan and other commonly used

prescription drugs into a gel for topical delivery. Components within essential oils,

such as linalyl acetate and linalool, are also absorbed through the skin.

During extubation, fear of oversedation can be a common cause of inadequate

pain- and anxiety-relief. Aromatherapy has no side effects and can actually facili-

tate extubation by promoting relaxation, decreasing anxiety, relieving pain, and

promoting trust between patient and caregiver. After extubation, clearance of se-

cretions can be greatly aided by the skilled use of mucolytic essential oils, such as

Eucalyptus globulus or Lavandula latifolia, which can be inhaled by the patient.

Mitchell (2002) found it was possible to decrease the amount of opioid narcotics

Chapter 16 Critical Care 277

needed while enhancing pain relief with the use of the “m” technique and essential

oils. She suggests applying essential oils to the skin with the “m” technique can al-

ter the pain pathway by affecting the transduction, perception, and modulation of

nociceptive (somatic and visceral) pain. For example, an application of an anti-

spasmodic essential oil, such as Roman chamomile, clary sage, or lavender, can

minimize the transduction phase of nociception by minimizing the effects of sen-

sitizing substances, such as prostaglandin, bradykinin, serotonin, and substance P,

which are released at the periphery. Mitchell (2002) has found aromatherapy in a

critical-care unit reduces stress, anxiety, fear, and insomnia, improves mood, pro-

motes relaxation, enhances coping, and increases a patient’s sense of control, all

without side effects.

Figure 6-1 in Chapter 6 shows the effect of 2% Lavandula angustifolia given

in a hand “m” technique by Mitchell prior to extubation. There have been similar

effects from Roman chamomile and rose essential oils with the “m” technique.

Mitchell further explains the patient appeared much calmer and less anxious as

she was carrying out the “m” technique procedure. The patient felt “able to trust”

her, and extubation was achieved far more easily than normal.

Henneman et al (2002) suggest a collaborative weaning plan for patients re-

quiring prolonged mechanical ventilation, which draws on a multidisciplinary

team. One advantage of aromatherapy is it can be carried out by any member of

that team.

Fear

Patients in a critical-care unit face more invasive and obnoxious procedures and

diagnostics than in any other unit. Invasive procedures are those such as the in-

sertion of hemodynamic monitoring lines, thoracentesis, paracentesis, and chest-

tube placement and removal. Diagnostics include those such as computed to-

mography scans, magnetic resonance imaging, and angiograms. Inhaling a

familiar aroma can do much to allay fears during these procedures and really helps

the claustrophobia and hyperventilation that can ensue.

Carrying out a hand, foot, or face “m” technique prior to the scheduled pro-

cedure can minimize the fear of cardiac catheterization. This will take only 5-10

minutes and can have a dramatic effect on the need for anxiolytics during the pro-

cedure. It is also a great way to enhance trust between patient and caregiver. Es-

sential oils to choose from are rose, neroli, mandarin, lavender, or Roman

chamomile. Please see Chapter 14 on cardiology for more information.

Adding three or four drops of essential oils to bath water can greatly im-

prove the mood of patients (and their caregivers!). Geranium is an excellent

choice as it appears to lift mood and reduce anxiety and can cut through some

unpleasant odors. Spritzing the room with a solution of Eucalyptus citriadora will

do much to improve the ambience but will also help cut down cross-infection

and the possibility of resistant organisms. Please see Chapter 9 on infection for

a more in-depth discussion of speciﬁc pathogens and essential oils that would be

effective.

278 Section II Clinical Use of Aromatherapy

Pressure Sores (Decubitus Ulcers)

Critically ill patients often cannot move by themselves and need to be turned

every few hours to prevent skin breakdown. Despite good nursing care and

alternating-pressure mattresses, decubitus ulcers (pressure sores) can occur. These

lesions are notoriously difﬁcult to heal. What is initially persistent erythema can

develop into necrotic ulceration involving muscle, tendon, and bone.

Pressure sores can be caused by the following:

simple pressure exceeding that of the blood pressure at the venous or arter-

ial end of capillaries (Pritchard & Mallett 1992);

shearing (when the patient is dragged up the bed) destroying the microcir-

culation in the underlying tissue; in serious cases, lymphatic vessels and

muscle ﬁbers can also become torn (Waterlow 1988);

friction causing stripping of the stratum corneum leading to superﬁcial dam-

age ( Johnson 1989).

Speciﬁc areas of the body are at risk for the development of pressure sores. These

include the sacral area when lying supine, the coccygeal area when lying supine,

the ischial tuberosities when lying laterally, and the greater trochanters when ly-

ing laterally. Inactivity, immobility, malnutrition, altered sensation, and advanced

age can contribute to the incidence of pressure sores, but they are also more com-

mon among patients with decreased levels of consciousness. Waterlow (1987)

produced at-risk scales to show the type of patient found in a critical-care unit is

more likely to be at risk for pressure sores than other type of patient.

Pressure sores can be graded according to their severity (stage I-stage IV)

and need different treatments for each stage (David et al 1983). The degrees of

severity range from unbroken skin with simple redness to destruction of skin and

the underlying tissue. Once the skin has broken down, careful treatment of the

ensuing wound is paramount to prevent infection. Gustafsson (1988) catego-

rized wounds as dry and clean, wet and oozing but clean, or open and contami-

nated.

Turner et al (1985) described an appropriate material for wound dressing as

“a material which, when applied to the surface of a wound, provides and main-

tains an environment in which healing can take place at the maximum rate”. An

essential oil diluted in a cold-pressed vegetable oil would ﬁt this description.

When the skin is red and sore but still intact, ﬂoral waters can be used to

bathe the skin and reduce surface heat. Chamomile (Matricaria recutita), he-

lichrysum, rose, and lavender ﬂoral water are good choices. When the skin is bro-

ken, a compress using ﬂoral waters with added essential oils can be used. How-

ever, when the wound has deepened, it is kinder to dilute the essential oils in a

carrier oil (or gel) to prevent the compress sticking to the sides of the wound and

increasing the trauma when the compress is removed. Calophyllum inophyllum

(palm kernel) carrier oil is an excellent medium in which to dilute the essential oil

because of its antiinﬂammatory action and gentle analgesic effects. Rosehip (Rosa

rubiginosa) carrier oil is also useful in the treatment of pressure sores. Aloe vera

gel would be an another excellent choice, particularly as it is so effective in the

Chapter 16 Critical Care 279

treatment of burns, which show a similar healing pattern to pressure sores

(Zawahry 1973).

See Table 16-1, 16-2, and 16-3 for some suggestions of suitable essential

oils, phytols, and hydrolats. If the wound is grossly infected, a higher concentra-

280 Section II Clinical Use of Aromatherapy

Table 16-1 h Suitable Essential Oils for Treating Decubitus Ulcers

Common Name Botanical Name

Lavender Lavandula angustifolia

Roman chamomile Chamaemelum nobile

Frankincense Boswellia carteri

Geranium Pelargonium graveolens

Yarrow Achillea millefolium

German chamomile Matricaria recutita

Common thyme Thymus vulgaris CT linalol and CT thujone

Rosemary Rosmarinus ofﬁcinalis CT verbenone

Myrrh Commiphora myrrha

Bergamot Citrus bergamia

Table 16-2 h Suitable Phytols (Infused Herbal Oils) for Treating

Decubitus Ulcers

Common Name Botanical Name

Echinacea Echinacea purpurea

St John’s wort Hypericum perforatum

Calendula Calendula ofﬁcinalis

Table 16-3 h Suitable Hydrolats (Floral Waters) for Treating

Decubitus Ulcers

Common Name Botanical Name

Rosemary Rosmarinus ofﬁcinalis CT borneol

Myrtle Myrtus communis

Elderﬂower Sambucus nigra

Roman chamomile Chamaemelum nobile

Lavender Lavandula angustifolia

Rose Rosa damascena

tion of essential oil will be needed to contain the infection; use up to 20% when

necessary. However, if the wound is just slow in healing, 3%-10% will sufﬁce.

Hartman and Coetzee (2002) found 8% solution was effective in treating deep,

slow-healing ulcers. solution in a carrier oil or phytol is necessary. Many stage II-

III decubiti are now covered with hydrocolloidal dressings until healing has taken

place. The suggestions in the tables are particularly relevant after initial healing

has begun and the dressings are removed. The selection of essential oils, ﬂoral wa-

ter, and infused herbal oils will decrease pain, promote ongoing healing, and can

help prevent reoccurrence. Ensure that ﬂoral waters and infused herbal oils are

purchased from a reputable supplier to avoid contaminated products.

In cases in which the ulcer is infected, please select essential oils that are ef-

fective against the relevant pathogen. See Table 16-4, as well as Chapter 9 on in-

fection, for some suggestions.

REFERENCES

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35-42.

Buckle J. 1993. Aromatherapy: does it matter which lavender essential oil is used? Nurs-

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Buckle J. 1998. Clinical aromatherapy and touch: complementary therapies for Nursing

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David J, et al. 1983. Normal physiology from injury to repair. Nursing. 2(11) 296-297.

Deans S, Svoboda K. 1990. The antimicrobial properties of marjoram (Origanum majo-

rana). Flavour and Fragrance Journal. 5(3) 187-190.

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Franchomme P, Penoel D. 1990. Aromatherapie Exactement. Limoges, France: Jollois.

Chapter 16 Critical Care 281

Table 16-4 h Some Examples of Antimicrobial Essential Oils

Common Name Botanical Name Use Against Reference(s)

German Matricaria recutita Staphylococcus Franchomme &

chamomile aureus, Proteus Penoel 1991,

vulgaris Valnet 1993

Lemongrass Cymbopogon citratus Shigella, E. coli, Onawunmi &

Bacillus subtilis Ogunina 1986

Juniper Juniperus communis Pseudomonas Janssen & Chin

1986

Sweet marjoram Origanum majorana Clostrium, Deans &

Salmonella Svoboda 1990

Gustafsson G. 1988. Guidelines for the application of disinfectant in wound care. Nurs-

ing RSA. 3(11-12) 8-9.

Hartman D, Coetzee J. 2002. Two US practitioners’ experience of using essential oils for

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crease duration of mechanical ventilation and length of stay in the intensive care unit

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Johnson A. 1989. Granuﬂex wafers as a prophylactic pressure sore dressing. Care-Science

and Practice. 7(2) 55-58.

Mitchell L. 2002. Personal communication.

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lemongrass. International Journal of Crude Drug Research. 24(2) 64-68.

Pritchard A, Mallett J (eds.). 1992. The Royal Marsden Hospital Manual of Clinical

Nursing Procedures, 3rd ed. Oxford, UK: Blackwell Scientiﬁc Publications.

Redd W, Manne S, Peters B, et al. 1994. Fragrance Administration to reduce anxiety

during MRI imaging. J Magnetic Resonance Imaging. 4(4) 623-626.

Sharman R. 2001. Anatomy of a rose. Cambridge, MA: Perseus.

Stevensen C. 1994. The psychophysical effects of aromatherapy massage following car-

diac surgery. Complementary Therapies in Medicine. 2(1) 27-35.

Turner T. 1985. Semi-occlusive and occlusive dressing. In Royal Society of Medicine In-

ternational Congress and Symposium Series No. 88. London: Royal Society of Medi-

cine. 5-14.

Urden L. 1997. From the patient’s eyes. Critical Care Nurse. 17(1) 104-105.

Valnet J. 1990. The Practice of Aromatherapy. Saffron Walden, UK: CW Daniels.

Woolfson A, Hewitt D. 1992. Intensive aromacare. International Journal of Aromather-

apy. 4(2) 12-13.

Waldman C, Tseng P, Meulman P, et al. 1993. Aromatherapy in the intensive care unit.

Care of the Critically Ill. 9(4) 170-174.

Waterlow J. 1987. Tissue viability. Calculating the risk. Nursing Times. 83(39) 58-60.

Waterlow J. 1988. Tissue viability. Prevention is cheaper than cure. Nursing Times.

84(25) 69-71.

Welsh C. 1997. Tissue viability. Touch with oils: a pertinent part of holistic hospice care.

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282 Section II Clinical Use of Aromatherapy

283

Dermatology

I have seen cosmic beings and other worlds, yet without seeing a ﬂower it is nothing.

William Elliott

Tying Rocks to Clouds

ncreasingly, transdermal therapeutic systems (TTS) are used as an alternative

to oral and parenteral pharmaceuticals. The skin, and therefore the care of

skin (dermatology), has become an important part of new drug delivery. This

is important to aromatherapy as many essential oils are applied to the skin. Fuchs

et al (1997) reported on the ability of carvone to be absorbed systemically from a

diluted massage. Carvone is a ketone that makes up 42.8% of spearmint (Bowles

2000).

However, many drugs are unsuitable for TTS because of their low perme-

ability, and components within essential oils may improve their permeability.

Almirall et al (1996) found that cineole, d-limonene, and pinene permeated the

skin and affected topical application of conventional drugs such as haloperidol

and chlorpromazine. Whereas cineole and d-limonene enhanced the transdermal

permeability of haloperidol, d-limonene reduced the transdermal permiability of

chlorpromazine. Cineole is an oxide found in rosemary, cardamon, spike lavender,

sage, and eucalyptus (Bowles 2000). Limonene is found in many citrus-peel oils.

Cornwall and Barry (1994) investigated the ability of 12 sesquiterpenes to en-

hance the drug 5 ﬂuorouracil and concluded several showed promise as clinically

acceptable penetration enhancers.

The skin is the largest organ of the body. It is also a stress barometer that pro-

vides the outside world with an indication of the serenity or confusion within.

Much of dermatology is concerned with putting topical drugs onto the skin.

However, skin problems may be linked to stress and diet. Possibly three of the

most common skin conditions suitable for aromatherapy are eczema, herpes, and

onychomycosis.

Eczema

Eczema is often used as a generic term to describe dermatitis although Ellis et al

(2002) suggests the two are not synonomous. Eczema is described as a “common

itching skin disease characterized by reddening (erythema) and vesicle formation

which may lead to weeping and crusting” (McFerran 1996). Eczema can be

divided into two deﬁnitive groups: speciﬁc, which includes atopic or allergic, and

a broad generic term covering generalized dermatitis. Eczema becomes clearer

if it is divided into four speciﬁc types: allergic, atopic, irritant, and seborrhoeic

(Schultz 2002).

Allergic eczema is caused by an allergen, and the allergy is unique to each

person. An example of this is latex allergy, one of the most common skin prob-

lems among health workers. Minute amounts of latex, sometimes only two mol-

ecules, can trigger a skin reaction. Other examples of allergens are wool, lanolin,

nickel found in jewelry, and rubber. Atopic eczema is associated with hay fever

and asthma and affects up to 20% of the population. Irritant dermatitis can affect

anyone and is related to the use of irritants such as biological washing powders

and detergent cleaning agents (Gascoigne 1993). The only difference is the

amount of irritant needed to produce an eczematous reaction. Seborrhoeic der-

matitis involves the nose, lips, eyes, and scalp and is associated with Pityrosporum

yeast infections.

The traditional treatment for eczema involves corticosteroid creams, avoid-

ance of foods such as dairy products, yeast, or food additives (in cases of allergic

or atopic eczema), and reduction of topical irritants.

While aromatherapy may aid the treatment of eczema either by reducing

stress or by acting at a topical, aniinﬂammatory level, if the underlying problems

contributing to the condition are not removed, the condition will not improve

greatly. Eczema could be made worse if an essential oil is chosen to which the pa-

tient is sensitive or, in the case of atopic eczema, if too high a concentration is

used. For this reason, patch testing should be mandatory for all eczema patients

(particularly atopic) who wish to try aromatherapy. Put double the concentration

of essential oil you wish to use on an adhesive bandage and apply to the patient’s

inner forearm. Leave in situ for 12 hours. Look for redness and itching. In addi-

tion, a careful case history, including details of potential antagonists (especially

herbal teas, ﬂowers, and pollens in cases of atopic eczema) and cosmetics (for con-

tact allergic eczema) should be tabulated.

Anderson et al (2000) carried out a study on atopic eczema that, at ﬁrst

glance, indicated massage with essential oils made the eczema worse. However,

this was a very unusual study as mothers chose the essential oil for their children

themselves from an offered selection of 36 “commonly used” essential oils. It was

not clear whether the mothers had any previous knowledge of or experience with

284 Section II Clinical Use of Aromatherapy

essential oils. Two of the oils they chose were spike lavender and Litsea cubeba.

Spike lavender contains up to 30% oxide (1,8-cineole) a common skin irritant, es-

pecially among young children (Price & Price 1999). Litsea cubeba often called

“May chang” is commonly used in natural perfumery and is 85% citral, a common

skin (and mucous membrane) irritant (Bowles 2000). It might be interesting to

revisit this study and analyze it without those two essential oils.

Kadir and Barry (1991) found that alpha-bisabolol (an ingredient in German

chamomile) enhanced the penetration of triamcinolone acetonide (a weak steroid

which was formerly used to treat severe eczema) by 73 times thereby suggesting

German chamomile could be used successfully with conventional topical treat-

ment. Another ingredient in German chamomile, chamazulene, was found to in-

hibit the production of leukotriene B4 in neutraphilic granulocytes in vitro

(Safayhi et al 1994).

Listed in Table 17-1 are some essential oils considered to be beneﬁcial in

treating eczema, followed by a discussion of the reasons for their use.

Lavandula angustifolia (true lavender) is very useful because of its recognized

healing properties for burns and wounds. Lavender appears to have a cell-

regenerating action, is soothing and sedative, and has a topical analgesic action that

will help the itching. It is also antibacterial and moderately antifungal. This was

the essential oil that proved so effective for Gattefosse’s burns (Tisserand 1993).

The almost antihistamine-like action of Matricaria recutita (German

chamomile) essential oil is due to the strong antiinﬂammatory effect of its three

sesquiterpenes: azulene, bisabolol, and farnesene (Mills 1991). This makes Ger-

man chamomile invaluable in the treatment of eczema. Its antiinﬂammatory

Chapter 17 Dermatology 285

Table 17-1 h Essential Oils for Eczema

Common Name Botanical Name Reference

True lavender Lavandula angustifolia Tisserand 1994

German chamomile Matricaria recutita Carle & Gomaa 1992

Tubaro et al 1984

Frankincense Boswellia carteri Duwiejua et al 1992

Roman chamomile Chamamelum nobile Rossi et al 1988

Balsam Myroxylon balsamum Tisserand 1993

Nagar matha Cyperus scariosus Gupta et al 1972

Cedarwood Cedrus atlantica Tisserand 1993

Fennel Foeniculum vulgare Mascolo et al 1987

Everlasting Helicrysum italicum Buckle 2001

Juniper Juniperus communis Mascolo et al 1987

effects have been well researched, and it is used in several pharmaceutical prepa-

rations. Carle & Gomaa (1992) found the alpha-bisabolol chemotype was the

most effective.

German chamomile was tested together with a steroid and a nonsteroid (hy-

drocortisone and benzydamine, respectively) preparation on mice. Although it

was not as effective as hydrocortisone, it was as effective as benzydamine (Tubaro

et al 1984). However, in another study on humans, Kamillosan Ointment, which

contains German chamomile, was found to be as effective as hydrocortisone

in 161 patients (Aertgeerts et al 1985). German chamomile was also found to

be effective in wound healing of patients following dermabrasion of tattoos

(Glowania et al 1987).

Roman chamomile, Chamemelum nobile, is also an antiinﬂammatory (Rossi

et al 1988). Although not as antiinﬂammatory as German chamomile, Roman

chamomile might be more acceptable. German chamomile is dark blue and very

pungent. Roman chamomile is colorless to pale blue with a pleasant, apple-like

aroma. The two chamomiles have very different chemistry.

A little-known essential oil, Cyperus scariosus (nagar matha in Sanskrit),

which is a grass-like herb, showed antiinﬂammatory activity in rats within 3 hours

of its application. The inhibition of granulous-tissue formation was thought to be

comparable to that achieved with hydrocortisone (Gupta et al 1972). This essen-

tial oil is not readily available.

Resins such as Boswellia carteri (frankincense) have traditionally been used in

India and Africa to treat inﬂammatory conditions (Duwiejua et al 1992). In a study

of the antiinﬂammatory effects of 75 species of plants on artiﬁcially induced in-

ﬂammation in rats, Foeniculum vulgare dulce (sweet fennel), Juniperus communis (ju-

niper), and Symphytum ofﬁcinale (comfrey) decreased inﬂammation by up to 50%.

Comfrey (an infused oil) also has antiulcer properties (Mascolo et al 1987) and

could form a useful base for the essential oil mix. Balsam and skin problems were

the subject of a doctoral thesis by Descouleurs, written in 1896 (Tisserand 1993).

Gattefosse reported Cedrus atlantica (cedar) was used to treat skin disorders in

an Algerian hospital in 1899 with great success (Tisserand 1992). Finally, my clin-

ical experience and that of my students is that Helicrysum italicum diluted in aloe

vera gel (3%) is very effective in reducing the heat and itchiness of eczema. It will

work within a few hours if it is going to work at all and is deﬁnitely worth a try.

Herpes

Cases of herpes simplex I and II reached epidemic proportions in the 1980s, and

currently statistics from the American Social Health Association show that up to

50 million Americans have genital herpes, and there are 1 million newly diag-

nosed infections each year (Susman 2001). Further, genital herpes affects one of

every ﬁve teens and adults in the United States and has increased 30% during the

past 10 years, according to ASHA, a private, nonproﬁt organization dedicated to

stopping sexually transmitted diseases (ASHA 2003).

286 Section II Clinical Use of Aromatherapy

The painful clusters of blisters reappear, usually in the same area, with ago-

nizing regularity—often monthly—and once the disease has been contracted, the

patient is infected for life. Outbreaks can be triggered by sexual activity, stress,

heat, hormonal changes, diet, and low immunity. Although the blisters often oc-

cur in the genital area (either internally or externally), they may also be found on

the thighs and buttocks. Extremely contagious at the blister stage, herpes can re-

main dormant for months or years in the spinal cord, ready to migrate down the

sensory nerves to the skin.

Orthodox treatment for herpes is with nucleoside analogues, such as Acy-

clovir, that introduce intracellular impediment to viral replication. These medica-

tions are taken orally and often leave a metal-like after taste. Essential oils that

may be effective against herpes in tissue are shown in Table 17-2. The table was

compiled with reference to various research studies carried out on human tissue

using extracts from plants (Cohen et al 1964; Kucera & Herrmann 1967; May &

Willuhn 1978).

A randomized, controlled, multicentered study on 115 patients by Wolbling

and Leonhardt (1994) found the aqueous extract of Melissa effective in treating

herpes. On the ﬁnal day (ﬁfth day) of treatment, 24 patients in the Melissa group

were symptom free versus 15 symptom-free patients in the placebo control group.

Scabbing and swelling were more reduced in the Melissa group, indicating reduced

cell damage and accelerated healing. Method of treatment was a proprietary-

brand cream (Lomaherpan) that contains 1% Melissa extract. The control was an

identical cream base without Melissa. The site of the herpes treated was the lips

in 34 in the Melissa group and 33 in the control group and on the genitals in four

Chapter 17 Dermatology 287

Table 17-2 h Essential Oils for Treating Herpes Simplex I & II

Common Name Botanical Name Reference

Cubeb Piper cubeba May & Willuhn 1978

Blue gum Eucalyptus globulus May & Willuhn 1978

Juniper Juniperus communis May & Willuhn 1978

Melissa Melissa ofﬁcinalis Wolbling et al 1994

Tea tree Melaleuca alternifolia Buckle 2001

Palma rosa Cymbopogon martinii Buckle 2001

Rosemary Rosmarinus ofﬁcinalis May & Willuhn 1978

Rose Rosa damascena Buckle 2001

Ravensara Ravensara aromatica Buckle 2001

Moroccan thyme Thymus satureioides Buckle 2001

in the Melissa group and six in the control group. A subgroup of 67 patients tested

positive for herpes labialis (type II, on the lips). The decline of the lesions re-

mained statistically faster in the Melissa group than the placebo group.

One-percent Melissa aqueous extract was tested for topical treatment of re-

curring herpes labialis (Koytchev et al 1999). This was a double-blind, placebo

controlled, randomized trial on 66 patients who had a history of four episodes of

herpes labialis per year. The Melissa cream was applied four times a day. There was

signiﬁcant reduction in size of affected area and blisters at day 2 in the Melissa

group. There was a rapid ameliorating effect on typical symptoms, reduction in

healing time, and prolonged periods between occurrences.

Both these studies used an aqueous extract. This is not the same as an essen-

tial oil. However, clinical experience of myself and my students indicates the es-

sential oil of Melissa is also extremely effective against herpes simplex I and II.

Melissa is the most expensive of all essential oils, and therefore is the most of-

ten adulterated. Frequently it is mixed with synthetics, lemongrass, or citronella.

These contaminants may have a worsening effect on irritated or abraded lesions

in irritant dermatitis, or, indeed, herpes.

A certain amount of anecdotal evidence indicates essential oils, applied to the

area when the tingling begins, can prevent herpes blisters from forming. There is

also anecdotal evidence that, when such oils are applied to the blisters, the pain

and itching are greatly relieved. The most commonly used essential oils have been

isolated from the 75 plants found to have virustatic activity. Despite the age of the

papers cited that investigated the ﬁrst four essential oils listed for treating herpes

(see Table 17-2), I have found these and the other essential oils in the table ef-

fective in 10 years of clinical experience. Severity, duration, and frequency of her-

pes outbreaks have decreased substantially with their use. A suggested protocol

for application is shown in Table 17-3. Each patient will respond to one particu-

lar essential oil or mix of oils. The reason the essential oils work could be because

they are lipophyllic and appear to dissolve the lipid capsule (or capsid) of the

virus. The most successful essential oil I have used has been Ravansara aromatica

(ravensara).

288 Section II Clinical Use of Aromatherapy

Table 17-3 h Protocol for Using Essential Oils in Treating Herpes

Symptom Topical Application Frequency

Tingling Undiluted essential oil Every 4 hours

Redness and swelling Undiluted essential oil Every 4 hours

Pustule formation Undiluted essential oil Every 4 hours

Broken pustule, raw skin 25% diluted essential oil* Every 4 hours

Raw skin 5% diluted essential oil Every 4 hours

*Dilute in cold-pressed vegetable oils, like sweet almond, or aloe vera gel.

In a study by Armaka et al (1999), isoborneol, a monoterpeneol found in sev-

eral essential oils, demonstrated viricidal activity against herpes simplex virus I by

inactivating the virus within 30 minutes of exposure. Further, a concentration of

0.06% isoborneol completely inhibited viral replication without affecting viral ad-

sorption. Isoborneol did not show signiﬁcant cytotoxicity when tested against hu-

man cell lines at 0.16%. Therefore essential oils containing a major proportion of

isoborneol might be useful in treating herpes. A high amount of borneol (up to

70%.) is found in Thymus satureoides ( Japanese thyme).

Geraniol, a monoterpenol found in many essential oils, was found to enhance

the antiherpetic activity of conventional treatment in a study by Shoji et al (1998).

Its action was thought to occur by changing the subcellular distribution of the

oligonucleotides. Geraniol is found in palma rosa (80%) (Bowles 2000) and Thy-

mus vulgaris CT gereniol.

Benencia and Courreges (2000) found eugenol was effective against herpes

simplex type I and II in monkey kidney-cell cultures and in vivo (in rabbits). The

monkey-cell cultures showed a dose-dependent sensitivity (higher doses in-

creased treatment effectiveness), and at least 50% of the viral activity was lost af-

ter contact with the diluted eugenol (250ug/ml) for one hour. Eugenol also ap-

peared to enhance the effect of Acyclovir. Eugenol appeared to prolong the

resistance of rabbits to developing herpes by 7 days, but all experimental animals

eventually became ill.

The antiherpetic activity of buds of Syzygium aromatica (clove) were alluded

to by Takechi et al (1985). However as clove is very high in phenols (70%), and

phenols are irritant to the skin and mucous membrane, clove bud (or leaf) is best

avoided.

Athlete’s Foot and Onychomycosis

Athlete’s foot (Tinea pedis) is the most common form of superﬁcial dermatophyte

infection in the developed world and infects approximately 10% of the popula-

tion (Tong et al 1992).

Onychomycosis (sometimes called Tinea ingium) is a superﬁcial fungal in-

fection that destroys the entire nail unit. It is a cousin of Tinea pedis, which causes

athlete’s foot. It is less contagious than athlete’s foot, but susceptibility increases

after trauma to the nail bed. Once contracted, it is extremely difﬁcult to remove

completely. Symptoms are a thickened nail that becomes discolored, brittle, or

chalky and ultimately disintegrates. Medical treatment includes debridement and

topical or systemic antifungals. Oral antifungal agents began with Griseofulvin in

1959 (Buck et al 1994), which was given orally for 6 months or until the nail grew

out. Side effects to Griseofulvin are nausea, vomiting, diarrhea, mental confusion,

and headaches.

Headaches are the most common side effect and can be severe, especially at

the commencement of treatment. The cure rate is 3%-38%. Ketoconazole is an-

other option, with the added advantage that it also treats yeast. The cure rate is

Chapter 17 Dermatology 289

higher at 50%-94%, and the side effects are less common, although they are more

serious and include idiosyncratic liver dysfuntion, requiring liver transplantation

(Knight et al 1991). Unfortunately, 50% of toenail infections recur within 4 years

of completion of treatment (Torok & Stechlich 1986). Itraconazole has cure rates

of 4%-92% but has only been evaluated in small studies (Piepponen et al 1992).

The previously mentioned conventional treatments are expensive and involve oral

medication.

The incidence of onychomycosis is increasing with no real satisfactory cure.

Buck et al (1994) carried out a multicentered, double-blind, randomized, con-

trolled study on onychomycosis using tea tree or clotrimazole. One-hundred sev-

enteen patients with distal subungual onychomycosis proven by culture took part

in the study. Patients received either twice-daily applications of clotrimazole so-

lution or 100% tea tree. Debridement took place at 0, 1, 3, and 6 months. Topi-

cal use of tea tree produced a similar result to oral doses of clotrimazole, with 55%

of the clotrimazole group and 56% of the tea tree group reporting improvement

or resolution after 3 months. The number of adverse reactions were similar; three

out of 53 for the clotrimazole group and ﬁve out of 64 in the tea tree group.

Syed et al (1999) carried out a randomized, double-blind, placebo-controlled

study to examine the clinical efﬁcacy and tolerability of 5% Melaleuca alternifolia

with 2% butenaﬁne hydrochloride incorporated in a cream. Sixty patients took

part in the study. There were 39 men and 21 women, and the average age was 29

years. Each participant had a history of onychomycosis for 6-36 months. After

using the cream for 16 weeks, 80% of the participants in the experimental group

were cured. No participant was cured in the placebo group. Four participants in

the experimental group experienced mild inﬂammation but did not discontinue

treatment. During follow-up no relapse occurred in the cured patients, and no

improvement was seen in the medication-resistant and placebo participants.

Elsethager (2000) investigated the effect of two essential oils (lemongrass

and tea tree) on 12 study participants who had onychomycosis for a minimum du-

ration of 1 year. One participant had it for more than 10 years. Two dilutions, 2%

tea tree and 3% lemongrass, were mixed together in grapeseed oil and given to

each participant, who rubbed the mixture well into the affected nail bed twice a

day for 2 months. It was thought there would be some visual improvement dur-

ing this time, although participants would need to continue treatment until the

whole nail had grown out. Only four people completed the treatment for 2

months. All stated their nails were less discolored, scaly, and cracked, and the dis-

comfort was less. A visual analog on effectiveness was completed, with zero as not

effective and 10 as extremely effective. One person rated the treatment a seven,

and the other three rated it a seven. Two of the four had previously used over-the-

counter medications (Tinactin and Dr. Scholl’s) which were rated zero. One of

the four participants had been offered an oral course of Griseofulvin, which she

had declined because she was concerned about the side effects.

Garg and Dengre (1988) found Cymbopogon citratus (West Indian lemon-

grass) effective against Trichophyton mentagrophytes. The most active component

290 Section II Clinical Use of Aromatherapy

of lemongrass was citral (70%-80%), which is thought to be responsible for

the antifungal activity of this plant. Lippia alba, which grows widely in Central

and South America, also has strong antifungal activity against Trichophyton

mentagrophyes var. interdigitale. Several chemotypes of the plant exist, and the es-

sential oil from the plant grown in Aruba is thought to be most suitable as it con-

tains 64% citral (Fun & Svendsen 1990).

Even at the low concentrations, essential oils can show very signiﬁcant an-

timycotic activity against Trichophyton mentagrophytes (Rai & Acharya 2001).

Sahi et al (1999) compared the efﬁcacy of Eucalyptus citriadora with commercial

antifungal drugs and found minimal concentration of the oil inhibited all the

tested pathogens, Microsporum nanum, Trichophyton mentagrophytes, and T.

rubrum, completely with fungistatic activity. Romagna et al (1994) reported the

antifungal effects of alpha-terthienyl from Tagetes patula on ﬁve dermatophytes.

Rai and Acharya (2000) found Tagetes erecta, T. patula, and Eupatorium triplin-

erve to be effective topical antimycotics.

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Chapter 17 Dermatology 293

294

Endocrinology

Without communication, no real understanding can be possible. Be sure you can

communicate with yourself. If you cannot communicate with yourself, how do you

expect to communicate with another person?

Tich Nhat Hanh

Anger

he endocrine system is the regulator of homeostasis (Anthony &

Thibodeau 1983). This balance is maintained through some two hundred

hormones in our bodies. The word hormone comes from the Greek hor-

maein, meaning to excite. In certain instances the nervous and endocrine systems

can regulate each other’s activities, as well as acting together to bring about

changes in physiology. Endocrine cells in the body occur in clusters in the en-

docrine glands. These glands secrete hormones directly into the bloodstream. As

hormones regulate our metabolism, growth, development, and reproduction, it is

clear they are a fundamental necessity to life. Hormones also govern our stress re-

sponse. Aromas interact with the limbic, hormonal, and endocrine systems as well

as impacting prostaglandin production and cell metabolism. This makes aro-

matherapy a valuable tool for treating conditions related to the endocrine system

(Table 18-1 introduces the main organs of the endocrine system).

Hormones play an important role in the mechanisms involving prosta-

glandins. Prostaglandins are a unique group of biological compounds that have a

5-carbon ring and serve important integrative functions in the body but do not

ﬁt the deﬁnition of a typical hormone. They are metabolized rapidly and so the

amount in the bloodstream at one time is very low (Anthony & Thibodeau 1983).

Three classes of prostaglandins—prostaglandin A (PGA), prostaglandin E

(PGE), and prostaglandin F (PGF)—have been isolated and identiﬁed from a

wide range of tissues. Aspirin is thought to exert its antiinﬂammatory action by

inhibiting PGE synthesis. Eugenol, carvacrol, thymol, and gingerol (all com-

pounds found within essential oils) have also been shown to inﬂuence PGE syn-

thesis (Bennett & Stamford 1988; Wagner et al 1986). Prostaglandin F (PGF) is

important in the female reproductive system (Alexander 2001).

All prostaglandins are intimately involved in endocrine regulation by inﬂu-

encing adenyl cyclase and adenosine 3,5-phosphate activity within the cell

(Anthony & Thibodeau 1983). Anything that interferes with that cellular activ-

ity indirectly affects the hormonal and endocrine system. Calcium regulates cel-

lular activity (Alexander 2001). Components within essential oils can interfere

with the release of calcium at a cellular level. This blocking mechanism has

been demonstrated for menthol, anethole, eugenol, and thymol (Melzig &

Teuscher 1991). These components are found in essential oils such as pepper-

mint, fennel, aniseed, star aniseed, bay, clove, Spanish marjoram, thyme, and

oregano (Sheppard-Hangar 1995; Budavari 1996).

Aromatherapy and the Female Reproductive System

Premenstrual syndrome (PMS) and menopausal problems are directly related to

the endocrine system (Alexander 2001). The uterus makes prostagladins to help

Chapter 18 Endocrinology 295

Table 18-1 h Main Organs of the Endocrine Systems

Pineal gland Regulates production of melatonin (a dark/light mech-

anism that affects how we sleep)

Pituitary gland Master endocrine gland divided into two lobes:

1) the anterior lobe governs growth, thyroid, adreno-

corticotropic, and reproductive hormones, namely

luteinizing and follicle-stimulating hormone

2) the posterior lobe secretes vasopressin (antidiuretic

hormone) and oxytocin (stimulates contraction of the

uterus during labor)

Thyroid Secretes thyroxin and governs metabolic rate

Parathyroid Controls calcium and phosphate levels

Adrenal cortex Produces corticosteroids

Adrenal medulla Produces adrenaline and noradrenaline

Islets of Langerhans Secretes insulin, glucagon, somatostatin, amylin, and

gastrin

Female gonads Produce estrogen and progesterone

Male gonads Produce testosterone

with labor, and the same prostaglandins can cause menstrual cramps. This is

why medications that block the synthesis of prostaglandin are effective in dys-

menorrhea. Alexander (2001) suggests it is possible that essential oils with va-

sodilatory or prostaglandin-antagonist properties might relieve the problem via

olfaction alone, although I think this is unlikely. During menopause, 50%-70% of

women experience a variety of physical and emotional symptoms (Schwingl et al

1994). Many of these symptoms can be ameliorated with certain essential oils.

PMS and menopause affect many millions of women every day. Fluctuation in es-

trogen levels can lead to profound mental and physical symptoms. Estrogen lev-

els drop after ovulation and at menopause.

There are three main forms of estrogen. Estradiol is the strongest form of es-

trogen our bodies make. Estrone is converted from estradiol in the liver, and Es-

triol is the weakest form of estrogen. However even estriol can have a pronounced

effect (van Der 1982).

Premenstrual Syndrome

PMS became a household name in England in 1987 when Anna Reynolds was

charged with the murder of her mother (a crime committed while suffering from

the effects of PMS) and jailed for life. Four months later, a petition signed by

6000 people launched an appeal for her release. On June 23, 1988, the British

court of appeals reduced the murder charge to manslaughter on the grounds of

PMS, and Reynolds was released. This was the ﬁrst time a woman had been al-

lowed to plead diminished responsibility due to “the time of the month.”

Women have known for many years that they can become irrational, irrita-

ble, weepy, and occasionally violent a few days before their menstrual period.

No one quite knows why this phenomenon affects some women and not oth-

ers. However, the chemistry of a woman’s brain actually changes during this

time and produces reactions she cannot control (Alexander 2001). The area

deep within the limbic system involved with mood control has more estrogen

receptors than other parts of the brain, which makes it more vulnerable to

changes in estrogen levels. One in 10 women becomes irritable, depressed, and

fatigued with PMS symptoms appearing 7-10 days prior to menses. However,

the more violent or aggressive PMS symptoms usually appear within 5 days of

the menstruation time. There is a difference in PMS behavior depending on the

side of the brain involved (Alexander 2001). The left side often produces symp-

toms of depression and irritability. The right side is associated with anger and

negative emotion.

In PMS there appears to be a ﬂuctuation in the levels of endogenous opioids

(these are abundant in the limbic system) and serotonin. In the ﬁrst half of the

menstrual cycle the levels of estrogen and endorphin interact with neurotrans-

mitters serotonin, dopamine, and norepinephrine to keep mood stability. When

estrogen levels ﬁrst begin to drop, immediately after ovulation, serotonin recep-

tors are primed (Rubinow et al 1998). When estrogen levels drop again prior to

menstruation, the brain registers estrogen withdrawal of serotonin.

296 Section II Clinical Use of Aromatherapy

Conventional medicine treats PMS with selective serotonin reuptake in-

hibitors (SSRIs) such as ﬂuoxetine, paroxetine, sertraline, and citalopram or a tri-

cyclic antidepressant related to SSRI such as clomipramine (Reid 2002). A sim-

pler but almost as effective method can be a large block of chocolate! Chocolate

has been found to increase serotonin and has been dubbed “the Prozac of plants”

by Forbes magazine (Bartlett 1999).

Aromatherapy can, in many instances, produce very reasonable results in

PMS if regular treatments are given throughout a period of several months. The

essential oils chosen are usually a combination of those thought to have estrogen-

like properties, such as fennel (Foeniculum vulgare), sage (Salvia ofﬁcinalis), or

clary sage (Salvia sclarea) (Zondeck & Bergmann 1938), and those that have

hormone-like properties, such as Scotch pine (Pinus sylvestris) and myrrh (Com-

miphora myrrha) (Franchomme & Penoel 1991). Salvia sclarea also has antiin-

ﬂammatory properties (Moretti et al 1997). Belaiche, a French MD who devotes

a whole volume of his work to female problems, suggests essential oil of sage,

thyme, or geranium for PMS (Belaiche 1979). Citral (an aldehyde found in

lemongrass, melissa, and verbena) demonstrates estrogen activity when applied

dermally to rats, although in doses much higher than would be normally used in

aromatherapy (Tisserand & Balacs 1995). Table 18-2 lists essential oils used in

the treatment of PMS.

Depending on the patient’s needs, another essential oil can be added to the

“balancing” essential oil that will help alleviate the symptoms of the imbalance. For

example, if a woman is showing symptoms of depression and is weepy, an essential

oil with an antidepressant action such as bergamot (Sheppard-Hangar 1995) or

rose (Rovesti & Columbo 1973) could be added to the balancing mixture. If she is

Chapter 18 Endocrinology 297

Table 18-2 h Essential Oils for PMS

Common Name Botanical Name Reference

Fennel Foeniculum vulgare Zondeck & Bergmann 1938

Sage Salvia ofﬁcinalis Zondeck & Bergmann 1938

Scotch pine Pinus sylvestris Franchomme & Penoel 1991

Myrrh Commiphora myrrha Franchomme & Penoel 1991

Clary sage Salvia sclarea Zondeck & Bergmann 1938

Geranium Pelargonium graveolens Belaiche 1979

Thyme Thymus vulgaris Belaiche 1979

Aniseed, fennel rans-anethole Albert-Puleo 1980

Lemongrass, melissa, Citral Geldof et al 1992

verbena

violent and irrational, a sedative such as angelica (Franchomme & Penoel 1991) or

ylang ylang could be used (Bucellato 1982). Geranium (Pelargonium graveolens) is

an excellent hormonal balancer. The aqueous extract of Pelargonium graveolens has

the added bonus of inhibiting platelet aggregation (Tzeng et al 1991), thereby pos-

sibly preventing extensive clotting during menstruation, which so often accompa-

nies hormonal imbalance. A Korean study (Han et al 2003) indicated that 2% clary

sage applied to the abdomen of menstruating women reduced the uterine ....and

substantially reduced dysmenorrhea.

I have had some success using tarragon in conjunction with estrogen-like es-

sential oils on women who have displayed aggressive PMS. One patient actually ad-

mitted “going for my husband with a knife.” Although tarragon (Artemisia dracun-

culus) has fallen out of favor recently due to its estragole content, the research that

gave rise to that view involved administering very large doses of estragole orally to

rats over a period of 12 months (Tisserand & Balacs 1995). The oral route would

ensure that substantially more estragole was absorbed than by the topical route, and

much higher doses were used in the study than are used in aromatherapy.

Buckingham (2000) investigated the effect of essential oils on 14 women

(aged 21-43) with moderate to severe PMS in a controlled study lasting 6

months. One symptom was chosen by each participant and matched to a speciﬁc

essential oil. The results indicated each of the chosen essential oils, except

surprisingly clary sage, had a beneﬁcial effect on menstrual symptoms. See Table

18-3 for study ﬁndings.

Menopausal Problems

The menopause is the natural cessation of a woman’s fertility. Estrogen levels fall

to 40%-60% of premenopausal level, and progesterone levels fall to almost zero

(Moskowitz 2001). Once looked upon with secret delight as the end of menstru-

ation and its accompanying messy problems, menopause now seems to be viewed

by many women with dismay and despair and by orthodox medicine as a condi-

tion to be ﬁxed. Menopausal depression is thought to be one of the main symp-

298 Section II Clinical Use of Aromatherapy

Table 18-3 h Essential Oils Used in Buckingham’s Study

Essential Oil Disorder Treated

True lavender Anxiety

True lavender Breast tenderness

Juniper Fluid retention

Juniper Breast tenderness

Clary sage Low-back pain

Geranium Mood swings

Geranium Nervous tension

toms of women seeking hormone replacement therapy (HRT) (Andrist 1998), al-

though older women seem more concerned with osteoporosis and younger

women with hot ﬂashes (Ettinger & Pressman 1999). Between one- and two-

thirds of woman discontinue HRT during the ﬁrst 2 years because of weight gain

and unwanted side effects such as bloating and breakthrough bleeding (Den

Tonkelaar & Oddens 2000).

Hot ﬂashes, night sweats, sleep disturbance, depression, loss of energy,

and loss of concentration are all common symptoms of menopause (Schmid &

Rubinow 1994). However, cessation of estrogen and progesterone production

does not happen overnight, and it is the interim imbalance that is so difﬁcult.

Essential oils such as rose (Belaiche 1979), cypress (Valnet 1993), or clary

sage can be helpful when used in a hydrosol spray or spritzer sprayed around the

face, neck, and shoulders during a hot ﬂash. A few drops of peppermint added to

the mix is wonderfully cooling. Essential oils that could be used for estrogen sup-

port include fennel (Marini-Bettolo 1979), sage (Franchomme & Penoel 1991),

and aniseed (Albert-Puleo 1980). Geranium (Holmes 1993) and rose give added

support. Using a mixture of essential oils on a daily basis can be very beneﬁcial ei-

ther on a tissue or in a bath or body lotion. I used menopausal oils in this way

for several years with no ill effect. Rotating the mix of calming and estrogen-

supportive essential oils will prevent the body from becoming inured to the es-

sential oils. The combinations and permutations of some 20 essential oils can

work out to be a great number of different mixes—all therapeutic and beneﬁcial

for menopausal symptoms (Table 18-4).

For night sweats, cypress, with its recognized deodorant effect and hormonal

properties, is comforting (Valnet 1993). For insomnia, any of the gently relaxing

and sedative oils could be added, but try also root of Angelica archangelica (Duke

1985). Increasing soy intake and taking daily food supplements such as red clover

and black cohosh will also help tremendously as these phytoestrogens can help

balance wildly ﬂuctuating hormone levels.

Chapter 18 Endocrinology 299

Table 18-4 h Essential Oils for Menopause

Common Name Botanical Name Reference

Fennel Foeniculum vulgare Marini-Bettolo 1979

Geranium Pelargonium graveolens Holmes 1993

Rose Rosa damascena Buckle 1997

Clary sage Salvia sclarea Rose 1996

Sage Salvia ofﬁcinalis Franchomme & Penoel 1991

Anise seed Pimpinella anisum Albert-Puleo 1980

Cypress Cupressus sempervirens Valnet 1993

Shiffman (1995) explored the effects of a selection of fragrance sprays currently

on the market with 56 women aged 45-60 in a placebo-controlled study. Four groups

were assigned depending on hormonal status: 1) still menstruating, 2) no longer

menstruating and taking estrogen, 3) no longer menstruating and taking estrogen

and progesterone, 4) no longer menstruating and not taking either estrogen or prog-

esterone. While the scents supplied were not speciﬁed and probably were synthetic,

the effects indicated that pleasant scents alleviated depression and confusion in

women at midlife and were more effective in those women taking hormone replace-

ment. Schiffman suggests the positive effects may be because pleasant aromas im-

prove mood, thus releasing a broad range of transmitters in the limbic system.

Kozlowski (2000) explored the use of clary sage and geranium on 11

menopausal women aged 47-56 using a 5% solution applied to the reﬂexology

point for ovaries and uterus on the feet. Clary sage produced some useful changes

in hot ﬂash intensity. One subject wrote that two nights after stopping clary sage,

the hot ﬂashes returned to their original intensity.

Both the above conditions occur exclusively in women and, fall more under

gynecology than endocrinology, so perhaps a very brief mention of diabetes (an

endocrine disorder that affects both men and women) and the use of essential oils

might be in order.

Diabetes

Baschetti (1998) explored the hypothesis that the epidemic of diabetes in newly

Westernized populations could be due to genetically unknown foods as well as a

surge in calories from increased fat intake. There were no instances of diabetes in

Nauru, an island in the Paciﬁc, in a 1933 medical survey. But by 1978, 44% of the

population had noninsulin-dependent diabetes mellitus (NIDDM). Similarly,

there was only one possible incidence of NIDDM among Pima Indians in Ari-

zona in 1908, but currently it is present in 50% of adults over 35 years of age

(Knowler et al 1981).

These two studies, and the dramatic increase in diabetes in the United States

during the last 10 years, suggest Westernized people could be adding something

to their diets that their bodies cannot metabolize. The increase in diabetes has

been linked to the increase in sugar consumption and to the increase in obesity.

Rosmarinus ofﬁcinalis (rosemary) was shown to suppress the insulin response

in a glucose-tolerance test in rabbits when plasma glucose levels remained at 55%

for 2 hours. Rosemary also caused hyperglycemia in rabbits with artiﬁcially in-

duced diabetes (Al-Hader & Hasan 1994).

Another study showed that Eucalyptus citriodora (lemon-scented gum) had a

hypoglycemic effect on rabbits (Revoredo 1958). Valnet states that geranium has

antidiabetic properties, although no clariﬁcation is given (Valnet 1993). Ylang

ylang is another essential oil thought to be useful in diabetes (Franchomme & Pe-

noel 1991; Sheppard-Hangar 1995; Price 1995), although again no research to

substantiate this view was given.

300 Section II Clinical Use of Aromatherapy

REFERENCES

Albert-Puleo M. 1980. Fennel and anise as estrogenic agents. Journal of Ethnopharma-

cology. 2(4) 337-344.

Al-Hader A, Hasan Z. 1994. Hyperglycemic and insulin release inhibitory effects of

Rosmarinus ofﬁcinalis. Journal of Ethnopharmacology. 43(3) 217-211.

Alexander M. 2001. How Aromatherapy Works, Vol. 1: Principle Mechanisms in Olfac-

tion. Odessa, FL: Whole Spectrum Books, 293.

Andrist L. 1998. The impact of media attention, family history, politics and maturation

on women’s decisions regarding hormone replacement therapy. Health Care For

Women International. 19(3) 243-260.

Anthony C, Thibodeau G. 1983. Textbook of Anatomy and Physiology. St. Louis, MO:

Mosby.

Bartlett J. Nov. 11, 1999. Meltdown. Forbes.com. www.forbes.com

Baschetti R. 1998. Diabetes epidemic in newly Westernized populations: is it due to

thrifty genes or to genetically unknown foods? Journal of the Royal Society of Medi-

cine. 91(12) 622-626.

Belaiche P. 1979. Syndrome premenstruel. In Traite de Phytotherapie et d’Aromathera-

pie. Paris: Maloine SA. 3: 60-64.

Bennett A, Stamford F. 1988. The biological activity of eugenol, a major constituent of

nutmeg, on prostaglandins, the intestine and other tissues. Phytotherapy Research.

2(3) 125-129.

Buccellato F. 1982. Ylang survey. Perfumer & Flavorist. 7(4) 9-10.

Buckingham C. 2000. Effects of Aromatherapy on PMS. Unpublished dissertation.

Hunter, NY: R J Buckle Associates.

Buckle J. 1997. Clinical Aromatherapy in Nursing. London: Arnold.

Budavari S (ed.). 1996. The Merck Index, 12th ed. Whitehouse Station, NJ: Merck.

Den Tonkelaar I, Oddens B. 2000. Determinants of long-term hormone replacement

therapy and reasons for early discontinuation. Obstetrics & Gynecology. 95(4) 507-

512.

Duke J. 1985. Handbook of Medicinal Herbs. Boca Raton, FL: CRC Press.

Ettinger B, Pressman A. 1999.Continuation of postmenopausal hormone replacement

therapy in a large health maintenance organization: transdermal matrix patch versus

oral estrogen therapy. American Journal of Managed Care. 5(6) 779-785.

Franchomme P, Penoel D. 1991. Aromatherapie Exactement. Limoges, France: Jollois.

Geldof A, Engel C, Rao B. 1992. Estrogenic action of commonly used fragrant agent

citral induces prostatic hyperplasia. Urological Research. 20(2) 139-144.

Han S, Hur M, Buckle J. 2003. A randomized trial of effect of aromatherapy on the

menstrual cramps in college students. In press.

Hahn T. 2001. Anger. New York: Riverhead.

Holmes P. 1993. The Energetics of Western Herbs. Berkeley, CA: NatTrop.

Knowler W, Pettit D, Savage P, et al. 1981. Diabetic incidence in Pima Indians: contri-

butions to obesity and parental diabetes. American Journal of Epidemiology. 113(2)

114-156.

Kozlowski G. 2000. Use of clary sage and geranium on menopausal symptoms. Hunter,

NY: R J Buckle Associates.

Marini-Bettolo G. 1979. Plants in traditional medicine. Journal of Ethnopharmacology.

1(3) 303-306.

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Melzig M, Teuscher E. 1991. Investigations of the inﬂuence of essential oils and their

main components on the adenosine uptake by cultivated epithelial cells. Planta Med-

ica. 57(1) 41.

Moretti M, Peana A, Satta M. 1997. A study on anti-inﬂammatory and peripheral anal-

gesic action of Salvia sclarea oil and its main components. Journal of Essential Oil Re-

search. 9(2) 199-204.

Moskowitz D. 2001. Hormones and balance. In Wilson K, Moskowitz D, Thomas D

(eds.), A Woman’s Health Resource. Portland, OR: Transitions for Health, Inc., 3-37.

Price S, Price L. 1999. Aromatherapy for the Health Professional. London: Churchill

Livingstone.

Reid R. 2002. Premenstrual syndrome. Retrieved March 17, 2003 from

www.endotext.org.

Revoredo N. 1958. Hypoglycemic action of Eucalyptus citriodora. Monitor de la Farmacia

y de la Terapeutica. 64: 37-38.

Rose J. 1992. The Aromatherapy Book. San Francisco: North Atlantic Books.

Rovesti P, Columbo E. 1973. Aromatherapy and aerosols. Soap, Perfumery and Cosmet-

ics. 46: 475-477.

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affective regulation. Bio Psychiatry. 44(9) 839-850.

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further study. American Journal of Psychiatry. 148(1) 844-852.

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rics & Gynecology. 84(1) 29-34.

Sheppard-Hangar S. 1995. The Aromatherapy Practitioner’s Reference Manual, Vol. 1.

Tampa, FL: Atlantic Institute of Aromatherapy.

Shiffman S. 1995. Pleasant odors improve mood of women and men at midlife. In

Gilbert A (ed.), Compendium of Olfactory Research. New York: Olfactory Research

Fund, Ltd., 97-103.

Tisserand R, Balacs T. 1995. Essential Oil Safety. London: Churchill Livingstone.

Tzeng S, Ko W, Ko FN. 1991. Inhibition of platelet aggregation by some ﬂavonoids.

Thrombosis Research. 64(1) 91-100.

Valnet J. 1993. The Practice of Aromatherapy. Saffron Walden, UK: CW Daniels.

van Der V. 1982. The pharmacology of oestriol. Maturitas. 4(4) 291-299.

Wagner H, Wierer M, et al. 1986. In vitro-Hemmung der Prostaglandin-Biosynthese

durch etherische Ole und phenolische Verbindungen. Planta Medica. 184-187.

Zondeck B, Bergmann E. 1938. Phenol methyl ethers as estrogenic agents. Biochemical

Journal. 32: 641-645.

302 Section II Clinical Use of Aromatherapy

303

Hospice and End-of-Life Care

The whole natural world is scented, yet until today, no one has sought to know why.

Rene-Maurice Gattefosse

Foreword to Gattefosse’s Aromatherapy

ospice care may involve care of the actively dying, but it is not the same

as end-of-life care. End-of-life care is just that: care of a person who is

in the immediate process of dying. Hospice care (also known as pallia-

tive care) means caring for someone who may not get better, but who is never-

theless not at death’s door and may live for many years (McCusker 1983). There-

fore, palliative care involves alleviating the effects of disease without curing

(Fowler & Fowler 1964). This may be unattractive to a medical system based on

curing, and Lagay (2001) suggests patients deemed incurable may be neglected.

Hospice care is a great challenge to health-care professionals because there are no

set protocols; each patient is different with different needs. However, this should

be health care’s ﬁnest hour.

The philosophy of caring cannot be reduced to a series of actions (Drew &

Dahlerg 1995). To be caring is to be holistic, so it is hardly surprising that aro-

matherapy is used and accepted so readily in hospice care, which sees itself as

holistic—dealing with the whole person. Chapman (1998) suggest that in hospice

care, professional judgement is mainly intuitive. Hillier (2001) writes hospice care

is like an iceberg, with the obvious “doing” comprising less than 15% of the ac-

tual care.

Ninety percent of cancer patients spend their last year of life in their own

homes (Doyle 1986), although during that last year many patients will be admit-

ted to a hospital for a short time. Most Americans say they would like to die at

home, but in reality 20%-50% of Americans die in hospitals (Wennberg 1999).

Hospice care is the process of helping patients live fully for as long as possi-

ble while alleviating suffering. Suffering can be emotional as well as physical. One

of the greatest emotional shocks a person can receive is the knowledge that he or

she has a terminal illness. This sets off an internal process of mourning, with the

associated feelings of numbness, anger, depression, and ﬁnally acceptance

(Childs-Gowell 1992). Many patients remain stuck in the second stage with the

question “why me?,” or they displace their anger and sense of unfairness to oth-

ers and make their lives miserable (Kubler-Ross 1978). Perhaps the answer to this

dilemma could be found in the following quotation:

The Pathless Path

There is no answer,

There never has been an answer.

There never will be an answer.

That’s the answer. (Gertrude Stein, 1925)

Our society does little to honor the process of mourning; there is no rite of

passage. The idea of mourning something other than death is given little support,

but patients in palliative care are mourning the death of their future. They know

there will be no happy ending, and although everyone has to die sometime, real-

ization of the close proximity of death comes as a bitter blow to many patients.

There is no way of knowing (outside a hospital) whether a person has a limited

time to live unless he or she chooses to share this knowledge. Many do not share

this information because they feel they cannot. Some ﬁnd it difﬁcult to put their

feelings into words, and some are fearful of an uncertain response (pity and forced

humor being equally unacceptable), so fear can keep patients locked in a world of

their own, unable or unwilling to communicate.

Aromatherapy and Palliative Care

Gentle touch and beautiful smells can cross these barriers. Touch communicates

a sense of acceptance to such patients, many of whom may have feelings of self-

disapproval (Pratt & Mason 1981). Touch and smell often penetrate the despon-

dency of a patient who is struggling to accept that life is no longer going to be as

he or she had hoped. Touch is an important commodity during palliative care be-

cause patients can often feel more “skin hunger” (Simon 1976). It opens up dia-

logue, while smells nudge memories. Together they can help patients who may

struggle with feelings of anger, denial, guilt, and frustration by allowing them to

verbalize those feelings and communicate at a deeper level.

Attractive smells give pleasure and can relax a patient sufﬁciently to allow

him or her to open up. Aromatherapy using the “m” technique allows a patient to

experience pleasure, relaxation, and acceptance simultaneously. Trust can occur at

a deep level between caregiver and patient. This level of intimacy allows caregivers

to show their profound love of humanity in a deeply moving way and provide

“comfort care” to their patients (Kolcaba 1995). Many health professionals desire

to give this level of care (Montgomery 1996).

304 Section II Clinical Use of Aromatherapy

Palliative care should embrace the whole family, who may be trying to “re-

main brave.” Smells are not easily hidden, and beautiful smells are an easy way to

begin dialogue with family members. It is not unusual for aromatherapy to act as

the catalyst, allowing patients and their relatives to begin talking to one another

at a useful level. This period before a patient enters the terminal stage is impor-

tant for a peaceful death. It is a time to clear old scores and resolve past disagree-

ments. It is a time of completion, so the process of dying, when it ﬁnally occurs,

can be as serene and digniﬁed as possible.

Aromatherapy can aid the management of pain and nausea in a complemen-

tary way, but perhaps aromatherapy’s greatest strength in palliative care lies in its

ability to facilitate communication at an emotional and spiritual level, giving feel-

ings of comfort and pleasure. For this reason, the choice of essential oils should

rest with the patient. Concentrate on offering a selection that could give pleasure

to the patient. If he or she is particularly withdrawn or depressed, an uplifting es-

sential oil known for its gentle antidepressant properties, such as bergamot (Cit-

rus bergamia) or frankincense (Boswellia carterii) would be appropriate. However,

at this particular stage of illness caregivers are offering esthetic aromatherapy,

rather than targeting speciﬁc problem areas.

End-of-Life Care

End-of-life care is estimated to account for up to 12% of all health-care spend-

ing in the United States (Emmanuel 1996). Annual expenditure for hospice care

is about $3.5 billion (Levitt et al 2000), although hospices operate with little ﬁ-

nancial aid and are given little state or federal help. For example, New York City

reimburses hospice medications at $1.50 per day, although the average cost for

drugs is $12 per day (Raphael et al 2001). Of the 9.3 million Americans who are

over the age of 85, 83% are women and 43% live alone. By 2060, the population

over the age of 85 (both sexes) will increase by 240%. Medicare spends 40% of its

budget on the last 30 days of a person’s life. However, the cost of the end-of-life

care for a 85-year-old is

⁄

lower than the cost of a 65-75-year-old patient

(Hogan et al 2000).

The Last Acts project, funded by the Robert Wood Johnson Foundation, was

created in 1997 to educate the public, policymakers, and health-care profession-

als on end-of-life care (Cassel & Demel 2001). The Last Acts project suggests the

following are fundamental to end-of-life care:

respecting patient goals, preferences, and choices;

comprehensive caring;

utilizing the strengths of interdisciplinary resources;

acknowledging and addressing caregivers’ concerns;

building systems and mechanisms of support.

The physical process of dying is recognizable (Newbury 1995). Bodily func-

tions cease, and the peripheral temperature drops as circulation fails, leaving the

skin mottled and discolored. Thirst is often the last craving, with food refused.

Many dying patients breathe through their mouths, which can become dry and

Chapter 19 Hospice and End-of-Life Care 305

cracked. Often their eyes are open, even though the patient may be asleep or un-

conscious. Rattling in the throat occurs when secretions collect in the throat and

the patient is too weak to cough. Although the patient may be unaware of the

sound, it is frequently distressing for relatives in the same room. A change in po-

sition may help, but aromatherapy and gentle massage may also alleviate this

problem (Tattam 1992). Cheyne-Stoke breathing (irregular breathing when the

patient doesn’t appear to breathe for long periods) often occurs in the days prior

to death. Patients may be aware someone is with them, even though they appear

to be deeply unconscious. Hearing is one of the last senses to go, so what is said

in front of a dying patient is important. This is the time for soothing music such

as the work of Therese Schroeder-Sheker (1998).

Many people have a fear of dying alone. Abandonment is a major patient fear,

and anecdotal evidence suggests patients who have “Do Not Resuscitate” orders

are ignored by medical staff (Sulmasy & Rahns 2001). When patients are at the

point of death, they may have been unconscious for some time, but it is still im-

portant to really be there with them. Talk gently to them, read their favorite po-

ems, tell their favorite jokes, and play their favorite music. Tell them you are there

for them, but be sure to give them permission to go. Touch and smell remain im-

portant, and aromatherapy using the “m” technique is a wonderful way to say good-

bye. Pleasant smells are of particular importance in terminal nursing. The smell of

death is something most people working in hospice work can recognize. Certainly

if there are any suppurating lesions, the smell in a patient’s room can be quite un-

pleasant, and patients remain aware of both smell and touch almost until the end.

Other small but highly effective ways to use aromatherapy in terminal nurs-

ing include incorporating ﬂoral waters. Currently available antiseptic mouth-care

lotions can be uncomfortable or burn mouths that are fragile and sensitive

(Gravett 1995). Floral waters (hydrolats) are ideal to use as they are water based,

dilute, and very gentle (Kusmerik 1996). Chamomile and cornﬂower ﬂoral waters

are useful for eye care, and linden ﬂowers, myrtle, and orange blossom are useful

for mouth care.

Floral waters provide a gentle way of using aromatherapy. Choose carefully as

some, like neroli, are more astringent than geranium and rose, which are more suit-

able for dry, papery skin (Catty 2001). Wounds can also be cleansed with ﬂoral wa-

ters as they are antiseptic and slightly acidic. Floral waters can also be used as com-

presses and are a soothing way to wipe a face.They are excellent to spray around the

bed and on the linen, as they are refreshing to both the dying person and relatives.

Floral waters will leave a very delicate scent behind and are usually tolerated even

by those with a heightened sense of smell. It is important to use true ﬂoral waters

and not synthetic blends added to water. Purchase them from a reputable supplier

to ensure the ﬂoral water does not contain fungal or bacterial contaminants.

Relatives learn more from what health-care professionals do than from what

they say (Dossey 1994). There is a need to involve relatives in end-of-life care, and

some can be encouraged to massage their loved one’s hands or feet gently. Help

them to choose a particular blend of aromas that has meaning for their loved one.

Perhaps the patient was particularly fond of the rose garden or maybe they always

306 Section II Clinical Use of Aromatherapy

potted geraniums. Perhaps they traveled extensively and enjoyed the scent of or-

ange blossom and ylang ylang. Maybe they lived in foreign countries and walked

through forests of eucalyptus or sandalwood. Perhaps they had a special herb gar-

den. Their favorite smells can be mixed together in a “farewell blend.” This highly

personal blend can be used constantly during the dying process and will become

identiﬁed with the person. Following death, this personalized “farewell blend” can

give tremendous comfort to relatives and will help during bereavement.

Katz (1999) carried out a study on 20 patients in the active dying process ex-

periencing terminal agitation or anxiety at her hospice in Pennsylvania. She ap-

plied 1% Lavandula angustifolia with the “m” technique to hands and feet. All the

patients had a decreased pulse and respiration, and all demonstrated physical re-

laxation by unclenching their hands. In 75% of cases, family members verbalized

that they had observed a decrease in agitation. Two comments from her study are

haunting. “There is a sense of peace I haven’t felt since the diagnosis was made,”

and, from a ﬁve-year-old “My granny feels better, and I helped.”

O’Keefe (2000) carried out a study on 10 patients using frankincense in a

foot and leg “m” technique and a drop of lavender on the pillow at her hospice in

Arizona. All patients were in the active stage of dying, and some of them died

within hours or days. After treatment, the restlessness of nine of the patients de-

creased. For most, their respiration slowed and became deeper as they became

quieter. Most of them slept peacefully following the treatment. The response of

the patients’ relatives was one of deep appreciation for this level of caring.

Ocampo (2000) carried out a controlled study on six terminally ill patients

experiencing moderate to severe pain at her hospice in New York. Eight volun-

teers were trained in the “m” technique and performed it on patients’ hands. All

patients receiving the “m” technique experienced considerable reduction in their

pain perception, according to a visual analog.The treatment group slept for longer

periods than the control group.

Perhaps the soul does not die but moves on, and just as a newborn child is

welcomed into this world, so should a soul be welcomed into its death. Whatever

the health-care provider believes, by caring for a dying patient in this way, using

familiar smells and gentle touch, the transition from life as we know it is cele-

brated in the most supportive and holistic way possible. Health-care providers are

privileged to be midwives and facilitators of this transition.

Thank you, my friend

For sharing your dying.

I can be with you

To catch a glimpse of the life you are leaving

And the life to which you return.

In the process, I can accompany your tumult,

Your fear, resistance,

And hope.

Thank you my friend

For sharing your soul. (Dorothea Hover-Kramer, 1993; reproduced with

kind permission of the author)

Chapter 19 Hospice and End-of-Life Care 307

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Chapter 19 Hospice and End-of-Life Care 309

310

Immunology

Everything we need to be whole and healthy is provided for us by nature but,

somewhere along the way, most of us have lost sight of this ancient wisdom.

Dr. Mariano Spieza

Holistic Physician and CEO Speizia Organic Care, Cornwall, England

ndrew Weil, MD, (1998) wrote “There is growing evidence that adjunc-

tive therapies can enhance immunity as well as increase the effectiveness

of conventional treatments and minimize their side effects.” During the

last few years it has become evident that essential oils, both through topical ap-

plication and inhalation, can positively impact the immune system by improving

mood, increasing brain activity, and enhancing other biological functions impor-

tant to health and healing (Alexander 2001). Indeed olfaction has a close link

with immunology; the secret of each of our individual aromas may lie in our im-

munology and the way our cells communicate with each other (Lewis 1974).

Immunology is a rapidly growing ﬁeld, this growth possibly having been pre-

cipitated by the HIV/AIDS epidemic and nurtured by mind-body medicine.

How we feel affects how we are, and that is of particular importance in the use of

aromatherapy. Candace Pert (2000) created a major conceptual shift in neuro-

science with the discovery that the brain, nervous, and immune systems commu-

nicate. She discovered a “gut feeling” about something is a tangible, physiological

function because the gut has opioid receptors. Recent studies indicate stress-

induced neuroendocrine activation can produce profound changes in immune

function (Robinson 1999).

The limbic system has the largest number of peptides and receptors, which

are the substates of emotion, and these are in constant communication with the

immune system. Lymphocytes also secrete endorphins and adrenocorticotropic

hormone (ACTH), a stress hormone previously thought to be excreted exclu-

sively by the pituitary gland. Cells can pick up the “scent” of a peptide on the re-

ceptors of its surface using a process known as chemotaxis (Pert 2000).

Immune System Function

The immune system is highly complicated: a sensitive balancing act linked by nerve

cells that receive directions from and send directions to the brain. Psychological and

emotional factors impact both antibody- and cell-mediated immune function. One

important function of the immune system is its ability to distinguish between self

and nonself. This allows the body to defend itself against infection without harming

its own cells. Alexander (2001) draws attention to the similarity between the im-

mune and olfactory systems: both respond instantly to vast numbers of molecules.

The organs of the immune system produce lymphocytes. These white blood

cells include T cells (so called because they mature in the thymus) and B cells,

which circulate antibodies. Antibodies are tiny proteins belonging to a family of

immunoglobulins. Antibodies will attach themselves to the surface of an antigen

(a foreign invader) much the way a key ﬁts into a lock. Each antibody recognizes

and attaches to a speciﬁc antigen.

T cells do not produce antibodies. There are four types of T cells and they

attack foreign invaders in different ways.

Killer cells are constantly on the alert in the bloodstream, looking for foreign in-

vaders. When they ﬁnd them, the killer cells attach themselves and release

toxic chemicals to destroy the invaders. Just like antibodies, killer cells are

programmed only to kill one thing, whether it is an infective agent, a cell that

has been infected, or transplanted tissue.

Nonkiller cells are also constantly on the alert. These cells can attack a broad

range of targets including both tumor and infection.

Helper cells stimulate B lymphocytes to produce antibodies.

Suppressor cells shut off the helper cells when enough antibodies have been pro-

duced.

For optimum health, helper and suppressor cells should be in balance.

HIV/AIDS patients have a deﬁciency of helper cells, whereas people with au-

toimmune disease have too many helper cells.

The basic role of the immune system is to defend the body. To do that, it

needs to know what is body and what is not. B lymphocytes tell the body if it has

been invaded, but there is another arm to the body’s defense system, namely the

cellular response, which involves the T lymphocytes.

Psychoneuroimmunology is the study of the reaction between the mind, the

nervous system, and the immune system. In an article published in the Lancet,

stress was linked to a depressed immune system (Cohen & Felten 1995). Research

has shown changes in hormone and neurotransmitter levels alter human immune

responses (Glaser & Glaser 1993). Research also indicates stress can affect the

immune response (Kiecolt-Glaser & Glaser 1991), increase susceptibility to the

Chapter 20 Immunology 311

common cold (Cohen et al 1991), adversely affect conception (Domar et al 1990),

increase the incidence of skin disease (Panconesi 1984), and affect a patient’s per-

ception of pain (Turk & Nash 1993).

Aromatherapy and the Immune System

If aromatherapy elicits the “feel-good” factor, then it may well enhance the im-

mune system. However, some essential oils may impact immune function at a cel-

lular level. Although there is nothing clear-cut here, Penoel (1993) suggests the

effects of phenols could be compared to those of human immunoglobulin M

(IgM). IgM is secreted for a short period of time when the immune system en-

counters a pathogenic organism.

Immunoglobulin G (IgG) is secreted for long-term defense. Penoel (1993)

thinks the action of IgG is mirrored by the behavior of monoterpenic alcohols.

Berkarda et al (1983) reported on the ability of coumarins to increase lymphocyte

transformation values in cancer patients. Coumarins are found (although only in

small quantities) in citrus-peel oils and lavender. Perhaps this is why Rovesti

(1973) thought lavender stimulated lymphocytosis. Lapraz is quoted as saying the

presence “of essential oils in the bloodstream produces leukocytosis” (Mitchell

1993). Valnet (1990) cites Novi who demonstrated the stimulant effect of

“essences of thyme, lavender, lemon, chamomile and bergamot on the white cor-

puscles by which curative leukocytosis is activated, enabling the body to combat

toxins and to resist infectious disease.” Roulier (1990) suggests clove, true ver-

bena, niaouli, and patchouli essential oils could help to balance the immune sys-

tem. However, no studies have measured the effect of aromatherapy on im-

munoglobulins in human blood or saliva—yet. Table 20-1 lists essential oils that

may assist immune function.

312 Section II Clinical Use of Aromatherapy

Table 20-1 h Essential Oils that May Help Immune Function

Common Name Botanical Name Reference

Clove Syzygium aromaticum Roulier 1990

Lemon verbena Lippia citriodora Roulier 1990

Niaouli Melaleuca viridiﬂora Roulier 1990

Thyme Thymus vulgaris CT thymol Valnet 1990

Lavender Lavandula angustifolia Valnet 1990

Lemon Citrus limon Valnet 1990

German chamomile Matricaria recutita Wagner 1985

Bergamot Citrus bergamia Valnet 1990

Patchouli Pogostemon patchouli Roulier 1990

Other essential oils thought to elevate levels of lymphocytes include Matri-

caria recutita (German chamomile), which increases the number of B lymphocytes

(Wagner 1985), and Citrus bergamia (bergamot), which is thought to be an

immune-system stimulant (Roulier 1990). Philippe Mailhebiau (1995) writes

that Thymus vulgaris CT thymol has strong immunostimulant properties and is

less hepatotoxic than Satureja montana CT thymol.

Perhaps two of the most common immunology problems encountered by

health professionals are rheumatoid arthritis and HIV/AIDS. Although there

is no suggestion that aromatherapy can “cure” rheumatoid arthritis or

AIDS/HIV, it may have a positive impact on immune function through the

feel-good factor. After all, Marette Flies, an eleven-year-old with lupus, was

able to produce the same physiologic response from smelling a rose as from re-

ceiving chemotherapy when she thought she was receiving both (Olness &

Ader 1992).

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, symmetrical, inﬂammatory polyarthritis

that affects 3% of the adult population. The peak onset is between ages 25 and

55, and females are more affected than males. Juvenile RA commonly presents

between ages 1-3 years. In addition to arthritis, 20%-35% of patients also mani-

fest severe deformity of rheumatoid modules. These consist of a central area of

ﬁbrinoid necrosis surrounded by macrophages and ﬁbrous tissue containing

chronic inﬂammatory cells. The wrist subluxes and the radial head becomes

prominent. Extensor tendons in the hand may rupture and adjacent muscles

waste. RA is an autoimmune disorder affecting individuals with a genetic predis-

position who are exposed to an appropriate antigenic stimulus. Once started, the

disease appears to be self-perpetuating. Irreversible destruction of the joint occurs

when granulation tissue invades subchondral bone, tendons, and joint capsule

(Anthony & Thibodeau 1992). Conventional treatment is with nonsteroid anti-

inﬂammatory drugs, such as ibuprofen, dexamethasone drugs, and cytotoxins.

As rheumatoid arthritis affects speciﬁc joints, these areas of the body lend

themselves to the use of compresses. As well as being of great topical comfort and

focusing attention on the affected area of the body (unlike taking a pill), com-

presses allow essential oils to be absorbed through the skin directly to the site of

pain and inﬂammation. A combination of application methods is usually beneﬁ-

cial, for example, a morning compress and evening bath (which can be a hand- or

foot-bath). It is important to choose the application method to suit the patient.

The whole process of preparing and treating an injured or painful area of the body

carries with it strong placebo effects and mind-body links, which may enhance

the efﬁcacy of the treatment. Of course, some of the essential oil will also be in-

haled, producing a more instant effect. Using aromatherapy in this way we are as-

sisting the body’s own self-healing mechanisms by drawing on the antiinﬂamma-

tory and analgesic properties of essential oils, as well as their ability to reduce

stress and thereby impact the immune system.

Chapter 20 Immunology 313

Essential oils have some of their most poignant antiinﬂammatory effects

at the level of dermis and epidermis (Boyles 2000). Sawada et al (1980) explored

the activity of euglobal III in a hexane extraction of Eucalyptus globulus and found

it inhibited granulation tissue, which forms inappropriately in cases of RA.

Euglobal III has the structure of a bicyclic sesquiterpene, so Eucalyptus globulus

may be a useful essential oil to try. Inﬂammation in RA is caused by an increased

ﬂow of blood to the affected area, bringing with it heat, swelling, and pain (Mills

1991). (For more information please see section of Chapter 12 on inﬂammation.)

I have found a mixture of essential oils that addresses each of these three symp-

toms can be helpful. Choose cooling, astringent, and analgesic essential oils, as

well as those that have antiinﬂammatory properties (Tables 20-2 and 20-3).

Sometimes heating inﬂammation can have a more soothing effect than cooling.

Some sesquiterpene lactones have powerful antiinﬂammatory properties because

they inhibit cellular response (Mazor et al 2000).

314 Section II Clinical Use of Aromatherapy

Table 20-2 h Antiinﬂammatory Components of Some Common

Essential Oils

Antiinﬂammatory

Common Name Botanical Name Component(s) Reference(s)

German Matricaria recutita Bisabolol, Carle & Gormaa

chamomile chamazulene 1992, Safayhi

et al 1994

Helichrysum Helichrysum italicum Italidiones Franchomme &

subsp. serotinum Penoel 1991

Rosemary Rosmarinus ofﬁcinalis 1,8-cineole Juergens et al

CT cineole 1998

Black pepper Piper nigrum Beta-caryophyllene Tambe et al

1996

Table 20-3 h Analgesic Components of Some Common Essential Oils

Analgesic

Common Name Botanical Name Component(s) Reference

Lavender Lavandula Linalyl acetate, Re et al 2000

angustifolia linalool

West Indian Cymbopogon Myrcene Lorenzetti et al 1991

lemongrass citratus

Peppermint Mentha piperita Menthol Tyler et al 1988

Turkish oregano Origanum onites Carvacrol Aydin & Ozturk 1996

Brazilian mint Mentha X villosa Rotundifolene Almeida et al 1996

Rheumatoid arthritis may be eased by cooling or by heat. Patients will know

which they ﬁnd most comforting. Using a cold (or hot) compress can augment

the effect of essential oils. If a patient says heat helps relieve the pain, add a drop

of an essential oil with vasodilatory properties such as Piper nigrum (black pep-

per) or clove to bring heat to the affected area. If the patient prefers a cooling ef-

fect, add Mentha piperita (peppermint) to cool the area. In all cases, it is impor-

tant to allow patients to choose the essential oils. Let them smell the mixture

before it is applied to their skin; after all, they will have to live with it! The “m”

technique can be a useful method of applying oils.

HIV and AIDS

The prevalence of human immunodeﬁciency virus (HIV) and acquired immune

deﬁciency syndrome (AIDS) continues to rise in the United States and in many

other parts of the world. In June 1999, the number of people living with

HIV/AIDS in the United States was 950,000 (UNAIDS 2001). It is estimated

that every minute, ﬁve people between the ages of 10 and 24 become infected

with HIV somewhere in the world (Sowell et al 1999). As HIV does not have

to be reported in many countries, the estimate is conservative (Beal & Nield-

Anderson 2000). Approximately 50% of people with HIV or AIDS are using

complementary and alternative medicine (CAM) to treat their illness (Dwyer et

al 1995). Initially, HIV-infected people or those who had progressed to AIDS

used CAM therapies thought to have immunostimulatory or antiviral properties

(Elion & Cohen 1997). However as antiretroviral drugs became more successful,

patients began choosing to add CAM to their conventional regimes for speciﬁc

symptom relief (Targ 2000). Commonly used therapies were acupuncture for pain

(Shlay et al 1998) and massage therapy (Ironson et al 1996) and herbal supple-

ments to boost immunity (Coss et al 1998). Although aromatherapy is a lesser-

known complementary therapy, it has much to offer in HIV/AIDS treatment in

terms of control of resistant infections, altering perceptions of pain, and the feel-

good factor.

There has been a tremendous increase in research into plants that could be

of value in the treatment of patients with HIV and AIDS. Some research has in-

volved speciﬁc plants that could inhibit reverse transcriptase production of spe-

ciﬁc tumours (Kusumoto et al 1992), while other research has concentrated on

additional antitumor and antiHIV agents (Cardellina & Boyd 1995). Many of

these studies have shown encouraging results, although the research is still in its

preliminary stages (Nakashima et al 1992; Mahmood et al 1993; De Tommasi et

al 1991; Schols et al 1991). Water and methanol extracts (not essential oil) of Rosa

damascena exhibited moderate antiHIV activity in a paper by Mahmood et al

(1996). Rosa damascena was found to reduce the maturation of the infectious

progeny virus due to selective inhibition of the viral protease. However, to date

it is aqueous extracts rather than the essential oils that have been investigated.

Yamasaki et al 1998 examined 45 aqueous herbal extracts from the Labiatae fam-

ily. Melissa ofﬁcinalis, Mentha piperita var. crispa (grapefruit mint), Ocimum

Chapter 20 Immunology 315

basilicum var. cinnamon, and Satureja montana showed potent antiHIV activity (at

a dilution of 16 g/ml).

Hypericin and pseudohypericin, components of Hypericum perforatum (St.

John’s wort), were found to be effective against HIV in vitro (Meruelo et al 1988).

However, the 1999 phase-1 study of 30 HIV-infected people with CD4 counts

lower than 350 cells/mm

found 48% of the subjects could not tolerate the severe

phototoxic side effects (Gulick et al 1999). This could be because the two

chemical components (hypericin and pseudohypericin) had been isolated from

the whole plant. In the case of essential oils (and herbs in general), when a com-

ponent is removed from the whole plant and used on its own, the results can be

skewed. A clear example of this is lemongrass. Citral is an aldehyde that makes

up 85% of lemongrass. When citral is removed from lemongrass and used at 50%

dilution on the skin, it can cause erythema. However, if the whole essential oil is

used, a 50% dilution will not result in erythema. This is because lemongrass also

contains d-limonene, a terpene that appears to have a “quenching effect,” so no

burning occurs (Tisserand & Balacs 1995).

There is no published research on the effects of essential oil of Hypericum

perforatum on the AIDS/HIV, but the essential oil is being used for depression.

New studies contraindicate the use of St. John’s wort with protease inhibitors, and

the essential oil might also need to be avoided (Breckenridge 2000). However,

while the essential oil does not contain hypericin and pseudohypericin, it does

contain quercetin, a pentahydroxyﬂavone (Wells 2001) that gives the essential oil

its dark-red color. Quercetin is noted by Duke (1992) as having in-vitro antiHIV

properties (inhibitory concentration  1 g/ml), which indicates the essential

oil could be an interesting new avenue for antiretroviral research.

Opportunistic infections can cause morbidity and death in people with HIV

(Torres 1993), but there is in-vitro evidence that candidiasis, cryptococcosis, her-

pes simplex, and tuberculosis (TB) are sensitive to speciﬁc essential oils. Because

candidiasis, herpes, and TB have been covered in other sections, this section will

concentrate on cryptococcosis.

Remember, the strength of aromatherapy lies in its feel-good factor and its

ability to alleviate symptoms of HIV/AIDS and the side effects of conventional

medicine rather than any ability to cure the underlying disease.

Cryptococcosis

This yeast infection is spread from pigeon droppings and begins as a sporadic dis-

ease manifesting with lung infestation. From the lungs, yeast cells migrate to the

central nervous system and brain via the blood. Standard treatment is ﬂuconazole,

itroconazole, or amphotericin B encapsulated in liposomes (Cordonnier 1993).

However, clinical resistance occurs fairly quickly.

Sixty percent of essential oils are known to possess antifungal properties

(Deans et al 1989), and aromatherapy is particularly suitable for lung treatment.

When essential oils are inhaled they directly target the affected area and do not

316 Section II Clinical Use of Aromatherapy

need to be digested as oral medication. Electrical or battery-operated diffusers and

nebulizers are the most effective ways of getting essential oils into the lungs. Neb-

ulizers are a very suitable method of treatment for lung infestations of yeast, fungi,

or bacteria as they ﬁll the air with a very ﬁne mist of micromolecules of essential

oil, and they can be programmed to come on and off at speciﬁc times. For recom-

mended distributors of essential oils and nebulizers, please see Appendix IV.

Effective Essential Oils

Voillon and Chaumont (1994) tested the susceptibility of a strain of Cryptococcus

neoformans isolated from the blood of a patient with AIDS to 25 essential oils and

17 separate chemical constituents found in essential oils. Antifungal activity was

tested by dilution method on solid Sabouraud dextrose agar DIFCO with chlo-

ramphenicol 0.005%. (The presence of chloramphenicol assured the inhibition of

possible pollution by bacteria that could confound the results.) Ten l of Cryp-

toccocus neoformans from the patient’s blood was spread on the culture. (A l is a

microliter or a millionth of a liter.) Cells were counted and the plates incubated

at 37° C for 48 hours. Then the minimum inhibitory concentration was measured.

Many of the essential oils used showed good fungistatic action. The best ef-

fects were from palma rosa, geranium, savory, sandalwood, thyme, marjoram, and

lavender. These are all common, inexpensive essential oils. What was interesting

about this study was that lavender and sweet marjoram, two essential oils previ-

ously been found to be ineffective against Cryptococcus neoformans on fungal

growth in vitro, were very effective when the fungus was isolated from infected

human tissue. This appeared to agree with the ﬁndings of Dr. Jean Valnet (1990),

who said the terrain of the patient is very important in control of infection.

Due to the high volatility, Voillon and Chaumont (1994) hypothesized es-

sential oils would be effective against pulmonary cryptococcosis, would easily

penetrate into the tissues due to their low molecular weight, and would easily

reach the cerebral spinal ﬂuid in cases of meningitis. The researchers further hy-

pothesized essential oils would be less toxic than conventional drugs as they have

fewer side effects.

Lemongrass, Eucalyptus globulus, palma rosa, and peppermint were the most

effective essential oils tested against Cryptococcus by Pattnaik et al (1996). Lemon-

grass was effective not only against Cryptococcus but against 11 other fungi tested

in low dilutions. Minimum inhibitory concentration for each of the four essential

oils against Cryptococcus was 5l/ml

-1

. While the way essential oils work as fungi-

cides is not completely clear, it seems metabolism and growth of the fungus is in-

hibited, often with a breakdown in the lipid part of the membrane, resulting in

increased permeability and/or rupture (Larrondo & Calvo 1991). The main con-

stituent of lemongrass is citral, and Larrondo and Calvo (1991) have compared

the topical and inhaled action of citral to the systemic effects of clotrimazole.

Patchouli was found to be effective against Cryptococcus and 16 other patho-

genic fungi and commensal bacteria in a study by Yang et al (1996). In this in-

vitro study, essential oil of patchouli from three different countries, China, In-

Chapter 20 Immunology 317

donesia, and India was compared. Interestingly, only the Chinese patchouli was

effective against Cryptococcus neoformans. This was attributed to the higher con-

tent of patchouli alcohol (41%) as compared to 20%-23% in the Indonesian and

Indian essential oils. These ﬁndings underline the importance of knowing the

chemistry of the essential oil. In this case, the chemistry was directly related to

where the plant was grown.

Soliman et al (1994) tested essential oil of rosemary (Rosmarinus ofﬁcinalis).

They investigated the essential oil distilled from two plants growing in different

climatic conditions. They found both rosemary essential oils were effective

against Cryptococcus neoformans in vitro and recommended either essential oil as

an effective treatment in AIDS patients with cryptococcal meningitis and pneu-

monia. While both rosemarys were effective, it could have been a different chem-

ical component in each oil that contributed to the success of the study.

Eugenol is a phenolic component found in several essential oils. An in-vitro

study found it to be effective against 33 strains of Cryptococcus neoformans using

isolates from human patients (Boonchild & Flegel 1982). The researchers con-

cluded eugenol would be effective against cutaneous mycoses, but toxicity tests

excluded the use of eugenol as a systemic agent. As a phenol, eugenol would not

be suitable for extensive use on the skin as it can be irritating and is hepatotoxic

(Schnaubelt 1999). Eugenol is found in clove and savory, two essential oils to be

used with caution on the skin but they could be used in small amounts in a neb-

ulizer. Table 20-4 lists essential oils used in the treatment of infections of Cryp-

tococcus neoformans.

318 Section II Clinical Use of Aromatherapy

Table 20-4 h Essential Oils for Treating Infections

of Cryptococcus neoformans

Common Name Botanical Name Reference

Rosemary Rosmarinus ofﬁcinalis Soliman 1994

Palma rosa Cymbopogon martini Viollon 1994

Geranium Pelargonium graveolens Voillon & Chaumont 1994

Marjoram Origanum majorana Voillon & Chaumont 1994

Sandalwood Santalum album Voillon & Chaumont 1994

Lemongrass Cymbopogon citratus Voillon & Chaumont 1994

Eucalyptus Eucalyptus globulus Voillon & Chaumont 1994

Patchouli Pogostemon cablin Voillon & Chaumont 1994

Basil Ocimum basilicum Voillon & Chaumont 1994

Cypress lavender Santolina chamaecyparissus Suresh 1995

Patients with HIV and AIDS are especially appreciative of touch and smell.

I have found that Boswellia carterii (frankincense) is particularly useful. It seems

to help even the most defensive patient to open up, often with tears of release.

Citrus aurantium (neroli) and Rosa damascena (rose) both have wonderful aromas

that most patients like. However, if the aroma seems too ﬂowery, Origanum mar-

jorana (sweet marjoram), Angelica archangelica (angelica root), or Santalum album

(sandalwood) are often acceptable alternatives.

Diarrhea is often a problem in the immune-compromised patient. Several

studies have indicated the oral use of essential oils might be one way of control-

ling this debilitating symptom. Hajihashemi et al (2000) found essential oil of Sa-

tureje hortentis (given orally) was effective against diarrhea in mice. Oraﬁdiya and

Elujoba (2000) conducted a controlled, in-vivo study with mice and found Oci-

mum gratissimum (Holy basil) to be an effective agent against diarrhea. The es-

sential oil reduced fecal output in a dose-dependent manner, with the highest

dose of 7.91 g/ml similar to the action of the control, loperamide (an opioid that

inhibits perastalsis), but at a fraction of the cost.

In a study on humans, a British physician (Gravett 2001) found that oral

doses of essential oils were as effective as conventional medication (codeine phos-

phate 120 mg and Buscopan 20 mg) in high-dose chemoinduced diarrhea. Eighty

patients were randomly allocated into two groups. The experimental group took

an essential oil blend: 15 drops of geranium, 10 drops of German chamomile, and

10 drops of patchouli which were mixed with tumeric phytol and divided into

three portions. The three portions were blended into warm water and honey and

taken three times a day. There was no difference in overall duration of hospital-

ization but the diarrhea in patients who took the essential oils was marginally less.

The cost of the aromatherapy treatment was about 40 cents a day compared to

more than $4 a day for conventional treatment. Finally, Lavandula intermedia CT

grosso was found to be effective against nontubercular opportunistic mycobac-

terum in a sternal wound (Gabrielli et al 1988).

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322 Section II Clinical Use of Aromatherapy

323

Obstetrics and Gynecology

Aromatherapy is a relatively modern name for an ancient holistic practice.

Aromatherapy gives us something that is sometimes lacking in other alternative

practices: quite simply, it has the power to make us feel good.

Romy Rawlings (1999)

Healing Gardens

Aromatherapy and Pregnancy

The use of essential oils during pregnancy is controversial, but most fears are un-

founded (Guba 2002). Some aromatherapy schools condone the use of essential

oils in pregnancy during the ﬁrst trimester, and some question their use at all.

Since the thalidomide tragedy, expectant mothers and their physicians have been

extra cautious of using anything that could have an adverse effect on the unborn

child or the security of the pregnancy. However, essential oils have been used

safely for hundreds of years by thousands of pregnant women in the form of per-

fumes, bath essences, and scented soap.

There are no records of abnormal fetuses or aborted fetuses due to the “nor-

mal” use of essential oils, either by inhalation or topical application. There are no

records of a few drops of essential oil taken by mouth causing any problems ei-

ther. However, there are a handful of records that link two speciﬁc essential oils,

pennyroyal and parsley seed, to abortion. The amount of essential oil (taken by

mouth) was extremely high—several milliliters at one time—which caused hepa-

totoxicity. This meant the body was unable to maintain the pregnancy. However,

there were two other cases recorded where the same amount of pennyroyal taken

by mouth did not result in the fetus being aborted, and the mothers recovered.

The amounts taken varied from 10 ml (in the case of pennyroyal) and 1.5-6 ml

for 8 consecutive days (parsley seed). This is between 100 to 200 times greater

than the normal amount of essential oil used in aromatherapy. (Usually only one

to ﬁve drops are applied topically to the skin or inhaled.) For internal use, the nor-

mal amount is 0.5-10 ml per day (Brinker 2000). The volume of one drop of es-

sential oil is equivalent to 0.05 ml. This works out to between 10 and 20 drops

per day. There are approximately 20 drops in a milliliter.

There is only one essential oil compound, sabinyl acetate, that has been

shown to have teratogenic effect in laboratory animals (Guba 2002). Sabinyl ac-

etate comprises 20% of savin (Juniperus sabina) and less than 10% of Spanish sage

(Salvia lavandulifolia). Both essential oils should be avoided in pregnancy and

have no aromatherapeutic use. More information on these oils is given in Chap-

ter 4.1 on toxicity.

There are several books available that cover the use of essential oils in preg-

nancy, including two good ones written by midwives: Aromatherapy in Midwifery

Practice by Tiran (1996) and Aromatherapy for the Mother and Baby by England

(1994). England attends 2500 deliveries annually, and Tiran is a lecturer in mid-

wifery at the University of Greenwich. In the United Kingdom, essential oils have

been used during pregnancy and delivery at many hospitals for approximately 15

years, and expectant mothers often appear at the delivery suite with their own box

of essential oils especially chosen for the birth of their child. Essential oils have

been used at Hinchingbrooke Hospital, Huntingdon, St John’s, and St Elizabeth’s

Hospitals in London and at the Radcliffe Inﬁrmary in Oxford, England, since

1987. It would be expected that any adverse effects would have appeared by now.

However, it is always best to err towards caution, and there is no need to use large

amounts of essential oils. Nonetheless, when used correctly, essential oils are very

safe in pregnancy. These substances can give the expectant mother a sense of em-

powerment, reduce the annoying side effects of pregnancy, and can help make her

feel beautiful. If there is a choice between a synthetic chemical (with no studies on

long-term effects) or an essential oil (with hundreds of years of use) it would be

judicious to choose the latter. Aromatherapy can be helpful for many symptoms of

pregnancy: general tiredness, aches and pains, nausea, insomnia, and backache.

Some essential oils are thought to have emmenagogic actions, meaning they

cause tiny uterine contractions and can bring on a menstrual period early. How-

ever the hormonal and physical effects of pregnancy are quite different from those

of the menstrual cycle, and Guba (2002) suggests the topical or inhaled effect of

emmenagogic essential oils will not compromise a stable pregnancy. There is con-

ﬂicting information on exactly which essential oils are emmenagogic. Some au-

thors believe Lavandula angustifolia is emmenagogic but also state it is safe to use

in the ﬁrst trimester (England 1994).

It is extremely unlikely that a secure pregnancy will be compromised because

a mother has used an emmenagogic essential oil. Babies are difﬁcult to dislodge in

a secure pregnancy. However, if the mother has had a previous miscarriage, it

would be prudent to avoid aromatherapy especially after the ﬁrst trimester. Brinker

(2000) suggests avoiding angelica, Roman chamomile, cinnamon, any citrus,

myrrh, lemongrass, hyssop, lavender, German chamomile, melissa, peppermint,

324 Section II Clinical Use of Aromatherapy

basil, oregano, black pepper, rosemary, sandalwood, vetiver, and ginger. However, I

have several friends who used aromatherapy throughout their pregnancies. They

have all been uneventful and have produced beautiful babies.

One of the most signiﬁcant medical events for a pregnant woman is the de-

velopment of pregnancy-induced hypertension (PIH) and its more severe com-

plications: preeclampsia and HELLP syndrome (hemolysis, elevated liver en-

zymes, and low platelets). The patient usually presents with epigastric pain and

blood pressure may or may not be elevated. HELLP is a variant of preeclampsia

and eclampsia.

Pregnancy-Induced Hypertension (PIH)

This condition occurs in 7%-10% of all pregnancies and causes 15% of maternal

deaths. Women who have a history of hypertension before pregnancy are twice as

likely to develop PIH. PIH can also lead to intrauterine fetal death through pla-

cental insufﬁciency. Orthodox treatment is bed rest with the feet elevated and in-

travenous magnesium sulphate. If the blood pressure does not come down to lev-

els below 150-110/110, labetalol, an alpha- and beta-adrenergic blocking agent,

is given. A blood pressure of 150-160/100-110 constitutes severe preeclampsia,

calling for antihypertensives (hydralazine or labetalol). Common side effects are

drowsiness, fatigue, pulse slower than 50 beats per minute, and nausea. The

mother is kept quiet in a darkened room. However, her mind is unlikely to be

quiet! At such a terrifying time, smell and touch can do much to help reassure a

woman, and reassurance can play an important role in this situation.

Nathan (2000), a midwife on Long Island, New York, used aromatherapy to

help a mother whose blood pressure remained above 200/100 despite intravenous

medication. The patient was continuously monitored for blood pressure and

pulse. Unable to control the hypertension, the attending physician asked Nathan

if she would try aromatherapy. After verbal consent from the patient, Nathan

used a 2% solution of Lavandula angustifolia in a hand “m” technique. Slowly the

blood pressure began to come down. After 15 minutes it was 150/85. The fetal

heart rate also improved, from mid 150s to mid 130s. Within 1 hour, the mother’s

blood pressure was 140/85. The patient was given 5 minutes of “m” technique

with dilute lavender every hour during the night, and her blood pressure was

maintained at 140/85. The mother was discharged 2 days later and went on to full

term. As a result of this case study, Nathan carried out a small project on eight

hypertensive patients in her maternity unit in 2000. Each patient chose rose or

lavender essential oil and received a 5-minute “m” technique on the hand. This re-

sulted in a measurable drop in blood pressure for each patient.

Essential Oils in Labor

Swingle (2001) carried out a study at the Newborn Family Center in Chenango

Memorial Hospital in Norwich, New York, on 25 laboring mothers. Four essen-

tial oils, lavender, geranium, frankincense, and clary sage, were used in 1% dilu-

tion. The oils were used from early labor through delivery. Each essential oil was

Chapter 21 Obstetrics and Gynecology 325

used for speciﬁc reasons. Lavender was used for relaxation, to relieve backache,

and to help expel the placenta, and was successful on all counts. Geranium was

used to decrease perineal swelling and to relieve hemorrhoids; it was also suc-

cessful. Clary sage was used to stimulate contractions but was not found success-

ful. Frankincense was used successfully for extreme anxiety between transition

and the second stage of labor. There were no side effects from any of the essen-

tial oils used and everyone commented on their nice aromas.

Adams (2000) carried out a controlled study on the use of lavender to reduce

patient anxiety when labor was induced at Desert Samaritan Hospital in Mesa,

Arizona. One or two drops of lavender were inhaled continuously, or at will, from

a cotton ball. Each of the 23 patients self-evaluated her anxiety level before the

lavender and 30 minutes after the lavender. The levels of evaluation were as fol-

lows: very nervous, nervous, OK, calm, and very calm. The lavender group had a

greater perception of reduced anxiety than the control group. Two subjects com-

mented that their headaches went away when they inhaled lavender. All had pos-

itive comments. The attending nurses’ comments ranged from “patient slept after

lavender,” to “more calm, much more mellow,” to “less anxious, physician very

pleased with effects of lavender.”

Burns et al (2000) evaluated the effect of aromatherapy on 8058 mothers

during an 8-year period (see Table 21-1 for a list of the essential oils used). Moth-

ers in labor were offered aromatherapy to relieve pain, anxiety, or nausea or to

strengthen contractions. Data from the unit audit were used to provide a com-

parison group of mothers not given aromatherapy (n  15.799). Aromatherapy

was offered by a core group of midwives who followed guidelines laid down by a

qualiﬁed aromatherapist.

326 Section II Clinical Use of Aromatherapy

Table 21-1 h Essential Oils Used in Burns et al (2000) Study

Common Name Botanical Name

Rose Rosa centifolia

Lavender Lavandula angustifolia

Jasmine Jasminum grandiﬂorum

Roman chamomile Chamaemelum nobile

Blue gum Eucalyptus globulus

Mandarin Citrus reticulata

Clary sage Salvia sclarea

Frankincense Boswellia carteri

Peppermint Mentha piperita

Lemon Citrus limonum

More than 50% of the mothers found aromatherapy useful. Only 14% of

mothers found it unhelpful. The number of adverse symptoms reported was low

(1%) and included symptoms commonly found in labor such as headache, nausea,

and itchy rash. Aromatherapy was typically used by mothers in established labor

(60%) or in the latent stage (29%). Of the women who used aromatherapy, 32% had

their labor induced. Fewer women needed pain relief in the aromatherapy group

than the control group, and fewer epidurals were given. During the 8 years of study,

the use of pethidine declined. In 1990, 13% of mothers used pethidine. By 1997,

use had dropped to less than 0.2%. Frankincense was found to be the most effec-

tive essential oil for pain. Rose was found to be the most helpful for anxiety (71%).

Peppermint was found to be the most effective for nausea (96%). Aromatherapy did

not appear to augment contractions. However, 70% of multigravidae in dysfunc-

tional labor did not require an oxytocin infusion, and 92% of the mothers went on

to spontaneous vaginal delivery. This is an unusually high ﬁgure. Only 36% of

women said they found aromatherapy helped strengthen their contractions, and the

most commonly offered essential oil for this was clary sage (87%).

Vaginal Infections

Yeast Infections

Vaginal yeast infection, caused by Candida albicans, is a common nuisance factor

in many women’s lives. It thrives in an acid environment and is sometimes the

side effect of antibiotics, or it may occur during pregnancy or when a woman is

immune compromised. It is often messy, uncomfortable, and embarrassing and

can reappear with depressing regularity. Antifungal drugs such as Terazol and

Femstat may only bring temporary relief. Other over-the-counter preparations

can be purchased, although some forms of this yeast infection have become resis-

tant to many of the orthodox preparations on the market (Goldway et al 1995).

Candidiasis is uncomfortable and often makes the sufferer feel powerless to cope

with it. However there is one essential oil that may eradicate this fungal infection

permanently and within only a few days (Belaiche 1985). It is called tea tree.

Belaiche (1985) wrote about its effect on vaginal infections 15 years ago.

Tea tree is the name of all species of Melaleuca, Leptospermum, Kunzea, and

Baeckea plants (Guenther 1972). In other words, specifying tea tree is not enough,

as it covers several hundred different plants. In New Zealand, Leptospermum

ﬂavescens is also known as tea tree, but this is a completely different genus, al-

though it belongs to the same family (Myrtaceae) as tea tree. The tea tree needed

to treat vaginal infections is Melaleuca alternifolia. The Australian government has

set standards for the amount of terpineol (an alcohol) and 1,8-cineole (an oxide)

in tea tree. Some tea tree imitations are available that contain high levels of 1,8-

cineole. Occasionally oxides can be uncomfortable when applied to irritated or

abraded vaginal tissue. To avoid this, make sure the bottle of essential oil includes

the botanical name, and purchase it from a reliable source. The functional group,

Chapter 21 Obstetrics and Gynecology 327

alcohols, is kinder on abraded vaginal tissue. The levels of 1,8-cineole and terpi-

neol will show up on a gas chromatograph/mass spectrometer.

Mix two or three drops of Melaleuca alternifolia in 5 ml of cold-pressed veg-

etable oil, like oil of evening primrose or sweet almond oil. Roll a tampon in the

mixture and then insert into the vagina. The simplest method is to mix the es-

sential oil and vegetable oil on a saucer and then roll the tampon in the mixture

until it is saturated. The tampon should be changed three times a day for a new

tampon with a fresh dilution of carrier oil and tea tree. The tampon also needs to

remain in situ overnight. It will not lead to toxic shock syndrome. This is a very

safe and effective method of eradicating candidiasis and many other vaginal in-

fections, and there appear to be no adverse side effects. However, a word of cau-

tion should be given. If the yeast infection has exposed, raw areas in the vaginal

wall, Lavandula angustifolia diluted in vegetable oil should be used ﬁrst. It can be

applied in exactly the same way, on a tampon, for 1 or 2 days until the excoriated

area has healed. This method has been used successfully in pregnancy with no ad-

verse effects to the mother or baby. Having suggested this treatment to many pa-

tients and colleagues over the last 10 years, I am conﬁdent Melaleuca alternifolia

should remove the infection within 3 days, regardless of how long the patient has

had the infection. Table 21-2 lists essential oils effective against Candida albicans.

328 Section II Clinical Use of Aromatherapy

Table 21-2 h Essential Oils Effective against Candida albicans

Common Name Botanical Name Reference

Melaleuca alternifolia

Mentha piperita

Cymbopogon martinii

Eucalyptus globulus

Cymbopogon citratus

Pelargonium graveolens

Pimenta racemosa

Vetiveria zizanoides

Santolina chamaecyparisus

Melissa ofﬁcinalis

Rosmarinus ofﬁcinalis

Lippia alba

Picea albies

Belaiche 1985, Pena 1962

Carson & Riley 1994

Pattnaik et al 1996

Chaumont & Bardy 1989,

Viollon et al 1993

Chaumont & Bardy 1989

Suresh et al 1997

Larrondo & Calvo 1991

Soliman et al 1994

Stiles et al 1995, Kartnig et al

1991

Tea tree

Peppermint

Palma rosa

Eucalyptus

Lemongrass

Geranium

Bay

Vetiver

Santolina

Melissa

Rosemary

Lippia

Austrian pine

Bacterial Infections

Bacterial Vaginosis

Bacterial vaginosis (BV) is a polymicrobial vaginal infection that affects

women of reproductive age (Cook et al 1992). Many of the bacteria, such as Pep-

tostreptococcus, are anaerobic and appear to replace the normally predominant Lac-

tobacilli. One of the main symptoms is copious, smelly discharge, often reducing

a woman to tears of frustration. The ﬁshy smell is from the amine compounds

produced by anaerobes. There is no inﬂammatory reaction, so there are no white

blood cells in the discharge. Orthodox treatment is oral Metronidazole, which

usually results in normal ﬂora and reduction of symptoms but often produces un-

pleasant side effects such as gastrointestinal upsets or unpleasant taste. A second

treatment is topical clindamycin cream (Cleocin). The cost of a tube of Cleocin

vaginal cream is high, approximately $50 for one-week supply. In 40% of cases

treated with oral Metronidazole, BV recurs within 3 months (Cook et al 1992).

Walsh and Longstaff (1987), Shapiro et al (1994), and Carson and Riley (1993),

tested tea tree against fusobacteria, Prevotella, and Peptostreptococcus bacteria by agar

and broth dilution, and all came up with comparable data. Whereas the previously

mentioned bacteria were susceptible, Lactobacilli were more resistant to tea tree, sug-

gesting that Melaleuca alternifolia could help restore the acid of the vagina and make

it more resistant to pathogenic bacteria. Blackwell (1991) treated a patient with BV

using Melaleuca alternifolia vaginal pessaries with good results. Self-medication with

alternative medicine is common among women with chronic vaginal symptoms

(Nyirjesy et al 1997), and diluted tea tree in cold-pressed carrier oil on a tampon can

be a very effective treatment. Diluted tea tree is pleasant to use and empowering to

the patient. It smells pleasantly antiseptic, and the tampon application makes the

vagina feel fresh. Usually, symptoms will disappear within one week.

Trichomonasas

Trichomonas vaginalis is a bacterial infection that causes inﬂammation of the

vaginal mucosa accompanied by an unpleasant, pungent discharge. The sufferer is

embarrassed and frequently complains of “feeling dirty.” Conventional treatment

is with systemic or cream Metronidazole. This is expensive. Humphrey suggested

tea tree for trichomonasas as long ago as 1930, and it was found effective by Pena

(1962). Diluted tea tree in cold-pressed carrier oil on a tampon is an effective

treatment. Usually, the bacteria will be gone within one week.

Because the vagina is situated closer to the urethra and essential oils are ab-

sorbed through the walls of the vagina, this is an excellent way of treating cysti-

tis. Essential oils can be absorbed systemically from vaginal application.

Dysmenorrhea

The menstrual cycle is delicately balanced and can easily be thrown out of

equilibrium by stress, illness, or a poor diet. Primary dysmenorrhea manifests

symptoms such as low-abdominal cramping that starts just before or with the

Chapter 21 Obstetrics and Gynecology 329

menstrual ﬂow. This is often associated with nausea, vomiting, headache, and

faintness. Secondary dysmenorrhea usually affects older women who have symp-

toms of congestion and aching associated with low-abdominal cramps that typi-

cally start up to one week prior to menstruation (McFerren 1996). There are

two ways to approach dysmenorrhea using aromatherapy, physically and psycho-

logically.

To address physical symptoms, use a mix of essential oils known for their an-

tispasmodic, hormonal balancing, or analgesic properties (Table 21-3). Many es-

sential oils have antispasmodic properties. Roman chamomile contains more es-

ters than any other essential oil (up to 310 including those from angelic and tiglic

acid) and is thought to be one of the most antispasmodic essential oils available

(Evans 1994). It is also a recognized analgesic (Wren 1988). Han et al (2002) car-

ried out a placebo-controlled study on 85 nurses with dysmenorrhea, using rose,

clary sage, and lavender in 3% dilution applied to the abdomen. The mixture re-

duced the severity of symptoms signiﬁcantly.

Some essential oils have topical analgesic effect (Table 21-4). Those that are

high in phenols such as clove may be too aggressive to apply to the skin of the

lower abdomen except in very low dilutions and are best avoided.

Geranium is thought to encourage regular ovulation (Belaiche 1979a) and

has been used for generations to balance ﬂuctuating hormonal levels during

menopause through its action on the adrenal cortex (Holmes 1993). Add a few

drops of geranium (Pelargonium graveolens) to the mixture and rub it gently into

the lower abdomen and lumbar area. The best geranium oil comes from Reunion

Island and is usually called Bourbon. For optimum results, repeat the mixture

every hour until dysmenorrhea symptoms have subsided.

Compresses can bring great comfort when applied to the low abdomen. A

hot-water bottle has been an effective remedy for period pains for eons. Placed on

330 Section II Clinical Use of Aromatherapy

Table 21-3 h Antispasmodic Essential Oils for Dysmenorrhea

Common Name Botanical Name Reference

Roman chamomile

Petitgrain

Spearmint

Rosemary

Peppermint

Sage

Lavender

Summer savory

Franchomme & Penoel 1991

Reiter & Brandt 1985

Bulat et al 1999

Al-Sereiti et al 1999

Taddei et al 1988

Lis-Balchin & Hart 1999

Hajihashemi et al 2000

Chamaemelum nobile

Citrus amara fol

Mentha spicata

Rosmarinus ofﬁcinalis

Mentha piperita

Salvia ofﬁcinalis

Lavandula angustifolia

Satureja hortensis

top of an essential oil compress, it will encourage more rapid absorption of the

essential oils, as well as giving the added comfort of heat. This can really help

painful cramps. The whole process of tending a painful area topically brings with

it strong placebo and mind-body links that can only enhance the efﬁcacy of the

therapy.

Psychologically relaxing essential oils can be given in a full body massage or

“m” technique. This will focus attention on the body and its state of relaxation

(unlike taking a tablet). Of course, some of the essential oil will also be inhaled,

producing a psychological effect. Severe dysmenorrhea sometimes brings with it

nausea. Inhaling a little essential oil of peppermint or spearmint will alleviate this.

Aromatherapy, used in this way, works along with the body’s own self-regulating

mechanisms.

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Chapter 21 Obstetrics and Gynecology 331

Table 21-4 h Analgesic Essential Oils for Dysmenorrhea

Common Name Botanical Name Reference

Lavender

Lemongrass

Peppermint

Ghelardini et al 1999

Viana et al 2000

Gobel et al 1994

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Chapter 21 Obstetrics and Gynecology 333

334

Oncology

If one learns from others but does not think, one will be bewildered. If on the other

hand, one thinks but does not learn from others, one will be in peril.

Confucius

Analects, Book II

ancer affects approximately one person in three (Stevenson 1996) and is

the general term applied to a series of malignant diseases that may affect

different parts of the body (Dewick 1989). The possible causes of cancer

are many and range from electromagnetic and chemical pollution to genetic pre-

disposition and severe stress. According to the American Cancer Society, approx-

imately 550,000 Americans die each year from cancer (Lam 2001). At least half

of them are thought to suffer symptoms such as pain, nausea, and emotional dis-

tress that conventional medicine either does not or cannot treat (Okie 2001).

Cancer has been around for a million years; traces of it were found in mummies

from the Great Pyramid at Giza (Lewis & Elvin-Lewis 1977). Humans do not

have a monopoly on the disease, as higher-order animals also suffer from cancer.

The three main orthodox treatments for cancer are surgery, radiation, and

chemotherapy agents. These treatments have saved lives but have been hard to

endure. Now, some of those treatments are being questioned. On May 17, 1999,

bone-marrow transplants received controversial press following an announcement

at the annual meeting of the American Society of Clinical Oncology in Georgia

that a multinational research program found “no evidence that bone marrow

transplants were any more beneﬁcial than chemotherapy in breast cancer” (Porter

1999). Five hundred twenty-ﬁve women in Scandinavia, 154 in South Africa, 553

in Philadelphia PA, and 61 in France took part in the randomized studies. The

researchers found that survival after bone-marrow transplants was 40%, not much

higher than a placebo.

Cancer-drug research has also had its share of bad publicity. Barlow (2001)

of the British Financial Times, wrote “clinical research into cancer drugs was

found to be eight times more likely to reach a positive conclusion when funded

by a drug company than when publicly funded.”

Aromatherapy and Cancer Treatment

Many plants and plant materials have been used to treat malignant diseases for

centuries. It is fascinating how the same plants keep being cited all over the world

for the treatment of cancer. For example, Dr. Fell completed a study of 25 cases

of breast cancer using the herb bloodwort at the Middlesex Hospital in London

in 1857. He chose bloodwort (Sanguinaria canadensis) because he learned it had

been used by American Indians for hundreds of years. Fell found all his cases

went into remission (Fell 1857). It is difﬁcult to establish whether this really hap-

pened, although Sanguinaria also has a long history of use in Russia for the treat-

ment of cancer (Lewis & Elvin-Lewis 1977).

Madagascan periwinkle (Catharanthus roseus) contains the alkaloids vinblas-

tine and vincristine, which have been useful in treating cancer (Dewick 1989).

More recently, Centella asiatica, sometimes called gotu kola or South African Pen-

nywort, was featured in an in-vitro study of cultured cancer cells. Centella appeared

to destroy 100% of the cultured cancer cells. When the study was conducted on

mice, Centella doubled the life span of mice with tumors. Centella has virtually no

toxic effect on normal human lymphocytes (Foster 1995). Centella asiatica can also

be obtained as an infused oil (phytol). Phytols are often used in aromatherapy and

are supplied by many essential-oil distributors.

Some essential oils, or components found within essential oils, have been

found to have antitumoral activity. Sclareol, a diterpenol in Salvia sclarea (clary

sage), was found to kill cell-lines of human leukemia and had an inhibitory con-

centration of lower than 20 (g/ml) (Dimas et al 1999). Delora et al (1994) found

myrrh had an anticarcinogenic effect on tumors induced in mice. Bergamottin, a

furanocoumarin found in bergamot (5%) and lemon (0.2%) was one of several

coumarins found to inhibit in-vitro tumor promoters (Miyake et al 1999).

Limonene is metabolized into perillyl alcohol by the body. Perillyl alcohol, a

monoterpenol also found in lavandin, peppermint, and spearmint, inhibited more

than 80% of all chemically induced breast cancers in animal studies (Haag &

Gould 1992) and was also found to regress pancreatic, mammary, and liver tu-

mors (Belanger 1998). Perillyl alcohol was found to have chemopreventative ac-

tivity against colon, skin, and lung cancer and to revert tumor cells to a differen-

tiated state. However, preliminary human trials have not demonstrated tumor

regression as of yet, but this could be because only part of an essential oil has been

used in isolation. It would be interesting to run the study using the complete es-

sential oil.

Chapter 22 Oncology 335

Treating Conventional Side Effects

The side effects of some conventional treatments for cancer can be very hard to

endure. Several of my friends are cancer survivors. I also had a small aromather-

apy private practice in England. My patients came by doctor’s referral or word of

mouth. Almost half of them had cancer, and the role of aromatherapy in their

treatment was one of support. The cancer patients were mainly undergoing

chemotherapy and radiation therapy following surgery and, without exception,

they found the going very tough. Many expressed their despair that conventional

medicine did not adequately address the unpleasant side effects of the cancer

treatment.

Several years ago, there was some controversy about the use of massage on

cancer patients, with the suggestion that massage could actually spread the dis-

ease (Goodman 1995). However, a study and rigorous review of the published lit-

erature indicates massage should not be contraindicated (McNamara 1994).

Bernie Siegel, MD, also states massage therapy is not contraindicated in a cancer

patient (Siegel 1996). Deep massage is rarely requested by an oncology patient.

What oncology patients usually prefer is a very light touch, more like stroking.

The “m”’ technique can be really valuable, particularly as it is so quick to learn and

to do and could be taught to family members and friends who are eager to help

but don’t know how.

Conrad (2000) investigated the effects of aromatherapy on a cancer support

group to see if diffused essential oils could decrease anxiety and encourage commu-

nication. Ten to 12 cancer patients met weekly. The preponderance was women, but

there were some men in the support group. Some individuals were receiving

chemotherapy or radiation therapy and some were 3- to 10-year survivors. Three es-

sential oils were chosen for their ability to calm and soothe. The study took six weeks.

During weeks one and two no essential oils were diffused, although the diffuser was

placed in the room and switched on. During weeks three and four, two drops of a

mixture of six drops lavender and four drops mandarin were diffused. During weeks

ﬁve and six, six drops of lavender and four drops of frankincense were diffused. The

diffuser was an AromaStream electric fan. Questionnaires were given to each of the

support group members with ﬁve simple questions. The questions ranged from

whether they could smell anything to whether they found communication more or

less difﬁcult. A Likert scale was used to tally the responses. The facilitator did not

know when the essential oils were being diffused or which ones were being used.

However the facilitator noticed major changes in the group when the essential oils

were diffused. During the lavender/mandarin week, there was more laughter and

sharing. The sessions seemed more ﬂuid and effortless. During the lavender/frank-

incense week, the group seemed more emotional and labile. There were more tears

than usual, and the group was challenging to facilitate. The participants recorded

they felt more relaxed when talking about difﬁcult subjects during the aromatherapy

weeks, particularly when the lavender/mandarin mixture was diffused.

336 Section II Clinical Use of Aromatherapy

Gravett (2001) reported on the effects of topically applied essential oils to an

infected Hickman arterial line. He used tea tree, Eucalyptus globulus, and lavender

(Lavandula angustifolia) in a 10% cream applied to the site twice a day. The con-

trol group received Povidone iodine spray, which is the standard treatment for an

infected line. Gravett notes that chemical antiseptic sprays can lead to cutaneous

sensitivity as well as to direct chemical damage and resistant organisms. Gravett

found that economically the essential-oil treatment was preferable and appeared

to work as well as the Povidone spray.

Researchers at Memorial Sloane Kettering Cancer Center in New York

used aromatherapy to reduce anxiety attacks of patients undergoing magnetic

resonance imaging. They diffused heliotropin and found it relieved anxiety

(Castleman 1996). Heliotropin is a close relative to vanilla. A pilot survey con-

ducted in 1995 showed a wide variety of cancer patients sought complementary

care therapy (Clover et al 1995). In a study involving two London hospitals, 16%

of patients who had received complementary therapies said they had wanted

them to gain emotional support and hope (Downer et al 1994). Perhaps aro-

matherapy can help during the “dark times,” and enhance the quality of care as

well as quality of life.

Nausea, constipation, depression, exhaustion, shooting pains, “feeling my

bones might break,” lymphedema, postradiation burns, hair loss, and insomnia are

possibly the most common side effects of radiation therapy and chemotherapy. Of

these symptoms, nausea, postradiation burns, hair loss, and lymphedema have

been selected for discussion in this chpater. As Dobbs, a British nurse, wrote

“complementary therapies may enrich our interventions and bring comfort and

better health to patients with cancer” (Dobbs 1985).

Nausea

The cytotoxic drugs used in chemotherapy for cancer have two well-known

side effects: nausea and immune supression (Bovbjerg et al 1990). One-third of

patients with cancer experience nausea and vomiting (Finlay 1995). Nausea is

common during radiation or chemotherapy treatment, and 24%-75% of patients

develop anticipatory nausea and vomiting during the course of repeated

chemotherapy (Bovbjerg et al 1990). Patients frequently report that everything

tastes different. They also say they are very sensitive to odors, often smelling

something they had not noticed before or feeling great distaste for a smell that

had not bothered them previously. While conventional medicine can be used in

the form of antiemetics, there are also essential oils that can reduce nausea. See

Table 22-1 for suggestions.

Just a few drops of one of the oils in Table 22-1 on a tissue can bring relief.

Sipping hot water with a sliver of ginger root can also frequently bring relief from

nausea and is a well-known remedy for morning sickness during pregnancy. A

more in-depth review of essential oils for nausea can be found in Chapter 11 on

nausea.

Chapter 22 Oncology 337

Patients receiving bone-marrow transplants frequently have to endure the

smell of dimethyl sulfoxide (DMSO). DMSO causes differentiation of malignant

bone-marrow cells (Toren & Rechavi 1993) and can help deliver anticancer sub-

stances to the site of the cancer (Wilner 1994). It also seems to enhance the ef-

fects of various cytotoxic agents while simultaneously reducing the toxicity of

conventional medication (Pommier et al 1988). Citrus essential oils such as lemon

and grapefruit are being used successfully to hide this aroma at Columbia Pres-

byterian Medical center in New York, according to my students. The essence of

oranges is a traditional treatment in Sicily for sea sickness.

Postradiation burns

Although most radiologists request nothing be put on the skin during

radiation, this is mainly to ensure the marks for radiation will not be removed

(Sheppard-Hanger 2000). It is extremely important that nothing should disturb

the marks. Maiche et al (1990) conducted their study (see following description)

throughout irradiation by applying a cream to the area before and after each ra-

diation treatment.

Before the area is marked, the skin can be prepared with undiluted naiouli

(Melaleuca viridiﬂora). This seems to toughen the skin and results in fewer and less

severe burns. Apply naiouli to the area three times a day for a week. Roulier (1990)

and Penoel and Franchomme (1990) both suggest using 50% naiouli immediately

before each radiation session and 50% in a St. John’s wort-infused oil or rosehip car-

rier oil after each session. Sheppard-Hanger (2000) also used spritzers of everlasting

(Helichrysum italicum) and blue tansy (Tanacetum annum) immediately following

each radiation treatment. Blue tansy is dark blue in color and high in chamazulene,

an antiinﬂammatory. Do not mistakenly use Tanacetum vulgare, another species of

Tanacetum. Tanacetum vulgare is yellow to pale blue and contains 60% thujone, a ke-

tone, and is not recommended for use in oncology or aromatherapy in general.

My patients have used tansy and everlasting in spritzers and also spritzers of

lavender and rose with good results. Yarrow and blue chamomile are also good

choices. Table 22-2 lists essential oils that can be used in post-radiation spritzers.

338 Section II Clinical Use of Aromatherapy

Table 22-1 h Essential Oils for Nausea

Common Name Botanical Name Reference

Peppermint

Ginger

Cardamom

Patchouli

Spearmint

Briggs 1993, Williams 1998,

Williamson & Evans 1988

Mowry 1982

Nadkarani 1992, Cabo &

Crespo 1986

Yang et al 1999

Buckle 1997

Mentha piperita

Zingiber ofﬁcinale

Elettoria cardamomum

Pogostemon cablin

Mentha spicata

To make a spritzer, add 4 ml of essential oils to 4 oz of water and put in a spray

bottle. Shake well before using. Anything to be used topically that has been stored

in an aluminum container or contains aluminum (such as antiperspirants) cannot

be used during radiation therapy as aluminum can interfere with the treatment.

When radiation therapy is ﬁnished, apply a compress. Mix antiinﬂammatory

essential oils like German chamomile, frankincense, or rose into a base of either

aloe vera gel or tamanu (Calophyllum inophyllum). An infused oil of gotu kola

(Centella asiatica) or comfrey (Symphytum ofﬁcinale) can also bring rapid relief and

help promote healing.

Maiche et al (1990) carried out a controlled, single-blind study on 50 women

ages 30-79 who had been operated on for breast cancer and who had received

radiation therapy. Kamillosan Ointment, a proprietary cream containing chamo-

mile that is widely available in Europe, was applied 30 minutes before radiation

and just before bed. Measurements were made by a physician using a four-point

scale (no change through moist desquamation). A comparison between the con-

trol group and the Kamillosan group showed no statistical signiﬁcant changes

overall, but skin deterioration appeared to happen later in the Kamillosan group,

and there were fewer patients who presented with Grade 2 (dark erythema) reac-

tions. In a further controlled study on leg ulcers, Kamillosan appeared to enhance

standard treatment of corticosteroids and antihistamines (Nasemann 1975).

Hair loss

In a randomized, double-blind, controlled study, hair loss due to alopecia re-

sponded well to topically applied essential oils (Hay et al 1998). Eighty-six pa-

tients took part in the study. The active group massaged thyme, rosemary, laven-

der, and cedarwood in a mixture of jojoba and grapeseed oil into their scalps daily.

The control group massaged their scalps with vegetable oils only. Measurement

Chapter 22 Oncology 339

Table 22-2 h Spritzers for Postradiation Burns

Common Name Botanical Name Reference

Lavender

German chamomile

Roman chamomile

Rose

Everlasting

Blue tansy

Yarrow

Tisserand 1993

Maiche et al 1990,

Williamson & Evans 1988

Maiche et al 1990,

Grieve 1931

Brud & Szydlowska 1991

Sheppard-Hanger 2000

Lavandula angustifolia

Matricaria recutita

Chamaemelum nobile

Rosa damascena

Helichrysum italicum

Tanacetum annum

Achillea millefolium

was taken three ways: through a standardized, professional photograph taken ini-

tially, and then again after 3 and 7 months. Measurement was on a four-point

scale and with a map of the alopecia traced onto transparent ﬁlm. This was con-

verted into a computerized image so exact calculations could be made. Nineteen

(44%) of the 43 patients in the active group showed improvement compared with

six (15%) of the control group (p  0.008).

When chemotherapy stops, usually the patient’s hair begins to grow again,

often more luxuriantly.

Lymphedema

Lymphedema occurs frequently following mastectomy but is also fairly com-

mon following lumpectomy if there has been removal of lymph glands. It stands

to reason that the lymph system will have more difﬁculty returning excess inter-

stitial ﬂuid to the blood if there has been a reduction in the number of lymph

pathways. The large, lymphatic vessel walls are contractile (so progress is in one

direction only), and when one or more of the lymph glands has been removed via

surgery or damage, lymph accumulates in the subcutaneous tissue causing the af-

fected limb to become swollen and tender (Badger 1995).

Lymph contains large protein molecules, and build-up of protein in the tis-

sue leads to chronic inﬂammation and, over a period of time, thickened, leathery

looking skin. After the initial phase of soft skin and pitting, chronic lymphedema

is characteristically nonpitting. Because of chronic inﬂammation, local immunity

is compromised, with subsequent bouts of cellulitis and poor resistance to insect

bites or minor cuts.

Lymphatic drainage should be carried out regularly, as there is no pumping

action by the lymph system itself. Normal lymphatic drainage relies on muscular

activity during exercise to move the lymph in the right direction. When this no

longer happens, the lymph needs a little extra help. However, because the prob-

lem occurs at a subcutaneous level, the pressure needed is extremely light and only

in the direction of the lymph. This is one instance where normal massage is con-

traindicated. The pressure of an ordinary massage can cause spasm in the lymph

vessels, temporarily suspending the lymphatic ﬂow (Idoux 1996), and most mas-

sage strokes are not suitable.

Lymphatic drainage is a completely different technique and needs to be

learned. Perhaps the most famous and accepted method is the Vodder method,

which was developed in Austria 50 years ago. Rather than a massage stroke,

which tends to be a two- directional movement with both hands working in op-

posite directions, lymphatic drainage works in one direction only: the direction of

ﬂow of the lymph, which is toward the main lymph ducts, away from the periph-

eries, and toward the thoracic duct. Regular sessions, daily if possible, can reduce

the size of a lymph-enlarged limb quite dramatically. The limb will feel lighter

and the skin more supple. The elbow (or other joint) will become more clearly

deﬁned, and there will be more tactile sensation. I have had success using

“tramlines,” running my ﬁngers gently, slowly, and repeatedly in the direction of

the lymph. With a bit of practice it was possible to feel the lymph move.

340 Section II Clinical Use of Aromatherapy

Aromatherapy can play an important role when the skin loses its elasticity

and infections become more frequent. However, it is unlikely that essential oils

could help the lymph to move. Table 22-3 lists carrier and infused oils used in the

treatment of lymphedema.

Essential oils can be useful to protect the engorged limb from bacterial or

fungal infection (Table 22-4). Choose an essential oil the patient likes, and avoid

those with an astringent action like Cupressus sempervirens (cypress).

Kirshbaum (1996) carried out a small study with eight patients with lym-

phedema using diluted lavender in a massage. She found aromatherapy massage

reduced pain and swelling and improved movement, a ﬁnding that seems to con-

tradict the conclusion of Idoux (1996). Casley-Smith (1999) found topically ap-

plied coumarins reduced edema, but not as effectively as when taken orally.

Beneﬁts of Aromatherapy for Cancer Patients

Aromatherapy is often used to enhance the quality of life of cancer patients. In a

study at the Marie Curie Center in Liverpool, England, patients received a massage

with or without Roman chamomile. The group that received the aromatherapy mas-

sage was found to have statistically signiﬁcant improved quality of life and reduced

anxiety (Wilkinson 1995). In another study conducted to assess the acceptability of

using aromatherapy in palliative care, doctors, nurses, paramedics, and volunteers

were reported to be extremely enthusiastic about the concept (Arnold 1995).

Corner et al (1995) used a premade mixture of lavender, rosewood, lemon, rose,

and valerian in their randomized controlled study of 52 patients with a variety of

cancers. Just over half of the patients received chemotherapy, radiation, or surgery

during the 8-week study. Patients were randomly assigned to a group to receive a

weekly massage with or without essential oils. A matching control group was se-

lected from patients who were unable to attend the 8-week course of massage. The

Chapter 22 Oncology 341

Table 22-4

h Skin-Friendly Essential Oils with Antibacterial

or Antifungal Actions

Common Name Botanical Name Reference

Lavender Lavandula angustifolia Valnet 1991

Frankincense Boswellia carterii Duwiejua et al 1993

Sweet marjoram Origanum majorana Ross et al 1980

Table 22-3 h Carrier and Infused Oils for Treating Lymphedema

Common Name Botanical Name Reference

Gotu kola

Oil of evening primrose

Passionﬂower

Price et al 1999

Earle 1991

Centella asiatica

Oenothera biennis

Passiﬂora incarnata

results showed a statistical difference in anxiety between the two groups receiving

massage, but pain and mobility showed almost equal improvement.

Evans (1995) conducted an audit into aromatherapy massage in cancer pa-

tients in a palliative-care setting. The study lasted 6 months and involved 69 pa-

tients. Participants were offered an aromatherapy session with an aromatherapy

massage and therapist advice on symptom control using aromatherapy. Eighty

percent of the patients felt they beneﬁted, although it is difﬁcult to assess whether

this was due to the essential oils, massage, or the one-on-one care. Everson (2002)

found that while her white-blood-cell (WBC) count fell with each chemother-

apy treatment, the WBC rebounded faster when she added bergamot to her daily

regimen. Table 22-5 lists isolates believed to have anticarcinogenic properties.

Essential Oils to Avoid in Oncology

Recent studies have indicated that phytoestrogens, once thought to be con-

traindicated in cancer, may actually reduce the risk of cancer and could therefore

be beneﬁcial. However, as the jury is still out and until more deﬁnite information

emerges, it might be prudent to avoid essential oils with estrogen-like properties

in tumors that are estrogen dependent. Estrogen-dependent cancers are breast,

uterine, and ovarian. It is extremely unlikely that the tiny amounts of estrogen-

like compounds used in aromatherapy would impact cancerous growth. As early

as 1938, Zondeck and Bergmann wrote about the estrogenic properties of phenol

methyl ethers. Essential oils thought to have an estrogen-like effect include fen-

nel and aniseed as they contain anethole (Albert-Puleo 1980). Anethole is a phe-

342 Section II Clinical Use of Aromatherapy

Table 22-5 h Isolates Thought to Have Anticarcinogenic Properties

Isolate Source Botanical Name Reference

Sclareol Clary sage Salvia sclarea Dimas et al 1999

Bergamottin Bergamot Citrus bergamia Miyake et al 1999

Perillyl alcohol Peppermint Mentha piperita Belanger 1998

Spearmint Mentha spicata

Lavandin Lavandula intermedia

D-limonene, Lemongrass Cymbopogon citratus Zheng et al 1993

geraniol

Carvone, Dill Anethum graveolens Zheng et al 1991

anethufuran,

limonene

Carvone, Caraway Carum carvi Zheng et al 1991

anethufuran,

limonene

nol methyl ether. Scareol (found in clary sage) and viridiﬂoral (found in niaouli)

are other components of essential oils that have structures similar to estrogen

(Franchomme & Penoel 1991). Therapists using aniseed and fennel on a daily ba-

sis found that their periods came earlier than usual. The link to geranium and rose

is really too tenuous, and both essential oils should be ﬁne to use in estrogen-

dependent tumors.

In-vitro studies on rat skin indicated that some essential oils enhance the

penetration of 5-ﬂuorouracil (5FU) (Abdullah et al 1996). Peppermint increased

penetration by 46 times, and Eucalyptus globulus increased penetration by 60

times. It might be advisable to avoid using these two essential oils topically near

the intravenous site during chemotherapy with 5FU.

Conclusion

In summary, aromatherapy is a way to “enrich interventions and bring comfort

and better health to patients with cancer” (Penson & Fisher 1995). Such actions

demonstrate caring. Perhaps this is the caring referred to by the nursing theorist

Orem as “a moral idea of nursing” (Leddy & Pepper 1993). However, caring is a

moral issue for all health-care professionals.

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Chapter 22 Oncology 345

346

Pediatrics

And when you crush an apple with your teeth, say to it in your heart:

“Your seeds shall live in my body.

And the buds of your tomorrow shall blossom in my heart.

And your fragrance shall be my breath,

And together, we shall rejoice through all the seasons.”

Kahil Gibran

The Prophet

here is a Chinese saying that “Children get sick easily, and sickness can

quickly become serious,” and another saying that “Children easily ill, eas-

ily cured.” There is no doubt that children in the hospital are very vulner-

able. They do indeed deteriorate or improve rapidly, and they need a tremendous

amount of love and support, particularly if their families cannot visit. Although

children are more adaptable than adults and often face very intimidating proce-

dures with wide-eyed interest and no apparent fear, many do display behavioral

problems just because they have become institutionalized.

Some of the most distressing aspects of hospitalization are the invasive med-

ical procedures, like venipuncture and the placing of nasogastric tubes. Aro-

matherapy can help soothe the child prior to these interventions. A few moments

of hand or face “m” technique can help relax children while you explain what is

going to happen, how long it will last, and how it will help them. Anxiety about

being hurt has been identiﬁed as one of a child’s greatest fears (Kurﬁt Stephens

et al 1999). Sweet orange oil was found to be helpful in the induction of 120 un-

premedicated children aged 5-14 years in a study by Mehta et al (1998). Children

in the essential oil group were signiﬁcantly more likely to say they would like to

have a similar anaesthetic technique again in the future (p⬍0.05). As nausea is

frequently a symptom of fear in children, lavender might be another useful es-

sential oil to use. Lavender straw (the discarded by-product of stream distillation)

still retains some aroma and was found to alleviate stress and travel sickness in 40

pigs being transported by road (Bradshaw et al 1998).

Aromatherapy is a natural thing to a child, whose early life revolves around

smell and touch. Babies identify their mothers through the mother’s smell

(Russell 1976). This is easy to understand when one realizes that babies are born

with structurally mature olfactory systems (Humphrey 1940). Young children up

to the age of 5 years are not repelled by smells that most adults dislike, such as fe-

ces. However, by the age of seven, many children are beginning to establish sim-

ilar “tastes” in smells to adults (Engen 1974). Children also display the facility of

“learned memory” early on, gravitating toward the smell of a perfume worn by

their mother, rather than another unknown perfume (Schleidt & Genzel 1990).

Therefore, familiar smells are more acceptable to children than other smells. This

is particularly important in the case of children from other cultures, who may re-

spond to exotic aromas with which Western children might not identify, such as

spices. Children can be extremely sensitive to smell. Schilcher (1997), head of the

Institute of Pharmaceutical Biology at Berlin’s Independent University, suggests

inhalation of volatile oils is an excellent method of choice for pediatrics.

Most of us ﬁnd it an instinctive action to cuddle and stroke a child. Aro-

matherapy takes that instinct a little further and adds some extra therapeutic

value. Parents and relatives can be taught very easily how to use the “m” technique

on a sick child, and they relish the feeling of being empowered to do something

in a situation most parents fear. This experience of empowerment can be made

more potent by the addition of an aroma with which both mother or father and

child are familiar and which they both like. Gentle aromas can soothe a child, but

the emphasis is on gentleness. It is necessary to use only half the normal number

of drops of an essential oil required for an adult. Please see Table 23-1 for dosage

recommendations for children.

Bear in mind that some children may have been subjected to abuse and will

not be receptive to touch, ﬁnding it more threatening than comforting. If this is

Chapter 23 Pediatrics 347

Table 23-1 h Doses for Children and Babies

Premies Floral waters only N/A

Newborn-6 months 1 drop in 20 ml 0.25%

6 months-2 years 1 drop in 10 ml 0.5%

2-5 years 1 drop in 5 ml 1%

5-10 years 1-2 drops in 5 ml 1-2%

More than 10 years 1-5 drops in 5 ml 1-5%

*unless treating speciﬁc infections, for example onychomycosis (toenail fungus) or hair lice.

the case, merely using the appropriate aroma can still be beneﬁcial. Children quite

like to be involved in choosing an aroma, especially if the choice is small. More

than four essential oils will demand too much effort from a sick child. Sometimes

a choice of just two will make aromatherapy acceptable, whereas if only one smell

is offered it might be refused. However, it is important never to insist; children

are patients with patients’ rights, no matter how old they are.

Of the possible problems that might be helped by aromatherapy, hyperactiv-

ity, attention deﬁcit hyperactivity disorder (ADHD), and head lice have been

chosen for discussion in this chapter. Clinical aromatherapy has an important role

in pediatrics alongside orthodox medicine. Aromatherapy can also bring comfort

to both child and parent and give a sense of empowerment to staff. Caring for sick

children is an emotionally draining experience, and caring for a dying child is one

of the most daunting tasks faced by any health professional (Hodson 1985).

Hyperactivity

Hyperactivity in children who have become hospitalized is common. This form

of excitable behavior is different from attention deﬁcit/hyperactivity disorder

(ADHD), which is a recognized mental disorder and will be covered in a later

section (McFerran 1996).

Every child will have a unique response to being hospitalized. Some children

become withdrawn, some become placatory, and others become hyperactive. It is

the hyperactive children who can become a source of irritation to staff and other

children. Aromatherapy can often help. The cause underlying the behavior may be

the strange environment and smells, which make the child feel threatened. Hy-

peractivity may be a means of asking for more attention or a means of communi-

cating a child’s sense of ill ease. The “m” technique with a familiar smell (Table 23-

2) may soothe a child and reduce hyperactivity. Sometimes mixing aromas to

produce a new but faintly familiar aroma can be beneﬁcial (Worwood 2000).

348 Section II Clinical Use of Aromatherapy

Table 23-2 h Essential Oils to Relax a Hyperactive Child in the Hospital

Common Name

Roman chamomile

Mandarin

Lavender

Neroli

Rose

Geranium

Sweet marjoram

Botanical Name

Chamaemelum nobile

Citrus reticulata

Lavandula angustifolia

Citrus aurantium ﬂos

Rosa damascena

Pelargonium graveolens

Origanum majorana

A foot or hand “m” technique is usually acceptable to a sick child. Teaching

parents to help their sick children is one of the most rewarding things I have ever

done. A mother’s touch, no matter how unfamiliar she is with any technique or

stroke, is what a child will usually recognize and respond to. Gentleness and slow

strokes are what matters. This is particularly important to remember if the child

is unconscious. If the mother wears a lot of bracelets, do not ask her to remove

them, as her child will remember how they sounded and how they felt.

Sometimes the smallest amount of a compound in an essential oil can have a

profound effect. One example is the smell of rose caused by an oxide present at a

concentration of only 0.1 parts per million. Another example is a compound

called indole present at trace levels in citrus oils, honeysuckle, and jasmine (Collin

& Hoeke 1993). In large amounts, indole smells vile and would make most peo-

ple gag because it contributes to the smell of rotting meat! However, indole has a

remarkable relationship with tryptophan and appears to aid its synthesis (Clark

1995). Tryptophan is found in various foodstuffs like chicken, milk, bananas, and

rice and is the chemical precursor of serotonin, the “feel-good” neurochemical

(Parish 1991). Using an essential oil containing a trace of indole may help a child

relax.

Attention Deﬁcit/Hyperactivity Disorder

ADHD is a combination of inattention, hyperactivity, and impulsive behavior

that is classiﬁed as a disorder when these behaviors are severe. ADHD is thought

to be a developmental failure in the brain circuitry that underlies inhibition and

self control (Tucker 1999). During the last 10 years, an increasing number of chil-

dren have been diagnosed with ADHD. It is the most commonly diagnosed be-

havioral disorder in children and the fastest growing disorder in adults. Since

1990, the number of children in the United States diagnosed with ADHD has

increased from 900,000 to more than 5.5 million. ADHD is thought to affect 5-

10% of all school-aged children. One and a half million adults also have been di-

agnosed with ADHD.

Charles Bradley ﬁrst noticed that amphetamine (Benzedrine) calmed hyper-

active children in 1937 (Gainetdinov & Caron 2001). Numerous studies carried

out since that time have shown that stimulants such as amphetamines interact

with plasma-membrane monoamine transporters (dopamine, serotonin, and nor-

epinephrine transporters) (Gainetdinov et al 1999). The current treatment for

ADHD is with a stimulant medication such as Ritalin. Sales of Ritalin have in-

creased 700% since 1990 (Haislip 2002). Little is known about the long-term ef-

fect of stimulants on brain chemistry, and there is increasing concern about the

long-term use of Ritalin (Breggin 1998).

Some research on ADHD suggests many different contributing factors are

involved, including sensitivity to the yellow dye tartrazine. However, no deﬁnite

cause for the disorder has been found. Recent research at Harvard and Massa-

chusetts General Hospital shows adult subjects with longstanding ADHD have

Chapter 23 Pediatrics 349

an abnormal elevation in their number of dopamine transporters. Ritalin was

thought to work by altering levels of dopamine. However, studies with rats sug-

gest Ritalin works by boosting serotonin levels in the brain. The researchers con-

cluded that ADHD may occur when the chemical balance between dopamine

and serotonin is thrown off (Caron 1999).

I have found that children with ADHD become more stimulated with seda-

tive essential oils such as Roman chamomile and lavender. So, I tried essential oils

with stimulant properties and found they had a relaxing effect. Because of this

ﬁnding, two of my students carried out two separate studies on ADHD using two

different essential oils. The ﬁrst study, by Sorenson (1999), was very simple and

involved observing four children with ADHD who were attending piano lessons.

When lavender (Lavandula angustifolia) was diffused into the air, all four children

became more inattentive and restless. When rosemary (Rosmarinus ofﬁcinalis) was

diffused into the air, three of the four children became more attentive and less

restless.

Sptizer (2000) carried out a study on 10 children (aged 7-9 years) attending

a school for children with special needs. Children who were prone to seizures

were excluded from the study. Two occupational therapists conducted the exper-

iment at the school and used a Likert scale for analysis. Baseline data were

recorded for four separate visits. This included the number of times the children

got out of their chairs, the number of times the children needed directions re-

peated, the number of times the children engaged in self stimulation (rocking),

and the number of minutes the children sustained attention to a particular task.

During the experimental stage, two drops of Rosmarinus ofﬁcanalis were placed on

an aromastone before each of the four occupational therapy sessions. (An aroma-

stone is a ceramic stone that uses electricity to gently heat a few drops of essen-

tial oil placed on the stone.)

As each child was so different, the data were discussed individually. In the

best case scenario, child six managed to focus with rosemary and sustained atten-

tion for up to 23 minutes, instead of 18 without the oil. Child one sustained fo-

cused attention for 9 minutes instead of 3 minutes. Child three was able to re-

main seated longer. Child four, who was prone to tantrums, did not have any

tantrums during the aromatherapy sessions. Child ﬁve did not have any self-

regulating problems, and therefore there was no room for improvement. Three

other children had slight improvements overall, two children had no difference,

and one child performed worse. Although this study is inconclusive, both occu-

pational therapists felt the ﬁndings warranted further study.

Pitman (2000) invited a group of 11 children with ADHD to choose three

essential oils from a selection of 15 oils that included stimulant and sedative es-

sential oils. The three were then mixed together, diluted in vegetable oil, and ap-

plied to the children’s wrists. The same mixture was sometimes used at home in

a bath or diffused into the air. The oils appeared to relax the children, increase

their concentration in class, and decrease disruptions, and the children all ap-

peared calmer. The parents agreed the essential-oil mixtures had helped their

350 Section II Clinical Use of Aromatherapy

children calm down. However, one parent said the child became hyperactive

when a citrus aroma was vaporized for too long.

Pediculosis (Head lice)

Head-louse infestation is common worldwide. In developed countries the infesta-

tion rate is increasing, especially in the 4- to 13-year-old age group (Mumcuoglu

1999). This increased infestation could be due to the incorrect use of effective

agents that has led to lice strains becoming resistant to insecticides. Compounds

such as Permethrin, malathion, and DDT are no longer sucessful (Combescot et

al 1996). Izri and Briere (1995) report on the ﬁrst case of resistant head lice in

France in Paris and Tours, citing that resistance had already occurred in the

United Kingdom. Most pediculicides are only partially ovicidal, resulting in an-

other batch of new lice after 10 days. It is important that a special lice comb is

used and all the eggs are removed after treatment, as some nits can remain glued

to the hair for several months, even if they are dead. Suffocating agents such as

olive, soya, or sunﬂower vegetable oil can be effective if used for more than 12

hours. While some studies have shown that essential oils can be pediculicidal,

there is no evidence that essential oils repel lice (Mumcuoglu 1999).

Veal (1996) tested seven essential oils and three blends (by Shirley Price) in

vitro. Aniseed, oregano, cinnamon leaf, red thyme, and tea tree all performed well

when tested in an alcoholic solution using overnight exposure. Veal concluded it

would be important to use the same essential oil in the rinse that was contained

in the original application. She recommended using an essential oil, vinegar, and

water solution but alcohol and water could also be effective. Phenols and pheno-

lic ethers, ketones, and 1,8-cineole appeared to be the compounds most likely to

kill lice.

Laurent et al (1997) reported that linalol, menthone, menthol, and limonene

were also effective larvicides and ovicides. Gauthier et al (1989) showed that a-

pinene was another effective compound against head lice in his study on the ef-

fectiveness of Myrtle.

Lahlou et al (2000) investigated the effectiveness of 24 essential oils and 15

of their isolated compounds against human head lice in vitro using microatmo-

sphere and direct application. Mentha pulegium (pennyroyal), Thymus broussonetti,

Chenopodium ambrosioides (American wormseed), and Ruta chalepensis were found

to be the most effective. Unfortunately, these essential oils are not the most suit-

able for children. (It was interesting that they did not include tea tree in their

study.) The lice died within 15 minutes of direct application by the essential oils.

However, the nits were a little more difﬁcult. At a 1:4 dilution of Thymus brous-

sonettii applied directly, 20% of the nits hatched. Of the isolated compounds, phe-

nols and phenolic ethers, ketones, and 1,8-cineole were the most effective.

Oladimeji et al (2000) investigated the effects of Lippa multiﬂora essential oil

on head and body lice and scabies and found it effective. In the study, 0.02 ml of

a 25% solution of Lippia in liquid parafﬁn was sufﬁcient to kill head lice within

Chapter 23 Pediatrics 351

2 hours. (The lice had been removed from the children to a petri dish.) Lippia

multiﬂora was more effective than benzyl benzoate at the same concentration, but

not as effective as kerosene.

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Chapter 23 Pediatrics 353

354

Psychiatric Care

The use of scents is not practiced in modern physic but might be carried out with

advantage seeing that some smells are so depressing and others so inspiring and

reviving.

Sir William Temple (1701)

Essay on Health and Long Life

nyone who believes scent does not have a profound impact on the human

psyche should read Perfume: The Story of a Murderer (Suskind 1987). The

novel is set in 18th-century France, and Grenouille, the lead character, is

born with a heightened sense of smell but without body odor himself. These two

factors rule his life and impact those around him with devastating consequences.

Pickover (1998) quotes Hippocrates, who wrote, “Men ought to know that from

nothing else but the brain come joys, delights, laughter and sports, and sorrows,

griefs, despondency and lamentations.”

Wiener (1966) of the New York Medical College suggested our bodies have

an internal and external communicating system that uses our nervous system

without alerting us to its existence. Such a system is made up of chemicals and

interacts with the other systems in the body by means of odor. He further sug-

gests that if someone had the ability to communicate consciously in this system

it could be distressing. Subsequent to this theory was the discovery that schizo-

phrenics give out a persistent aroma discernible to dogs and rats. This aroma be-

comes more pronounced when they are in crisis (Smith & Sines 1960).

Certainly there is a link between depression and the inability to smell (anos-

mia) (Douek 1988). Aristotle noted that pleasurable aromas could contribute to

the well being of humans, and both malodors and bad odors impact on our health.

Stand next to a garbage dump downwind for just a few moments and you get a

good sense of this! Malaria literally means “bad air” as it was believed that odor

emanating from marshes caused the disease (King 1988).

The use of psychoactive products evolved along two related paths: for reli-

gious or recreational pursuits and to modify normal behavior (Alexander 2001).

The effects of aromas on the brain were ﬁrst tested by Moncrieff (1966) using an

electroencephalograph to monitor changes in brainwave patterns. He found that

basil, black pepper, cardamom, and rosemary induced mainly beta patterns and

that jasmine, neroli, and rose induced mainly delta patterns (Moncrieff 1977).

Beta brain patterns (13-40 cycles per second) are concerned with attention and

alertness. Delta brain patterns (0-4 cycles per second) are concerned with eupho-

ria and calmness (Mureriwa 2001). Dodd and Van Toller (1983) compared the ac-

tion of chemical components found in essential oils to the action of psychotropic

drugs such as antidepressants. Torii et al (1988) reported on the electrical changes

of the brain and the similarities between emotion and the sense of smell. King

(1988) postulated the relation between odor and olfaction was probably a two-

way relationship.

A report in the Journal of the American Medical Association suggests a study of

smell could shed light on some of the symptoms of schizophrenia. Dr. Daniel

O’Leary from the University of Iowa Hospitals and Clinics exposed 18 people

with schizophrenia and 15 healthy volunteers to a pleasant smell (vanilla) and an

unpleasant smell (O’Neil 2001). An imaging device was used to track blood ﬂow

to different areas of the brain, and subjects were asked to rate each smell. The

mental imaging showed big differences between the two groups in the mental

processing of the unpleasant smell. The limbic system appeared to be highly ac-

tive in healthy subjects but largely unused with people with schizophrenia. The

latter depended more on frontal cortical areas usually reserved for functions such

as decisionmaking. This misuse of brain circuits could play a role in paranoia.

Insanity or mental illness is an area of fear for many people, and yet almost

everyone has experienced insanity at some time in their life: a crazy decision, a

wrong choice, a mad moment, a dark time. I remember when my son went miss-

ing. He was only 2 years old and my daughter was a newborn. One moment he

was there next to the cheese counter in the supermarket, and the next moment he

was gone. During the following 2 hours I experienced a sense of insanity and all

reality appeared put on hold.

During times like this, one’s link with reality can seem blurred as sensory

perception becomes skewed and basic physical needs are forgotten. This is when

familiar smells and reassuring touch may help ﬁnd a way out of the fog and back

to reality. Patients with mental-health problems are a constant reminder just how

fragile sanity is.

Aromatherapy and Mental Illness

“Components within essential oils that alter brain chemistry and relieve psychi-

atric symptoms have brought great hope and help to many people” (Alexander

Chapter 24 Psychiatric Care 355

2001). Sugano (1992) suggests natural fragrances can provide a cost-effective and

efﬁcient alternative to many common drug treatments, especially stimulants and

sedatives. Tisserand (1988) suggests olfactory “ecstasy” was discovered by man at

a very early age, and that aromatics can be perceived as drugs. Alexander (2001)

suggests that “EOs [essential oils] for the brain that have antidepressant, mood-

balancing, anxiolytic and hormone regulating properties are nourishment at the

biochemical level.”

Most synthetic psychotropic medications have limited efﬁcacy and signiﬁ-

cant side effects, and preliminary ﬁndings suggest several treatments based on

natural substances are as effective and safe as the synthetic pharmaceuticals in

current use (Lake 2000). Lake’s review article on the use of herbs for neurologi-

cal problems is a must-read. However, the number of herbs he covers is limited

by space. The Napralert database (which I have used extensively for this book)

contains more than 1000 citations on herbs useful for psychiatry.

Many health professionals working in psychiatric units have been grateful for

strong sedatives when patients have become psychotic and unmanageable. How-

ever, there are some people who are may just have a poor ability to cope with life.

This could be due to genetics, environmental issues, or just one of those unex-

plainable things. However, with the demand for a cure, or at least medicine, seems

to be a growing group of people who take antidepressant drugs but who are not

clinically depressed. They are just life depressed. In the words of Patch Adams,

MD (1997), “Prozac has replaced a hug.” It is this shadowy area in which aro-

matherapy may help. While all the hi-tech advances in the world cannot rewire

the brain, something as simple as an essential oil can enable the brain to reregu-

late itself (Alexander 2001).

Addiction

Today’s society is an addictive one, and it often rewards socially acceptable addic-

tions like workaholism, in addition to accepting shopaholics and nicotine addic-

tion, condoning alcohol addiction, and prosecuting drug addiction. Yet the ethos

behind addiction—instant gratiﬁcation—is at the very core of today’s society.

People want things instantly. Large portions are required even if they cannot be

eaten. Everything must be big. It is as though people feel too small in a world that

undervalues them. Reassurance of worth is sought from external sources rather

than from within. It is as though people have a hole in their wholeness and are

hungry for anything that will stop the feeling of emptiness. Health professionals

are often presented with evidence of a sick society in which individuals who do

not ﬁt in or are unable to cope are isolated, ridiculed, or forgotten.

A few detoxiﬁcation programs have included herbal treatment protocols for

the management of acute benzodiazepine or opiate withdrawal with positive ef-

fects (Rasmussen 1996). But there is scant if any published literature on the use

of essential oils for alcohol or benzodiazepine withdrawal. However, some anec-

dotal success with weaning patients from antidepressants and night sedation us-

ing both nontouch modality (diffusers at night and face tissues during the day)

356 Section II Clinical Use of Aromatherapy

and the “m” technique has been achieved. The process was very gradual and un-

der physician control. This is not recommended unless physician support is given.

Limited success with helping reduce the cravings of women withdrawing from al-

cohol has also been achieved using speciﬁc inhaled essential oils (Lundgren

1999). A protocol that has been used is shown in Table 24-1.

The idea that an olfactory stimuli might reduce craving for nicotine was in-

vestigated by Seyette and Parrott (1999). They found that both negative and pos-

itive aromas decreased cravings against a nonodoriferous control in nicotine ad-

diction. The sense of smell is lessened in a heavy smoker; nevertheless,

aromatherapy has achieved some modest success. DaCosta (1999) explored in-

haling essential oil as a means to reduce the craving of nicotine withdrawal. The

three essential oils tested were lavender (Lavandula angustifolia), Helicrysum

italicum, and Angelica archangelica. Four male subjects who smoked at least 10 cig-

arettes a day and had tried to stop smoking in the past were recruited. The period

immediately after breakfast, lunch, and supper were chosen as those were the

hardest times to abstain from smoking. The normal period the test subjects could

wait before smoking (baseline) was minimal, less than 2 minutes. Each essential

oil was then tested separately for 5 consecutive days, divided by a dry-out period

of 2 days, and the subjects timed how long they could last without a cigarette. An-

gelica root appeared to be the most helpful, with subjects able to wait an average

of 53 minutes before having a cigarette. This was considerable improvement on 2

minutes, although inhaling angelica did not prevent them from smoking after 53

minutes.

Chapter 24 Psychiatric Care 357

Table 24-1

h Protocol for Coming Off Benzodiazepine or Night Sedation

with Aromatherapy

Week 1 Choose aroma(s) from a selection of six.

Choose touch or nontouch application. Apply oil in ofﬁce.

Give written instructions on when and how to use aromatherapy.

Week 2 Reduce medication by

⁄

Week 3 Reduce medication by further

⁄

Week 4 Remain on

⁄

medication .

Week 5 Reduce medication to

⁄

Week 6 Remain on

⁄

medication.

Week 7

⁄

medication alternate days.

Week 8 Remain on

⁄

alternate days.

Week 9

⁄

medication twice a week.

Week 10

⁄

medication once a week.

Rose and Behm (1994) used black pepper essential oil as an aid in a smoking-

cessation program. They hypothesized that clients needed to experience the res-

piratory-tract sensations that accompany cigarette smoking to quit successfully,

and they believed black pepper essential oil could simulate those sensations. They

found “the vapor of black pepper essential oil, when inhaled, partially reproduces

the respiratory tract sensations experienced when smoking, thereby reducing the

craving for cigarettes.”

Newsham (2001) explored the effect of aromatherapy as an adjunct to auric-

ular acupuncture for drug detoxiﬁcation at Yonkers General Hospital in New Jer-

sey. This was a study compared to a historical control. Two hundred eighty-two au-

ricular treatments (some subjects received more than one treatment) were given

with ambient odor of lavender in the room. The comparison group received 230

auricular treatments without lavender. Two standard aromatherapy diffusers were

used to diffuse a room of approximately 400 square feet. Twenty drops of lavender

were placed in the nebulizer. All patients routinely completed a short questionnaire

before and after treatment. Analysis was done to see if there was any difference be-

tween the aromatherapy group and the comparison group. Fifty percent of patients

did not complete the full 21 days of treatment. The actual treatment range was

1-14 with an average of 4. Data were collected monthly and aggregate data were

used. Questions ranged from “How are you feeling right now?” to “How would you

rate any cravings you have right now?” The choice of answers was on a 0-5 scale.

There was no difference between the aromatherapy group and the compari-

son group in the number of patients who said they felt “very good” physically or

emotionally after the treatment. There was a difference in those who felt “good”

physically and emotionally. Physically, there was 6% change in the comparison

group and a 24.8% change in the aromatherapy group. Emotionally, there was

4.6% change in the comparison group and a 24.9% change in the aromatherapy

group. However, there seemed to be no difference in the cravings. More than half

the patients said they were unable to smell the essential oils diffused into the room.

Caldwell (2001) explored the effects of ylang ylang (Cananga odorata) in a

small, controlled study of 10 women suffering from cravings following with-

drawal of substance abuse. All women were taking orthodox medication. The par-

ticipants were randomly split into two groups: an experimental group and a con-

trol group. The experimental group was given essential oil of Cananga odorata

(ylang ylang) to inhale, and the control group received plain almond oil. Both

groups were told that they were using ylang ylang oil. The participants were self-

selecting and limited to women dealing with chemical addiction. All 10 partici-

pants had either stopped using and were still experiencing cravings, or were try-

ing to stop using and were experiencing cravings.

Each participant put two drops of the oil on a cotton square and put the

square in her pillowcase every night for seven nights. The participants were also

asked to put two to three drops of oil on a cotton hanky, carry the hanky with them

for seven days, and smell it if they experienced a craving. The participants were

asked to record the number of cravings, their intensity, and any other comments.

358 Section II Clinical Use of Aromatherapy

The results showed the number of cravings for the essential oil group went

down more than for the control group. However, ylang ylang did not prevent

cravings completely. Four out of 5 women in the experimental group believed

“smelling the oil relieved the stress and anxiety of that moment.” None of the par-

ticipants using the almond oil expressed this feeling. Caldwell (2001) notes that

ylang ylang’s positive effect might be enhanced by using a diffuser at night.

Olfactory loss is common in alcoholics (Shear et al 1992), cocaine users

(Schwartz et al 1998), and heroin addicts (Perl et al 1997). Loss of smell is not

thought to affect the transfer of the volatile molecules unless there is damage to

the olfactory nerve. Loss of smell in addicts is thought to be due to damage to the

cortical and subcortical brain regions (Shear et al 1992), but it is possible there is

nerve damage due to snorting or snifﬁng cocaine, heroin, and glue.

Bipolar Disorder

Approximately 2.5 million Americans are thought to be affected with bipolar dis-

ease. Originally named manic-depression, the disease was discovered by German

psychiatrist Emil Kraepelin after carefully observing many patients in the 19th

century (DRADA 2001). Kraepelin found many patients had spontaneous re-

mission of symptoms that could last for months or years before relapsing and that

patients who had suffered episodic periods of illness in their 20s were more likely

to have them in their 40s. Psychiatrists today conclude that bipolar disease is a re-

lapsing illness that may recur more frequently as the patient ages. Bipolar disease

is thought to run in families, and recent research is concentrating on chromosome

18 in an attempt to locate the gene responsible (Stine et al 1995). However, bipo-

lar disease is quintessentially a disease of the Western world. The World Health

Organization conducted studies over a 25-year period and found that in under-

developed countries, psychotic disorders such as bipolar were fewer, less severe,

and resolved more rapidly (Sartorius 1990).

People, and in particular scientists, have a fascination with putting things in

categories. Since manic-depressive disorder became bipolar disorder, bipolar has

been divided into seven subcategories:

1. Pure mania;

2. Mixed mania (symptoms of mania and depression appearing simultane-

ously);

3. Rapid cycling (four or more episodes a year);

4. Secondary mania (appearance of mania after another illness);

5. Bipolar disorder with coexisting substance abuse;

6. Bipolar disorder type II (mildly manic states); and

7. Cyclothymia (chronic mood cycles with depression or mania too mild to

be classiﬁed).

Because mental illness is thought of as a brain disorder, magnetic resonance

imaging is frequently used as a diagnostic tool (DRADA 2001), although there

are inconsistent ﬁndings. The areas of the brain examined are the amygdala, the

entorhinal cortex, and the asymmetries—areas of the brain bigger on one side

Chapter 24 Psychiatric Care 359

than the other. In the brain of a normal, right-handed person, the brain area for

language is much bigger on the left side (Pearlson 1996). Pearlson also found

schizophrenic patients had greatly shrunken entorhinal cortexes and striking re-

versal of some key brain asymmetries. In bipolar patients these structures looked

normal, although the amygdala was slightly shrunken. In mood-disorder patients,

the amygdala was signiﬁcantly shrunken on the left side.

Many neurological problems are a function of altered brain pattern and a

change in neurochemicals. Conventional drug treatment is with Lithium, dival-

proex (Depakote), and carbamazepine (Tegretol). However, all three have signif-

icant side effects. Bowden (1996) suggests Lithium has a narrow band of effec-

tive blood levels before reaching toxicity. However, Purol-Hershey (2002), a

psychiatric nurse and teaching professor, states that the band 0.5-1.2 mg is pretty

broad for lithium. The information on Tegretol suggesting precautions for “emo-

tional or mental problems” could be perceived as rather strange as the drug is pre-

scribed for bipolar disorder (Winter Grifﬁth 1997). However, Tegretol is also an

antiseizure medication with mood-stabilizing features. Table 24-2 has been cre-

ated from information in Treatment Options in Bipolar Disorder by Bowden (1996)

360 Section II Clinical Use of Aromatherapy

Table 24-2 h Commonly Used Medications for Bipolar Disorder:

Beneﬁts and Common Side Effects

Lithium

Depakote

Carbamazepine

Pure mania, history of

depression, family his-

tory of bipolar disor-

der, previous favorable

response to Lithium,

few previous episodes,

full relief between

symptoms

Mixed mania, nonfa-

vorable response to

Lithium, mood swings,

adverse effects less se-

vere, attention deﬁcit

hyperactivity disorder,

substance abuse

No family history of

bipolar disorder, bipo-

lar disorder is a sec-

ondary condition, lack

of response to other

medication

May correct

chemical imbal-

ance in brains’

transmission of

nerve impulses

that inﬂuence

mood and be-

havior

Increases gamma

aminobutyric

acid, which in-

hibits nerve

transmission to

parts of the brain

Analgesic, anti-

convulsant

Weight gain, dry

mouth, confusion,

poor concentra-

tion, shakiness,

tremor, increased

urination

Loss of appetite,

nausea, diarrhea,

tremor, unusual

weight gain (or

loss), menstrual

changes

Dizziness, blurred

vision, headaches,

back-and-forth

eye movement

(nystogmus)

and the Complete Guide to Prescription and Nonprescription Drugs (Winter Grifﬁth

1997).

The human body is controlled by extremely delicate mechanisms that rely on

hormonal and chemical communication. Each person has a slightly different body

chemistry that requires different things to achieve homeostasis. Like herbs, es-

sential oils are therapeutically multifaceted. Therefore, the components within an

essential oil may produce a different reaction in one person than in another, de-

pending on the availability of receptor sites (Mills 1991). For example, an essen-

tial oil may work to reduce blood pressure (acting as a hypotensor) if that is what

is required for homeostasis, or it may not if the blood pressure is normal for that

person. When a plant has the ability to change function it is called adaptogenic.

Many essential oils also have a balancing effect on the emotions.

Various antipsychotic agents have antagonistic interactions toward a whole se-

lection of receptor sites including serotoninic, adrenergic, and histaminic. There-

fore their ongoing effects on the autonomic nervous system are complex and un-

predictable (Alexander 2001). This is the case with each of the hundreds of

components in essential oils that interact with many receptor sites. While antide-

pressants work by making the neurotransmitter serotonin linger in the gaps be-

tween brain cells, essential oils are thought to work as serotonin agonists, which

can push the serotonin system into overdrive. This makes the brain more sensitive,

rather like turning up the volume on a radio so very weak stations can be heard.

There is no suggestion that bipolar patients should give up medication in fa-

vor of aromatherapy. There is little if anything published on bipolar disorder and

aromatherapy. However, essential oils may enhance orthodox medication so

dosages may be kept sufﬁciently low and reduce side effects. However, a few psy-

chiatric nurses who were my students have had some success with stabilizing pa-

tients using aromatherapy. As these were case studies it is difﬁcult to say whether

the patients’ stability would have happened anyway. Other case studies by psychi-

atric nurses have indicated aromatherapy may help reduce the need for orthodox

medication and still retain stability (Table 24-3).

A set ritual or protocol is useful when working with bipolar patients. This is

worked out in detail with the patient: the when, where, and how of treatment. Es-

sential oils need to be experienced for the ﬁrst time in a stable, calm, balanced sit-

uation with supervision. When this pattern is well established, the essential oils

can be experienced in the patient’s own setting. This is akin to preparing a “psy-

chological comfort blanket.” This setting of a psychological trigger is similar to

Bett’s research (1994) with epilepsy. He found massage with ylang ylang set a

precedent so strong that ultimately patients had only to think about the aroma of

ylang ylang to prevent a seizure occurring.

Tisserand and Balacs (1995) suggest several essential oils should be avoided

with patients who are prone to seizure. It might be a good idea to avoid them in

bipolar patients as well. These oils are listed in Table 24-4.

The ﬂowers of Matricaria recutita (German chamomile) contain apigenin,

which can completely inhibit central nervous system benzodiazepine binding

Chapter 24 Psychiatric Care 361

without sedation. There are no known negative side effects (Viola et al 1995).

Apigenin occurs in the CO

extract but not in the steam-distilled extract of Ger-

man chamomile. Valerian root (Valeriana ofﬁcinalis) has been shown to reduce

mild to moderate anxiety and may be useful in substance withdrawal (Brown

1994). Essential oil of valerian root is available and could be combined with

Melissa ofﬁcinalis essential oil for an enhanced sedative effect. Valerian is safe

to inhale in pregnancy, and long-term use does not produce dependency. The

362 Section II Clinical Use of Aromatherapy

Table 24-3 h Balancing Essential Oils that May Be Useful in Cases

of Bipolar Disorder

Table 24-4 h Essential Oils to Avoid in Bipolar Disorder

Essential Oil Suspect Component Amount (approximate)

White camphor Camphor 30%-50%

Hyssop Pinocamphone 70%

Nutmeg Myristicin, Elemicin 3%-14%

0.1%-4.6%

Pennyroyal Pulegone 55%-95%

Tansy Thujone 66%-81%

Botanical Name

Pelargonium graveolens

Lavandula angustifolia

Santalum album

Angelica archangelica

Rosa damascena

Pogostemon cablin

Cananga odorata var. genuina

Valeriana fauriei

Vetiveria zizanoides

Nardostachys jatamansi

Melissa ofﬁcinalis

Citrus bergamia

Salvia sclarea

Common Name

Geranium

Lavender

Sandalwood

Angelica root

Rose

Patchouli

Ylang ylang

Valerian

Vetiver

Spikenard

Melissa

Bergamot

Clary sage

therapeutic effects are thought to be through gamma-aminobutyric acid-antago-

nistic action (Lake 2000).

Lake (2000), a board-certiﬁed psychiatrist, reports the oral intake of St John’s

wort (Hypericum perforatum) is effective in certain mild depression, seasonal af-

fective disorder, and other neurological malfunctions. Essential oil of Hypericum

perforatum offers a more concentrated version that so far has not shown any of the

photosensitivity problems connected with the oral intake of St. John’s wort. This

could be an interesting area for further research.

REFERENCES

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364 Section II Clinical Use of Aromatherapy

365

Respiratory Care

Scent has a persuasive power stronger than words, appearances, feelings and wishes.

There is no defense against the persuasive power of scent; it looks into us, like the air

we breathe enters our lungs, it fulﬁls us perfectly and there is no antidote to it.

Patrick Suskind (1987)

Perfume: The Story of a Murderer

f all the clinical specialties, perhaps respiratory care is the most obvious

candidate for aromatherapy, for when we inhale to smell, we inhale to

breathe as well. Why bother with digesting essential oils and “ﬁrst pass”

(metabolizing them via the liver) when inhaled oils may work as well? Falk et al

(1990) noted the high solubility of ␣-pinene in human volunteers. Alpha pinene

(22%) is found in rosemary essential oil, camphor chemotype. Falk et al found

60% of ␣-pinene was absorbed through inhalation, but only 8% was exhaled. The

rest was excreted in the urine, suggesting inhaled essential oils could also treat

cystitis. Some essential oils taken by mouth are exhaled. Some essential oils given

rectally are excreted through respiration. Pulmonary excretion of 1,8-cineole,

menthol, and thymol was demonstrated following rectal application in rats, al-

though the percentage exhaled was extremely small (Grisk & Fischer 1969).

Air pollution has become more prevalent, especially in cities and especially

during the summer. Inner-city air seems to contain less and less oxygen and more

and more environmental toxins. In fact, for more than 30 years, environmental in-

ﬂuences have been linked to chest problems (Cruz-Coke 1960). Environmental

pollutants range from dust mites to cockroaches and latex to second-hand smoke.

Cases of asthma and chronic bronchitis doubled between 1982 and 1994, and

more than 14 million Americans are now diagnosed with asthma (Weil 1997).

Three in 10 people consult their doctor at least once a year about a respiratory

disease, with the most common complaint being upper-respiratory tract infection

(Newman-Taylor 1995). In the United Kingdom, 10% of all prescriptions are for

drugs to treat respiratory problems (Lung and Asthma Information Agency

1995), and one in seven children has asthma. In 1995, 5600 deaths in the United

States were attributed to asthma (Weil 1997).

While some kinds of asthma could be exacerbated by essential oils, other

kinds can be greatly ameliorated. Eucalyptus radiata and Styrax benzoin (benzoin)

have been used by health professionals to treat respiratory infections for many

years (Stevenson 1995). Essential oils to avoid in asthma are those high in alpha-

and beta-pinene or delta-3-carene, as they were found to cause airway and

breathing discomfort during a study by Filipsson (1996) on turpentine. Bowles

(2000) also notes that inhalation of pinene-rich essential oils could cause this

problem in asthma. Alpha-pinene is found in Scotch pine (Pinus sylvestris), at a

level of 42%.

There are two chronic respiratory problems becoming endemic in the United

States, namely recurrent bronchitis and tuberculosis. These will be discussed in

this chapter.

Chronic Bronchitis, Asthma, and Sinusitis

Recurrent chest infections, or chronic bronchitis, are on the increase. Each out-

break of the disease begins with a dry cough followed by a mucolytic stage with

a productive cough. The underlying problem may be infection, viral or bacterial,

or it may be chronic inﬂammation similar to an allergy.

Essential oils have been used in cough medicines for many years (Boyd

1954). The expectorant action of a cough medicine is mainly due to the local ac-

tion of aromatics on the lining of the respiratory tract during exhalation, after the

medicine has been swallowed (Boyd & Sheppard 1970). Boyd (1967) found sys-

temic expectorants (including glyceryl guaiacolate) have little pharmacological

expectorant action. but some inhaled expectorants, such as cedar leaf, have an ef-

fect, even at a subliminal level (Boyd and Sheppard 1968). Kendig et al (1967)

found water vapor (steam) to be the most effective means of liquefying secretions,

and Boyd and Sheppard conclude in their 1970 paper that “inhaled expectorants

may be superior to systemic expectorants.” This certainly opens the way for aro-

matherapy as a useful modality for upper-respiratory infections.

Boyd and Sheppard (1970) found the expectorant effect of inhaled nutmeg

oil was due to its high camphene content (60%). However, the amount of cam-

phene may be adversely affected if the nutmeg has been irradiated (Wilmers &

Grobel 1990). According to The Merck Index (Budavari 1996) camphene is

found (to a lesser degree) in the oils listed in Table 25-1.

An ointment containing camphene and menthol was found to be effective in

reducing bronchospasms by 50% when it was insufﬂated through the respiratory

system of laboratory animals, but it was only slightly effective when applied cu-

taneously (Schaefer & Schaefer 1981). Applying essential oils to an airway with

366 Section II Clinical Use of Aromatherapy

nasal ointment has also been shown effective in stimulating airway secretary

glands and reducing mucus. However, caution is needed in pediatrics. In another

study, children were mistakenly given nosedrops that contained menthol or euca-

lyptol (constituents of essential oils) instead of saline drops. Adverse effects

ranged from irritated mucous membrane to tachycardia (Melis et al 1989).

In a randomized trial involving 182 institutionalized patients, “essence” drops

containing mint, clove, thyme, cinnamon, and lavender appeared to reduce the

frequency of bouts of chronic bronchitis (Ferley et al 1989). The essential oils

most effective in this study were clove, lavender, lemon, marjoram, mint, niaouli,

pine, rosemary, and thyme. This could be because some essential oils are known

to destroy airborne Staphylococcus aureus and Streptococcus pyogenes within hours,

and these would be an effective way of preventing ailments such as bronchitis

(Bardeau 1976). Other essential oils frequently used to treat chest infections are

Boswellia carterii (frankincense) and Pinus sylvestris (Scotch pine) (Sheppard-

Hanger 1995; Abdel Wahab et al 1987).

Charron (1997) carried out an exploratory study on 40 patients with

bronchial and sinus congestion. Patients inhaled two drops of Spike lavender

ﬂoating in a bowl of hot water. All patients cleared their mucus immediately with

results lasting from 20 minutes to 2 hours. Some patients who had been on yearly

repeat antibiotics no longer needed them.

A 3% solution of frankincense, Spike lavender, and lavender was used in an

exploratory study of eight patients with asthma (Spear 1999). Application was

topical to chest and back. The age of patients ranged from 14-70 years. Four pa-

tients registered a moderate improvement in their peak-ﬂow meters, and three

registered a substantial improvement. Six patients noticed a change in their emo-

tional attitude, and the same six felt their sleep was much improved. No patient

became worse, but one patient noticed no improvement.

Lockhart (2000) used inhaled essential oil of Frankincense on eight subjects

(20-52 years of age), ﬁve females and three males, throughout a period of 6 weeks.

Following patch testing and assessment for allergies, the subjects were given a

bottle of pure essential oil from the same supplier (same batch number) and asked

to inhale it when they felt an asthma attack coming. A Likert scale was used at

Chapter 25 Respiratory Care 367

Table 25-1 h Essential Oils Containing Camphene

Common Name

Neroli

Citronella

Bergamot

Cypress

Ginger

Botanical Name

Citrus aurantium

Cymbopogon nardus

Citrus bergamia

Cupressus sempervirens

Zingiber ofﬁcinale

the end of 6 weeks. All subjects felt their anxiety levels decreased when they in-

haled the frankincense, and all subjects decreased the use of their normal inhalers.

Pitcher (2001) studied the effects of inhaled Mentha piperita on 20 adult pa-

tients (age range 18-90) with chronic sinusitis. Five of the 20 patients had a his-

tory of medically diagnosed asthma. Four patients used inhalers daily. No patients

were using prescription decongestants daily, although 12 patients used over-the-

counter decongestants as necessary. Smokers were excluded from the study. Undi-

luted peppermint was inhaled for 10 minutes at a time. A small cushion with two

drops of peppermint on it was kept by the bedside to assist with night breathing.

Measurements of nasal congestion, sense of smell, headache, and postnasal drip

were taken. There was a signiﬁcant improvement in all symptoms. Inhaler users

reported a decline in the number of times they used their inhaler. No side effects

were reported. When the symptoms returned at a later date, each participant

reached for the peppermint bottle again!

Machon (2001) carried out a controlled study to evaluate the effects of a mix-

ture of Eucalyptus globulus, Ravansara aromatica, Pinus sylvestris, and Mentha

piperita essential oils on sinus infections. Eight subjects (ﬁve females and three

males) used three drops of the mixture in a steam inhalation for 10 minutes, three

times a day for 5 days. Three subjects (both male and female) acted as controls

and received only steam inhalation. Baseline measurements of pain, sense of well-

ness, color of mucus, and amount of mucus were taken using a visual analog scale

of 0-10. The essential-oil group was consistently more improved with three of the

ﬁve members completely clear of congestion and two nearly free. By the ﬁfth day,

their mucus was clear. In the control group, the congestion remained the same,

and the mucus remained green in color.

Rudansky (2000) used Eucalyptus globulus to good effect to aid expectoration

in a patient with cystic ﬁbrosis. The subject, a 36-year-old woman, had pneumo-

nia and plural edema and was being treated with intravenous antibiotics (6 weeks

on and 3 weeks off ). She was also dependent on an oxygen-concentrator ma-

chine. Her mucus was thick, dense, and ﬂecked with blood. Working with the

woman’s physician, Rudansky was able to increase the subject’s lung elasticity

causing a measurable reduction in pulse and oxygen demand. She used regular in-

halations and body treatments to help the woman relax. The cycle of intravenous

antibiotics was reduced, and at the time of writing the patient had received no an-

tibiotic cover for 2 months and was doing well. The patient felt the heaviness in

her lungs had decreased substantially, and she was sleeping better.

Mattys et al (2000) carried out a randomized, double-blind study to explore

the effects of myrtol. Myrtol is a standardized distillate marketed under the brand

name Gelomyrtol and contains ␣-pinene, 1,8-cineole, and d-limonene. Six hun-

dred seventy-six patients were divided into four groups. The experimental group

received myrtol orally (4 ⫻ 300 mg daily) for two weeks. The two control groups

received either cefuroxine (2 ⫻ 250 mg daily) or ambroxol (a mucolytic agent),

and the fourth group received placebo capsules (four daily) for 14 days. Patients

368 Section II Clinical Use of Aromatherapy

receiving myrtol experienced a signiﬁcant reduction in coughing. Lung ausculta-

tion improved signiﬁcantly. Myrtol was found to be comparable to the other med-

ications (and superior to the placebo) and carries no risk of causing bacterial re-

sistance.

Essential oils with expectorant properties may be unable to ﬁght the infec-

tion causing the problem, in which case the cause of the symptom is not being

addressed. An aromatogram would be needed to culture the bacteria and ﬁnd out

to which essential oil it was sensitive. There are laboratories that can do this (see

Appendix 3 and Chapter 7 on infections for more details). In many instances

the infection may linger in sinuses (Belaiche 1979a). Some infections that are re-

sistant to antibiotics can be alleviated with the use of the correct essential oil

(Carson et al 1995). Table 25-2 lists essential oils I have used to treat respiratory

problems.

Belaiche (1979a) found thyme (Thymus vulgaris) and cinnamon (Cinnamo-

mum zeylanicum) were effective against Streptococcus aureus and lavender (Lavan-

dula angustifolia), marjoram (Origanum majorana), and winter savory (Satureja

montana) effective against Staphylococcus aureus (Belaiche 1979). Eucalyptus globu-

lus (2%) will kill 70% of ambient Staphylococcus aureus within hours. Duke writes

that in Cuba essential oil of Eucalyptus globulus is used to treat all lung ailments

(Duke 1985).

Chapter 25 Respiratory Care 369

Table 25-2 h General Respiratory Aid Essential Oils Used by the Author

Common Name

Ravansara

Gully gum

Spike lavender

Sweet marjoram

Lavender

Niaouli

Scots pine

Rosemary

Thyme

Tea tree

Blue gum

Cypress

Botanical Name

Ravansara aromatica

Eucalyptus smithi

Lavandula latifolia

Origanum majorana

Lavandula angustifolia

Melaleuca viridiﬂora

Pinus sylvestris

Rosmarinus ofﬁcinalis CT cineole

Thymus vulgaris CT linalol, CT thujanol

Melaleuca alternifolia

Eucalyptus globulus

Cupressus sempervirens

Tuberculosis

Tuberculosis (TB) is a mycobacterial disease spread by droplet infection. Primary

TB is usually pulmonary. A peripheral lesion forms, and its draining nodes are in-

fected, so there is early spread of the bacillus throughout the body. Immunity

rapidly develops, and the infection becomes quiescent at all sites. The most com-

mon nonpulmonary primary infection is in the ileocecal junction and associated

lymph nodes (Hope et al 1993). Postprimary TB occurs when any form of im-

munocompromise allows reactivation. The lung lesions progressively ﬁbrose, par-

ticularly in the upper lobe. Sometimes the bacilli can spread to other parts of the

body, setting up nodular lesions called tubercules (McFerran 1996). Sometimes

bone, brain, or genitourinary tract is involved.

TB was relatively well controlled in the Western world by Bacille Calmette-

Guerin (BCG) vaccine, and infection numbers fell to 10 in 100,000 people

by the end of the 1980s (MacSween & Whaley 1992). In 1996, the Centers for

Disease Control recommended the BCG vaccine be used only for health workers

in whom there was a high likelihood of multiple drug-resistant (MDR) TB. The

incidence of the disease has increased quite dramatically throughout the last 15

years. This trend is directly related to immigrant communities who were not vac-

cinated in their country of origin, and also to the spread of AIDS.

One-third of the world’s population is infected with TB. Annual global

deaths are approximately one million, and TB is the leading cause of death due to

an infectious agent in the world (NIAID 2002). Recently, MDR TB has ap-

peared. Outbreaks have occurred in hospitals, correctional institutions, residen-

tial-care facilities, and homeless shelters. In the United States, several hundred

people have contracted TB at their workplace. TB has also caused concern in the

aviation industry as commercial pilots and crew have been infected by passengers

(WHO 1998).

Although there still are antibiotics to treat MDR TB, these medications are

expensive, have side effects, and are slowly becoming ineffective. MDR TB is

more difﬁcult to treat than TB, as it requires expensive second-line drugs to be

taken for at least 18 months compared with cheaper, ﬁrst-line drugs taken for

only 6 months in cases of TB. The cost of ﬁrst-line treatment is approximately

$120 for a 6-month course. The cost of second-line treatment is approximately

$10,000 (Davies 2001).

Before the advent of para-aminosalicylic acid and isoniazid, patients with TB

were sent to sanatoriums, often located high in the mountains and frequently

close to pine forests, because it was thought that breathing mountain air laced

with pine essence would aid recuperation. Sanatorium windows contained no

panes of glass so air could ﬂow freely through the facility.

There is no suggestion that aromatherapy should replace conventional treat-

ment for TB. However, essential oils can enhance a patient’s quality of life. Some

essential oils have been found effective against TB in vitro, and some have been

found to increase the potency of orthodox medicines. Valnet (1993) was one of the

370 Section II Clinical Use of Aromatherapy

ﬁrst physicians to document the use of aromatherapy in the treatment of TB. He

found essential oil of hyssop neutralized the TB bacillus at a concentration of 0.2

parts per 1000 (Valnet 1993). This ﬁnding was similar to that of Hilal et al (1980).

Hilal found the volatile oil of hyssop was effective using different chromatograph

and spectral methods. Hyssop is eliminated through the lungs. Due to the high

percentage of the ketones iso-pinocamphone and pinocamphone (70%), this es-

sential oil should not be taken orally and many feel it is contraindicated in epilepsy.

It also has a pronounced hypertensive action (Valnet 1990). However, in view of

Valnet’s ﬁndings of hyssop’s effectiveness as such a very low percentage (0.002%),

hyssop could play a part in TB control if used in low dosages.

Despite the fact that most of the research on TB and essential oils has been

conducted on animals, there are a few papers that suggest essential oils might be

effective against TB in humans. A Russian paper reports the results of a 2-month

study on the effects of inhaled essential oils. The symptoms of 81.8%-95.6% pa-

tients disappeared, and their body masses increased (Petrosian et al 1999). Un-

fortunately, only the abstract is in English and the name of the essential oil is not

given. TB is rampant in Russian correctional facilities where a virulent, resistant

strain is endemic.

Lall and Meyer (1999) found that 14 out of 20 South African-plant ex-

tracts (extracted with acetone) were effective against isoniazid- and riampin-

resistant strains of TB at 0.5mg/ml using the agar-plate method. A further rapid-

radiometric method often used for drug susceptibility testing conﬁrmed in-

hibitory activity. Eight of the plants showed activity against the resistant strain at

1.0mg/ml. One of the plants belonged to the Helichrysum genus (spp. melanacme),

although the other plants were unfamiliar. Gupta and Viswanathan (1955) re-

ported on the tuberculostatic activity of Occimum sanctum (Holy basil) and Piper

betle (betle juice). In a further paper they found that Occimum canum inhibited the

growth of TB in dilution of 1: 50,000 (Gupta & Viswanathan 1955a).

Kufferath and Mundualgo (1954) found Eucalyptus globulus enhanced the

activity of streptomycin, isoniazid, and sulfetrone in the treatment of TB

(Kufferath & Mundualgo 1954). Schaubelt (1994) wrote that Cupressus semper-

virens (cypress) and Pinus sylvestris (Scotch pine) are also effective against TB.

The essential oils should be diffused continuously over several months and

are best used in rotation. Steam inhalation and/or use of a nebulizer will help get

the essential oils deep into the lungs. Sputum tests will indicate if the infection is

being contained. Hopefully further in-vitro research will show that other essen-

tial oils also have TB activity, and these can be added to a general mix of four es-

sential oils. It might be helpful to add Lavandula angustifolia and/or tea tree to

enhance immune function. In addition, the patient should take steam inhalations

with four drops of the essential oil mix three times daily to get the essential oils

deep inside the lungs. Adding an antiinﬂammatory essential oil such as Helichry-

sum italicum, German chamomile, or frankincense will help soothe the mucous

membrane. Table 25-3 lists inhaled essential oils of use in the treatment of pul-

monary TB.

Chapter 25 Respiratory Care 371

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372 Section II Clinical Use of Aromatherapy

Table 25-3 h Inhaled Essential Oils to Use with Pulmonary TB

Botanical Name Common Name Reference

Blue gum Eucalyptus globulus Kufferath & Mundualgo 1954

Niaouli Melaleuca viridiﬂora Kufferath & Mundualgo 1954

Marjoram Origanum majorana Valnet 1993

Holy basil Occimum sanctum* Gupta & Viswanathan 1955

Hyssop Hyssopus ofﬁcinalis Hilal et al 1978

Juniper Juniperus communis Duke 1985

* low doses; suggested amount below 0.5%

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Chapter 25 Respiratory Care 373

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374 Section II Clinical Use of Aromatherapy

375

Appendix I

Education

ost aromatherapy courses on the market are intended for the lay public

and have a recreational or esthetic approach, such as making perfumes,

soaps, or cosmetics, or the aromatic content of the science of food addi-

tives. While these courses are interesting, they are not relevant to clinical practice.

Certiﬁcation

Certiﬁcation can mean one of two things: the student has attended a course (al-

though he or she may not have learned anything) or the student has attended a

course and passed the required examination.

The term certiﬁed usually implies a student has passed the required examina-

tion and is therefore, in the mind of the certifying body (which may or may not

be the school that set the examination), competent in that subject. A certiﬁed per-

son is often described as licensed to use that training, as in the case of a certiﬁed

lawyer or accountant. However, in the ﬁeld of aromatherapy, there is no licensing

body either in the United States or United Kingdom that can license an aro-

matherapist. The closest thing in the United Kingdom is a self-regulating body

called the Aromatherapy Organization Council (AOC), which sets a core cur-

riculum for aromatherapy training for lay people.

Choices of Training

There are three types of aromatherapy training: professional, academic, or within

a speciﬁc discipline such as nursing. Any of these courses could have an esthetic

or clinical focus.

Professional

National Association for Holistic Aromatherapy

The National Association for Holistic Aromatherapy (NAHA) is the largest

aromatherapy organization in the United States with just under 1000 members.

As NAHA is a membership organization, it cannot offer certiﬁcation itself. How-

ever, NAHA does set guidelines for a national curriculum and approves schools

and educational programs that heed these guidelines. A list of NAHA-

approved schools and programs can be obtained from their Web site: www.naha.org.

NAHA-approved training is divided into Level One and Level Two. Level

One requires 30 hours of training and covers a minimum of 10 essential oils. Level

Two requires 200 hours of training, but the number of essential oils to be covered

is not stated. Level Two also includes “the clinical science of at least ﬁve common

ailments for each system covered.” The systems listed are reproductive, circulatory,

nervous, endocrine, lymphatic, musculoskeletal, and digestive. Students must write

a 5-10 page research paper, complete 10 case histories, and pass an examination of-

fered by the school. NAHA does not inspect schools or approve the exam.

Aromatherapy Registration Council

The Aromatherapy Registration Council (ARC), a not-for-proﬁt organization in

the United States, was set up in 2000 to mirror the work of the AOC in England.

The ARC has a curriculum and national examination. The exam is held four

times a year in different locations and is run by the Professional Testing Corpo-

ration (PTC). The curriculum content is available from the PTC. Areas covered

on the examination are given as follows: 20% basic concepts of aromatherapy, 30%

scientiﬁc principles, 35% administration, and 15% professional issues. There are

no prerequisites to the examination but “a completion in a program of aro-

matherapy or one year of full-time experience in aromatherapy is recommended.”

For more information, see www.aromatherapycouncil.org.

PTC runs certiﬁcation tests for different modalities. For information on the

PTC, please see their Web site: www.ptcny.com. At the time of writing, the aro-

matherapy exam does not involve any speciﬁc clinical questions because the exam

is open to lay people. I am an active and supportive member of ARC and helped

set the ARC exam. It is hoped that in time the exam will include an optional clin-

ical section speciﬁcally for licensed health professionals.

Academic Training

University Programs

Academic credit is given for some aromatherapy courses. One credit is equivalent

to 11-15 hours of class at a particular level. The level at which the learning occurs

will also be taken into account (undergraduate versus postgraduate) and will be

reﬂected in the cost of each credit. Some aromatherapy courses are in the process

of being accredited by a university. My own course, Aromatherapy for Health

Professionals, is at the time of writing this book (2002) in the accreditation

process. Several universities are beginning to look at creating aromatherapy pro-

grams. Academic training may concentrate on theory or research review and have

wonderful library access, but unless the instructors are clinicians with years of ex-

perience and the students are given sufﬁcient hands-on training, academic courses

may not produce clinically qualiﬁed practitioners. The curriculum may or may not

conform to ARC guidelines. Look for a well-rounded course with lots of hands-

on practice directed by experienced instructors. An added bonus in a university

program is the chance to carry out research.

376 Appendix I Education

The University of Minnesota began a four-credit program in 2001 aimed at

“providing foundational knowledge in therapeutic uses of essential oils for health

science students and professionals, including skills in critiquing the aromatherapy

research literature. The focus is on 33 speciﬁc essential oils as well as general prin-

ciples and chemistry.” This is a Web-based course sequence with 2 days each se-

mester on campus. Grading criteria include participation (including online dis-

cussion assignments), a written exam, case studies, and a report on an essential oil.

Other universities that offer aromatherapy courses include Washington State

University, University of Indiana, The College of New Rochelle, Bastyr Univer-

sity, and New York University.

State-Approved Schools

While it is encouraging that some schools teaching aromatherapy are state ap-

proved, this does not mean the content of the aromatherapy courses taught at that

school is approved. State approval usually only means the school complies with

regulations regarding safety and insurance.

Distance Learning

Discussing theory and analyzing research is excellent, but practical experience is

irreplaceable—particularly with a therapy that involves smell and touch. However,

distance-learning courses are an excellent way to begin and acquire base knowledge,

and I have created a short home-study and on-line course myself (www.rjbuckle.com).

Education within a Speciﬁc Discipline (relevant to licensed

health-care professionals)

Courses are being set up in complementary medicine for many health-care disci-

plines. These may or may not include separate training in aromatherapy.

Clinical Competency

To show clinical competency, licensed health professionals need to have com-

pleted an educational program recognized by their licensing body. Ideally, this

should involve a course endorsed by a professional body or that at least gives

continuing-education units (CEUs) for their professional modality.

Testing should be via a method that demonstrates clinical competency. Because

clinical competency is involved, the instructor should be someone recognized as a

health professional. To ensure fair and objective marking, the examination or test-

ing should involve someone other than the person who taught the course.

Endorsed Programs

This means that the course content has been approved by an external accrediting

body such as the American Holistic Nurses Association. One example is my

course, which is a 250-hour CEU program endorsed by the American Holistic

Nurses Association. For details on training in United States, Australia, Korea, and

Japan, please visit www.rjbuckle.com, which is listed in resources. Training in

South America, Korea, and Australia is expected to start in 2004.

Appendix I Education 377

Approved Providers

An approved provider means that the educational organization creating the aro-

matherapy course is approved by an accrediting body to give CEUs to physicians,

nurses, massage therapists, pharmacists, and so on. One CEU is equivalent to 50

minutes of classroom teaching. There are several training programs that provide

nursing or massage therapy CEUs, such as The Institute of Integrative Aro-

matherapy, The Institute of Dynamic Aromatherapy, The Atlantic Institute of

Aromatherapy, The Paciﬁc Institute of Aromatherapy, The Australasian College

of Aromatherapy, and my company, R J Buckle Associates, among others. Some

hospital groups approve speciﬁc educational providers to teach aromatherapy to

their employees. R J Buckle Associates is an approved educational provider to the

Planetree Hospital Group.

Speciﬁc Training for Nurses

The Royal College of Nursing (RCN) in England issued guidelines for nurses

wanting to use aromatherapy. These state that a nurse “should know his/her sub-

ject and have received training.” There is no requirement that the aromatherapy

course should be nursing based. However, if aromatherapy is to be used to en-

hance nursing, the instruction probably should be clinically based and nurse cen-

tered. Nurses in the United Kingdom who use aromatherapy are part of nursing

care are covered under RCN insurance for up to £3 million. To date, no claims

have been made.

The guidelines for using aromatherapy issued by the RCN include the fol-

lowing:

• Supervised practice;

• Anatomy, physiology, pathology, and pharmacology;

• Practical and theoretical examination;

• Holistic approach;

• Supervised clinical practice;

• Counseling/communication and self-development skills training;

• Appropriately qualiﬁed teachers;

• Support for the trainee therapist;

• A sensible tutor/pupil ratio (Royal College of Nursing 1993).

REFERENCES

Royal College of Nursing. 1993. Choosing a complementary therapy. London: Comple-

mentary Therapies in Nursing Special Interest Group, Royal College of Nursing De-

partment of Nursing Policy and Practice.

378 Appendix I Education

379

Appendix II

Policies, Protocols,

and the Occupational

Safety and Health

Administration (OSHA)

Sample Hospital Patient Care Policy and Procedure

Most health facilities require a health-safety policy in place. If aromatherapy is to

be integrated into a facility, this is the ﬁrst thing that needs to happen. I am ap-

preciative of the hospitals that worked with me to create policies and protocols

and to those facilities that shared their documentation with me.

Purpose

To outline the management of patients receiving aromatherapy treatment.

Deﬁnitions

Clinical aromatherapy is the controlled use of essential oils to enhance health

and well being, which targets a speciﬁc symptoms.

Topical application refers to the “m” technique, light massage, a compress

with water, carrier oil, or gel (spore or bacteria free) on cotton squares directly

over the affected area, or a bath (hand, foot, sitz, or full).

Inhalation can be indirect or direct, differentiated as follows:

• Direct inhalation means applying two to ﬁve drops of essential oil to a tissue

and breathing normally for up to 15 minutes, applying two to ﬁve drops of es-

sential oil on a cotton ball placed under the pillowcase, or ﬂoating two to ﬁve

drops of essential oil on a bowl of hot water and inhaling the aroma for up to

10 minutes. Patients should remove spectacles and keep eyes closed.

• Indirect inhalation means using an electric nebulizer or battery-operated dif-

fuser to diffuse ﬁne particles of essential oil within a room.

Carrier oil is a cold-pressed vegetable oil. The most frequently used is sweet

almond oil. Carrier oils have speciﬁc properties. Culinary oils are not suitable.

Patch testing is the process used to determine if a person is sensitive to po-

tential allergens in an essential oil. Two drops of the mixture at double the con-

centration to be used are put on an adhesive bandage, attached to the patient’s up-

per arm, and left for 12 hours.

Goals

• To promote a sense of well being

• To promote relaxation and reduction of stress

• To reduce or alleviate physical, emotional or spiritual symptoms

Indications

• Stress and related disorders

• Anxiety, depression, sadness, grief, anger

• Insomnia

• Digestive disorders, cramping, nausea

• Pain

• Muscular problems

• Inﬂammation

• Infection

• Mental agitation

• Premenstrual syndrome, menopausal problems

• Slow wound healing

Contraindications

• Use with caution in pregnancy, epilepsy, hypertension, estrogen-dependent tu-

mors, and patients with sensitivities and allergies.

Policy

• Essential oils should be used in a clinical setting by a licensed health profes-

sional trained in the use of essential oils. Such training should be clinical and

should be acceptable to the establishment where the health professional works.

Such training should cover safety precautions, potential side effects, and con-

traindications related to the use of each essential oil (see Table A2-2 and Box

A2-2).

• Treatments should be offered after consultation with the patient and after re-

ceiving their verbal consent or that of their family when applicable.

• Aromatherapy does not require medical order except for perceived prescriptive

use. Nurses need to check with their Board of Nursing (see Chapter 6).

• Treatment will vary according to each patient and his or her needs (see Table

A2-1).

• Essential oils used should be limited to the attached list (see Table A2-3).

• Full botanical name will be used.

• Aromatherapy will be offered in addition to conventional treatments.

• The dignity of the patient will be respected at all times.

380 Appendix II Policies, Protocols, and OSHA

• A Material Safety Data Sheet (MSDS) and Gas Chromatography/Mass Spec-

trometry (GCMS) is available for each essential oil used (see Box A2-1).

A health professional using aromatherapy as part of patient care will do the

following.

• Check with patients about skin reactions to nuts, essential oils, perfumes, cos-

metics, or pharmaceuticals

• Know how to take a proper case history to decide if the patient has a condition

or is taking a drug that might contraindicate speciﬁc essential oils

• Know how to perform a patch test and use this in appropriate cases

• Ensure all undiluted essential oils (singles or mixtures) used by patients are ad-

equately labeled and in bottles with integrated drop dispensers

• Advise patients not to ingest essential oils (except as part of speciﬁed treatment

given by a person with prescription authority)

• Have sufﬁcient knowledge of clinical practice to know when to avoid a partic-

ular procedure and when to obtain further medical assistance

Appendix II Policies, Protocols, and OSHA 381

Table A2-1 h Sample Protocol and Policy

Procedure Important Points

Assess patient

Obtain history, including allergies,

medications, skin integrity, and liked

and disliked aromas.

Explain the procedure.

Select essential oil and identify

method to be used. Advise about

photosensitivity when relevant.

Ensure patient privacy. Provide

treatment.

If a skin reaction occurs, remove

essential oil with milk or carrier oil,

wash the area with unscented soap

and water, pat dry, and leave in open

air for 10 minutes.

Evaluate the patient’s response and

document the treatment in the

medical records.

Be aware of patient sensitivities: see

safety guidelines.

Provide information about aro-

matherapy.

Effects of inhalation are rapid; topical

action is slower. Choice to be deter-

mined by patient’s condition and tar-

geted outcome.

Be sensitive about others in the room.

Complete an occurrence report and

notify the appropriate staff. Provide

follow-up care.

Documentation includes assessment,

choice of essential oil, method, and

outcome.

Practitioner Safety

Practitioner safety measures should include the following.

• Maintain good ventilation in treatment areas.

• Air the treatment room between treatment sessions.

• Wash hands before and after patient contact.

• Take a minimum of 5 minutes to breathe fresh air after each treatment.

An algorithm can be a simple and clear way to explain a thought process.

Please see Fig. A2-1 for an algorithm exploring the use of lavender as a sleep aid.

382 Appendix II Policies, Protocols, and OSHA

BOX A2-1 Sample Material Safety Data Sheet (MSDS)

Individual Safety Data Form for Speciﬁc Essential Oil

HP’s name Patient’s name Date Time

Florence Nightingale John Doe 11/11/96 3 p.m.

Essential oil: Melaleuca alternifolia CT terpineol

Number of drops: 1-5

Known Hazards Risks

Xn: Cat 3 carcinogen R10/22/38

 190 mg/kg Flammable, harmful if swallowed, not

irritating to the skin

Safety Other safety data

S24/25 No sensitization (Ford 1988)

Avoid contact with skin and eyes No phototoxicity (Ford 1988)

Nonirritant

Emergency Treatment:

• If swallowed, drink full-cream milk and seek medical attention.

• If in eye, irrigate with vegetable oils or full-cream milk followed by water,

then seek medical attention

Application Method Contraindications Precautions

Topical, inhalation — Avoid using teatree with high

1,8-cineole content

Other Information:

• Can be used neat on insect bites/stings/zits

• Can be used in gargle and mouthwash (1–2 drops)

• Can be used vaginally diluted in carrier oil

• Insoluble in water: dissolve in alcohol/milk

• Ensure correct chemotype  low cineole. Cineole can be a mucous-

membrane irritant.

Sources: AMA Council on Medical Service Report “Growing Nursing Shortage in the

USA.” South Florida Business Journal; California Nurses Association

Appendix II Policies, Protocols, and OSHA 383

Table A2-2 h Accident Procedures

Problem Answer

Essential oil in the eye Irrigate the eye with milk or carrier oil, then

with water. Keep the bottle to show which

essential oil was being used. Seek medical as-

sistance.

Used an undiluted essential oil Dilute with carrier oil, then wash with non-

(high phenols), skin burned perfumed soap and water and dry. Seek med-

ical assistance.

5 ml (or more) essential oil Give milk to drink, and keep the bottle.

taken orally Seek medical assistance. Essential oils, when

taken in amounts greater than 5 ml by

mouth, should be treated as poisons.

Bottle of essential oil dropped Use a paper towel to soak up essential oil and

and broken, essential oil and collect the glass. Put mixture in more paper.

glass on ﬂoor Dispose in double-sealed plastic bag.

BOX A2-2 General Safety

Storage

All essential oils should be stored as follows:

• Locked up

• Out of reach of children

• In a cool place

• In tightly closed containers

• Away from food, drink, or animal feed

• Away from heat

• Away from naked ﬂames

Labeling

All bottles containing essential oils should be clearly marked with indelible

labels that include the following:

• Full botanical name

• Relevant safety information

• Quantity of oil

• Company name and address

Packaging

• All essential oils should be packaged in colored glass bottles that include

an integral dropper of standard (20 drops per ml) size.

Continued

384 Appendix II Policies, Protocols, and OSHA

BOX A2-2 General Safety—cont’d

Procedures

• Essential oils should only be used in a clinical setting by a member of the

staff or an outside contractor qualiﬁed in aromatherapy and who has per-

mission to use them.

• Whenever possible, essential oils should be used in enclosed areas to pre-

vent the aromas from spreading.

• All essential oils used should be documented in the patient-care plan.

• The positive and negative effects of essential oils should be evaluated and

noted.

• Use topically in 1%-5% dilution, except in speciﬁc situations as recom-

mended by safety guides.

• When used in a bath with the elderly or small children, essential oils

should be dissolved in a small amount of milk to avoid possible corneal

damage during splashing.

• Essential oils that carry a high risk should be avoided. They are listed in

safety guides (Tisseland, Balass 1995). A suggested list of safe oils can be

found in Table A2-3.

Clothing

• No special clothing is required, but some essential oils such as German

chamomile may leave stains.

Disposal

Essential oils are highly ﬂammable and carry intense aromas. They should be

disposed of in a sealed, polythene bag.

Table A2-3 h Some Essential Oils Suitable for a Clinical Setting

Common Name Botanical Name

Yarrow Achillea millefolium

Angelica Angelica archangelica (root)

Frankincense Boswellia carteri

Ylang ylang Cananga odorata

Roman chamomile Chamomelum nobile

Bergamot Citrus bergamia

Mandarin Citrus reticulata

Neroli Citrus aurantium var. amara ﬂos

Petitgrain Citrus aurantium var. amara fol

Myrrh Commiphora myrrha

Appendix II Policies, Protocols, and OSHA 385

Table A2-3 h Some Essential Oils Suitable for a Clinical Setting—cont’d

Common Name Botanical Name

Cypress Cupressus sempervirens

Palma rosa Cymbopogon martini var. motia

Lemongrass Cymbopogon citratus

Blue gum Eucalyptus globulus

Gully gum Eucalytpus smithi

Lemon gum Eucalyptus citriodora

Fennel Foeniculum vulgare

Everlasting ﬂower Helichrysum italicum

Juniper Juniperus communis

True lavender Lavandula ofﬁcinalis

Spike lavender Lavandula latifolia

Lavandin Lavandula hybrida CT grosso

German chamomile Matricaria recutita

Tea tree Melaleuca alternifolia

Melissa Melissa ofﬁcinalis

Peppermint Mentha piperita

Basil Ocimum basilicum (European)

Marjoram Origanum majorana

Geranium Pelargonium graveolens

Black pepper Piper nigrum

Rose Rosa damascena

Rosemary Rosmarinus ofﬁcinalis

Clary sage Salvia sclarea

Sandalwood Santalum album

Clove bud (only use diluted) Syzygium aromaticum

Thyme Thymus vulgaris CT linalol

Vetiver Vetiveria zizanioides

Ginger Zingiber ofﬁcinale

Client Complaint: Sleeping Problem

Perform history and physical examination

(Rule out and treat contributing causes, such as pain, GI upset,

psychiatric conditions, medication interactions, and poor sleep

habits. Rule out and treat medical conditions).

Persistent sleep problem

(psychotropic medication usually considered here)

Discuss traditional

treatments

Client allergy or dislike

of lavender oil?

Would client consider aromatherapy via inhalation?

Yes No

Institute aromatherapy and sleep educationConsider alternative

essential oils or

traditional treatments

Provide client with sleep diary

Reevaluate client sleep

and review sleep diary

Sleep improved?

Begin treatment: One drop of essential oil of

lavender at bedtime, placed on pillow case

or on cotton ball then placed in pillow case

Yes No

Reevaluate: history and physical exam;

contributing factors of sleep problems;

correct use of lavender oil

Continue aromatherapy

as needed and continue

to evaluate sleep

Consider continued aromatherapy trial

or discuss traditional treatments

Yes No

Figure A2-1 Nonpharmacological Approach to Sleep Problems in the Elderly. Kindly

supplied by Sherry Simpson (2001).

Regulations and Health

In the United States, the two most important groups of regulations aromatherapy

needs to address are those proposed by OSHA and JCAHO. For more informa-

tion about JCAHO, see their Web site at www.jcaho.com. The most interesting

part of the site for aromatherapy is the section on mind/body, spirituality, cultural,

and psychosocial needs of patients.

OSHA is concerned with the transport, storage, and spillage of quantities of

hazardous material. Essential oils fall into this category, particularly in large

amounts. OSHA requirements go well beyond those normally required for aro-

matherapy use. However they are presented here in the unlikely event they might

be needed. The people most likely to use this chapter are those preparing the

MSDS for various essential oils.

The latest information on OSHA can be obtained from their Web site:

www.osha.gov. A wide variety of materials including standards, interpretations,

directives, and more can be purchased on a CD-ROM from the US Government

Printing Ofﬁce. To order, apply to

Superintendent of Documents

PO Box 371954

Pittsburgh, PA 15250-7954.

OSHA is divided into 10 regions. OSHA requires that MSDS be completed

for any substance used on or with the public. Their toll-free compliance-

assistance number is 1-800-321-OSHA(6742) or (202) 693-2100. Alternatively,

a contact number may be sent to OSHA and their Compliance Assistance Phone

Service will contact you, if you are located in the United States. To send a day-

time contact number, forward your message to [email protected].

A formal letter describing the particulars of the workplace and question also

can be mailed to:

Department of Labor—OSHA

200 Constitution Avenue NW

Room N3603

Washington, DC 20210

OSHA

OSHA was created for the following purposes.

• Encourage employers and employees to reduce workplace hazards and to

implement new, or improve existing, safety and health programs

• Provide for research in occupational safety and health to develop innova-

tive ways of dealing with occupational safety and health problems

• Establish “separate but dependent responsibilities and rights” for employ-

ers and employees for the achievement of better safety and health condi-

tions

• Maintain a reporting and recordkeeping system to monitor job-related in-

juries and illnesses

Appendix II Policies, Protocols, and OSHA 387

• Establish training programs to increase the number and competence of oc-

cupational safety and health personnel

• Develop mandatory job safety and health standards and enforce them ef-

fectively

• Provide for the development, analysis, evaluation, and approval of state oc-

cupational safety and health programs.

OSHA does not cover self-employed people, farms that only employ family

members, or working conditions regulated by other federal agencies. OSHA is

concerned with safety and risk management of potentially hazardous substances

in the workplace. Hazardous substances include essential oils, as they are ﬂam-

mable and in some cases are skin irritants or sensitizing. The object of OSHA for

aromatherapy is to assess and evaluate risk, thereby reducing the possibility of

harm for those using essential oils either directly or indirectly. Risk and safety

phrases to be used are listed in the material safety data sheet (MSDS). By stan-

dardizing them in this way, anyone looking at an OSHA document on an essen-

tial oil will immediately recognize its potential risk. MSDSs are required by

OSHA. Some parts of the documentation may help health professionals and

health administrators make an informed judgment about the safety of each es-

sential oil in a clinical setting. However, much of the data involves estimates, not

actual exact evidence.

OSHA assessment requires the person wanting to use essential oils to be

aware of any potential hazards and risks involved. Essential oils that are deﬁned

as dangerous (corrosive, irritant, or toxic), need to be clearly identiﬁed as to the

maximum exposure limit and the occupational exposure limit of any given essen-

tial oil. This will indicate the toxicity of an essential oil. Toxicity is measured by

the oral dose needed to kill 50% of experimental animals (LD

). It is expressed

in milligrams per kilogram of body weight (mg/kg). The dose needed to kill 50%

of experimental animals when taken other than orally is the lethal concentra-

tion(LC

). Degrees of toxicity are listed in Table A2-4.

Essential oils are classiﬁed simply with a T (for toxic) hazard sign. An essen-

tial oil classiﬁed in this way will also have speciﬁc risk phrases on its labeling such

388 Appendix II Policies, Protocols, and OSHA

Table A2-4 h Degrees of Toxicity

Extremely toxic Up to 1 mg

Highly toxic 1-50 mg

Moderately toxic 50-500 mg

Slightly toxic 0.5-5 g

Virtually nontoxic 5-15 g

Relatively harmless Up to 15 g

as “toxic if inhaled, toxic if swallowed, toxic if in contact with the skin,” or “harm-

ful if inhaled, harmful if swallowed, harmful if in contact with the skin,” and spe-

ciﬁc safety phrases. Lists of essential oil classiﬁcations/guidelines are available

that grade essential oils by giving them hazard symbols and acceptable risk (R)

and safety (S) phrases. Some essential oils, such as cedarwood, clary sage, and

geranium, have no hazard symbol or R and S number. Some, like grapefruit and

lemongrass, have no hazard symbol and no safety phrase but carry a risk phrase

such as R10, which means ﬂammable, or R38, which means irritating to the skin.

An MSDS identiﬁes potential hazards of transporting and storing essential oils

and is intended to warn people of any risk factors. It will include the features

listed in Box A2-3. A list of organizations that give registration numbers is in

Table A2-5.

Essential oil product identiﬁcation includes the plant material, physical con-

stants, registrations (usually in the form of numbers), and safety and toxicity con-

siderations such as the ﬂash point (the temperature at which an essential oil will

ignite). This information should be available from the essential-oil dealer. Sam-

ple MSDS is shown in Box A2-4.

Flavor and Extracts Manufacturers Association

The Flavor and Extracts Manufacturers Association (FEMA), the oldest and

largest national association of the ﬂavor industry, produces many data sheets

on essential oils (as well as ﬂavor data sheets). They can be obtained in sets. The

Appendix II Policies, Protocols, and OSHA 389

BOX A2-3 Information Found on Material Safety Data Sheets

(MSDSs)

1. Identiﬁcation of the substance/preparation and company

2. Composition/information on ingredients

3. Hazards identiﬁcation

4. First-aid measures

5. Fire-ﬁghting measures

6. Accidental-releases measures

7. Handling and storage

8. Exposure controls/personal protection

9. Physical and chemical properties

10. Stability and reactivity

11. Toxicologic information

12. Ecologic information

13. Disposal considerations

14. Transport information

15. Regulatory information

16. Other information

BOX A2-4 Sample Material Safety Data Sheet (MSDS)

for Tea Tree

Product Identiﬁcation

Name Tea tree

Botanical name Melaleuca alternifolia

Chemotype Terpineol

FEMA number

CAS number 68647-73-4

Extraction Steam distillation of the leaves

Speciﬁcations

Odor Fresh, eucalyptus type, herbaceous, antiseptic

Origin Australia

Appearance Clear to faintly yellow

Analytical Data

(1) Physical constants Speciﬁc gravity: 0.895–0.905 g

Optical rotation: @ 20°C  6.59.5

Refractive index: @ 20°C 1.476 to 1.481

Solubility: 1 vol of oil in 0.75 vol of 85% ethanol

(2) Chemical composition See GLC

Toxicity

Low cineole content  6% (as used for medicinal and dental purposes) re-

ported to be nonirritant. LD

 400 mg (Ford 1988)

Flash Point

57–61°C

Table A2-5 h Organizations that Give Registration Numbers

CAS Chemical Abstracts Service

EINECS European Inventory of Existing Chemical Substances

FEMA Flavor and Extracts Manufacturers Association

IFRA International Fragrance Association

RIFM Research Institute for Fragrance Materials

CTFA Cosmetic Toiletry and Fragrance Association

INCI International Nomenclature of Cosmetic Ingredients

EFFA European Flavor and Fragrance Association

IOFI International Organization of the Flavor Industry

FDA Food and Drug Administration

AIS Association Internationale de la Savonnerie et de la Detergence

USES Uniform System for the Evaluation of Substances

Research Institute for Fragrance Materials (RIFM) was established in 1966 and

is a not-for-proﬁt. The expert panel is independent of any manufacturing inter-

ests. RIFM collects and researches raw perfumery materials. The information is

submitted to the International Fragrance Association (IFRA) (established in

1973). The IFRA produces guidelines for individual fragrance ingredients and is

involved in risk management. IFRA publishes a “banned list” of 50 substances,

and a further 58 have limitations for use. Some essential oils have many more

regulatory numbers. Other important fragrance organizations are in Table

A2-6. Opdyke’s monographs on fragrance raw materials (1978) are also a good

source of information.

Risk phrases give an indication as to how ﬂammable an essential oil may be,

if it is harmful when swallowed, if there is a risk of eye damage, if it may cause

birth defects, etc. Safety phrases provide an indication of how to store the oil and

dispose of it and what it will mix with. Both phrases are expressed as numbers.

Mandarin has risk phrase number R10 (ﬂammable) and safety phrase number S3

(keep in a cool place). R65 relates to the potential of a substance to cause lung

damage after swallowing and is concerned with substances that contain more

than 10% of aliphatic, alicylic, or aromatic hydrocarbons. This is a relatively new

risk hazard that only came into being in May 1988. An example of the different

numbers given to one essential oil is in Table A2-7.

Some essential oils are not on the list of any of the fragrance organizations

mentioned. Ravensara is one such example. When an essential oil is not listed, it

should be possible to evaluate its risk and safety issues based on the chemical

components within the essential oil. Therefore the simplest thing is to look them

Appendix II Policies, Protocols, and OSHA 391

Table A2-6

h Other Important Organizations within the Fragrance

Industry

IFEAT International Federation of Essential Oils & Aroma Trades

COLIPA The European Cosmetic, Toiletry and Perfumery Association

NAFFS National Association of Flavors and Food-Ingredient Systems

FF Fragrance Foundation

Table A2-7 h Example: Citrus reticulata blanco Regulatory Numbers

REFM 250

FEMA 2657 (GRAS)

FDA 182.20

CAS 8008-31-9

up in a phytochemical database or a reference book such as Essential Oil Safety.

(Tisserand & Balacs 1995). While this section has gone into tremendous detail,

the important thing to remember is essential oils are safe when used correctly.

REFERENCES

Burﬁeld T. 2001. Toxicity myths. www.aroma-science.com. Sept. 2002.

Ford R. 1988. Tea tree oil. Food and Chemical Toxicology. 26: 407.

Opdyke D. 1978. Monographs on fragrance raw materials. Food and Cosmetics Toxicol-

ogy. 16: 783-784.

Simpson S. 2001. Personal communication.

Tisserand R, Balacs T. 1995. Essential Oil Safety. London: Churchill Livingstone.

392 Appendix II Policies, Protocols, and OSHA

393

Appendix III

The White House Commission

on Complementary

Alternative Medicine Policy

he White House Commission on Complementary Alternative Medicine

Policy (WHCCAMP) was created on March 8, 2000, by executive order.

The 2-year commission will ultimately report to the president with leg-

islative and administrative recommendations to ensure US public policy will max-

imize the beneﬁts of complementary and alternative medicine (CAM) (Gordon

2002). The commission includes 20 members who represent a diverse range of ex-

perts in biomedical, medical, and CAM ﬁelds. The chair, James Gordon, MD, is

helped by the following commissioners.

Bernier, George, MD Kerr, Charlotte, RSM, RN, MAC

Bresler, David, PhD Larson, Linnea, LCSW

Chappell, Thomas Low Dog, Tieraona, MD

Chow, Efﬁe, PhD Ornish, Dean, MD

DeVries III, George Paz, Conchita, MD

Fair, William, MD Pizzorno, Joseph, MD

Fins, Joseph, MD Rolin, Buford

Guttierrez Veronica, DC Scott, Julia

Jonas, Wayne, MD Tian, Xiaoming, MD

Warren, Donald, DDS

The National Center for Complementary Alternative Medicine (NCCAM),

which is part of the National Institutes of Health (NIH), divides CAM is divided

into ﬁve categories. These categories are alternative medical systems, mind-body

interventions, energy therapies, manipulative and body-based methods, and bio-

logically based treatments (see Table A3-1).

Testimony indicated that coverage of CAM had been included by some em-

ployer-sponsored health plans as a direct response to employee requests. The

commission held meetings in Washington DC, Seattle, San Francisco, New York,

and Minneapolis, and spoke positively about encouraging rigorous research ($220

million was allocated for 2002).

The commission reported on four key areas:

1. Education and training of health care practitioners

2. Research to increase training of health care practitioners

3. Provision of health care professionals and the public with reliable infor-

mation

4. Guidance in appropriate access to and delivery of CAM

The report was ﬁled after 14 meetings lasting over 18 months, in which sub-

missions were heard from 1700 people and organizations from groups as diverse

as the National Heart Lung and Blood Institute, the National Cancer Institute,

the Food and Drug Administration, Blue Cross/Blue Shield, and the Journal of

the American Medical Association, as well as many CAM practitioners and their

organizations. It has 29 recommendations and 100 action items—too many to list

here. But the response to the commission’s recommendation by Dr Tieraona Low

Dog MD and Joseph Fin MD is available at www.whccamp.hhs.gov/sfc.html.

Nurse Practice Acts

While the use of complementary therapies, including aromatherapy, has increased in

the last few years, there is little reference in any published articles to the state prac-

tice laws and how they impact the professional use of CAM. However, licensure laws

do affect the use of CAM. Sparber (2001) reports on a study of state Boards of Nurs-

ing (BON) policy conducted for WHCCAMP, the National Center for Comple-

mentary Alternative Medicine, and the Health and Human Services Bureau of

Health Professions. The study found that liberalization of licensure laws to practice

CAM has been associated with a signiﬁcantly increased use by physician and non-

physician CAM providers. CAM was viewed as representative of the “integrative na-

ture of nursing practice rather than as an alternative method of care.”The report sug-

gests nurses are in a unique position to bridge the gap between orthodox, Western

health care and CAM.

394 Appendix III The White House Commission

Table A3-1 h Categories of Complementary Alternative Medicine

Alternative Medical Systems: Acupressure, biologically based therapies, orien-

tal massage, diet and nutrition (not herbs)

Mind-Body Interventions: Art, biofeedback, focused breathing, holistic nurs-

ing, humor, meditation, music, visual imagery, yoga

Manipulative and Body-Based Systems: Aromatherapy, cranial-sacral, deep-

muscle massage, efﬂeurage, Esalen, feldencras, friction, Heller work, infant mas-

sage, Lomilorri, lymphatic drainage, myofascial, neuromuscular, petrissage, re-

ﬂexology, shiatsu, structural integration, Swedish massage

Energy Therapies: Healing touch, Reiki, therapeutic touch

Biologically Based Systems: Herbs

The Louisiana BON www.lsbn.state.la.us deﬁnes CAM as a “broad domain

of healing resources that allow registered nurses to promote and/or enhance care

supportive to or restorative of live and well being.” Sparber (2001) has written an

important document that clariﬁes the situation for many nurses. BONs are re-

quired to monitor the scope of practice issues and protect the public through li-

censure and practice acts. Employers also have a role in safe practice. Anecdotal

reports indicate that although some nurses may consider certain complementary

therapies to be questionable, professional nurses who use these therapies report

their patients do experience an “increased level of comfort and well being”(Spar-

ber 2001). The ﬁfth WHCCAMP category was not included in the article as it

is concerned with the prescriptive authority for herbal and other natural products.

However, some boards did have recommendations for advanced nursing practice.

At the time of writing, 47% of BONs had taken a position that allows nurses

to practice a range of complementary therapies. Thirteen percent were in the

process of deciding on their policy, and 40%, although they did not have any for-

mal policy, did not discourage nurses from using complementary therapies as part

of their care (Table A3-2). Some states, noticeably Minnesota, have recently

passed policies that cover the use of CAM by nonlicensed health professionals

(www.minnesotanatucalhealth.org). Sturn and Unutzer (2001) write that the exis-

tence of a practice act that gives nonphysicians speciﬁc rights to deliver CAM is

likely to increase the supply of persons practicing CAM.

The ﬁrst state BON to issue a formal statement on CAM was Arizona (1991).

This BON states that a nurse may hold dual professional licensure/certiﬁcation, but

the nurse will be held to the standard of the highest nursing credential he or she

holds. “A professional, practical or advanced practitioner who has acquired or de-

veloped a specialized knowledge base in complementary therapies will be held to

the standard of care for the nursing credential” (www.azboardofnursing.org). Ken-

tucky followed in 1996, after several inquiries from nurses wanting to know if

they could use their complementary-therapy skills to enhance nursing care

(www.kbn.state.ky.us). In 1997, Massachusetts (www.state.ma.us/reg/boards/rn)

and Pennsylvania (www.dos.state.pa.us) made general-position statements describ-

ing complementary therapies as being “within the scope of nursing practice” but

noting that “the nurse had responsibility for safe practice.”

Most BONs agree that the very nature of nursing lends itself to a framework

that welcomes these noninvasive, complementary practices, and that much of the

thinking behind nursing is similar to that underlying complementary therapies

(Sparber 2001). What has come out of the WHCCAMP report is the need for

documented training that clearly shows skills, knowledge, and competency in a

CAM discipline. Credentialing is recommended to ensure safe practice and to in-

dicate to other health professionals that nurses have learned another discipline. It

is suggested that nurses do not use titles such as “nurse massage therapist” unless

they are certiﬁed in massage. However, some states disagree with this. The New

York BON says nurses “cannot hold themselves out to be nurse reﬂexologists—

but they can say that reﬂexology is a service included as part of their overall

care” (O’Brien 2001). New York requires nurses who wish to use CAM to have

Appendix III The White House Commission 395

Board of Nursing is Deliberating Practice of CAM

Delaware

District of Columbia

Georgia

“received special training or education in this area and have received a certiﬁcate

of competency” (O’Brien 2001). The Oregon BON has stated that “complemen-

tary therapies ﬁt within the deﬁnition of the practice of nursing” (Amdell-

Thompson 2001). For up-to-date information on all State Boards of Nursing, see

the web site of the National Council of State Boards of Nursing (www.ncsbn.org/

public/regulation/boards_of_nursing_board.htm).

According to the WHCCAMP report, aromatherapy is accepted as part

of nursing care in over half the states in the United States. What is also clear is

that while there are many types of touch, there only appears to be one kind of

aromatherapy, and that is the one associated with topical applications. This is a little

strange as much of the psychological impact of essential oils will be from inhalation.

396 Appendix III The White House Commission

Table A3-2 h CAM Policies of Individual US States and Territories

Board of Nursing Has Issued Statement Permitting Practice of CAM

Arizona

Arkansas

California

Connecticut

Illinois

Iowa

Kansas

Louisiana

Maine

Maryland

Massachusetts

Mississippi

Missouri

New Hampshire

New York

Nevada

North Carolina

North Dakota

Minnesota

New Jersey

New Mexico

Ohio

Oregon

Pennsylvania

South Dakota

Texas

Vermont

West Virginia

Washington

Board of Nursing Has No Formal Position, but Does Not Necessarily

Discourage CAM

Alabama

Alaska

Colorado

Florida

Georgia

Hawaii

Idaho

Indiana

Tennessee

Utah

Virginia

Virgin Islands

Washington

Wisconsin

Wyoming

Kentucky

Michigan

Montana

Oklahoma

Puerto Rico

Rhode Island

South Carolina

The American Holistic Nurses Association (AHNA) has for many years

been the standard bearer for a more holistic approach to nursing care and more

recently has embraced complementary therapies in nursing. In 1994, the AHNA

approached me and asked me to create a course in clinical aromatherapy for

nurses in the USA. The course, Aromatherapy for Health Professionals was en-

dorsed by the AHNA in United States. In 2000, I worked with the AHNA to

produce the following statement on complementary therapies in nursing:

Nursing Complementary and Alternative Modalities (NCAM) offer therapies that

supplement conventional nursing care. NCAM encompasses a broad range of heal-

ing resources that allow registered nurses to integrate such therapies into the nurs-

ing process, which can interface with traditional medical and/or surgical therapies

in order to enhance and promote preventive, supportive, or restorative care.

AHNA is an organization of professional nurses dedicated to the promotion

of health and healing of the whole person: body, mind, emotions, behavior, and

spirit. Holistic nurses utilize nursing interventions that can impact body, mind,

emotions, behavior, and spirit. Holistic nurses integrate nursing theory and prac-

tice models for health care that:

1. Promote and enhance health and well being, or support peaceful dying so

that the person is as independent as possible

2. Manage prescribed care directed toward the prevention and complications

of illness

3. Guide the healing of self and others.

For further information, see the AHNA Standards of Holistic Nursing Practice by

Frisch et al (2000) and Holistic Nursing: A Handbook for Practice (Keegan et al 1999).

The AHNA believes in the integration of NCAM into conventional nursing

care so the client can derive beneﬁt from the best of all interventions available.

The National Institute of Health Center on Complementary and Alternative

Medicines groups CAM practices into ﬁve major domains (National Center for

Complementary and Alternative Medicine 2000):

1. Alternative medical systems are complete systems of theory and practice

developed outside the Western biomedical approach (examples include

acupuncture and Oriental medicine).

2. Mind-body–based modalities include behavioral, psychological, social,

and spiritual approaches to health.

3. Biologically based modalities include natural and biologically based prac-

tices and holistic nursing interventions, such as special diets/nutrition, bio-

chemical monitoring, and aromatherapy.

4. Manipulative and body-based methods

5. Energy therapies

The AHNA recognizes the major domains of CAM as modalities that fall

within the realm of holistic nursing practice, except for Alternative Medical

Systems, which may require additional preparation to practice. The AHNA be-

lieves nurses must fulﬁll the educational and licensing/certiﬁcation qualiﬁcations

required by those disciplines.

Appendix III The White House Commission 397

The AHNA believes the integration of CAM into conventional practice of-

fers opportunities for a higher quality of care. However, the AHNA does not

equate the practice of a CAM modality with holistic care. Rather, holistic care is

deﬁned as the interventions built upon basic nursing practice. Nursing practice is

deﬁned and built upon by three standardized languages for classifying what and

how nurses practice nursing. They are as follows.

1. Nursing Interventions Classiﬁcation (NIC): is a comprehensive stan-

dardized nomenclature describing treatments nurses perform: more than

486 direct and indirect interventions (McCloskey & Bulechek 1999).

2. Nursing Diagnoses Deﬁnitions & Classiﬁcations (NANDA Associa-

tion, 2000)

3. Nursing Outcomes Classiﬁcation contains treatment outcomes repre-

senting all nursing-practice settings and clinical specialties (260 nursing-

sensitive patient outcomes organized in seven domains and 29 classes)

Federal law governing the practice of nursing requires registered nurses to prac-

tice within the scope appropriate to their educational level, knowledge, skill, and

abilities. It allows registered nurses to perform additional acts (such as NCAM) rec-

ognized within the standards of nursing practice and that are authorized by the

nurse’s state BON. Furthermore, registered nurses may employ and initiate such

therapies as part of an overall plan of nursing care to meet nursing and patient goals

(provided the patient has granted informed consent). Goals for the patient include

pain reduction, improved comfort, relaxation, improved coping mechanisms, reduc-

tion or moderation of stress, modiﬁcation of unhealthy behaviors, and enhancing a

sense of well being. In all practice settings, the registered nurse must have written

policies and procedures in place that guide the performance of such modalities. For

more general questions on nursing, complementary therapies, and their legality,

contact www.legalnurse.com.

REFERENCES

Amdell-Thompson M. 2001. State boards of nursing (BONs)—Oregon. Retrieved April

2, 2003 from Mary.AMDELL-[email protected].us

Frisch N, Dossey B, Guzzetta C, et al. 2000. AHNA Standards of Holistic Nursing

Practice. Gaithersburg, MD: Aspen.

Gordon J. 2002. Interim Progress Report. Alternative Therapies. 7(6) 32-40.

McCloskey J, Bulechek G. (eds). 1999. Nursing Interventions Classiﬁcation (NIC).

London: Harcourt.

National Center for Complementary and Alternative Medicine. 2000. Five-Year Strate-

gic Plan. June 26. Retrieved October 2001 from http://www.niccam.nih.gov.

O’Brien L. 2001. State boards of nursing (BONs)—New York. Retrieved April 2, 2003

from Lobr[email protected].

Sparber A. 2001. State Boards of Nursing and Scope of Practice of Registered Nurses

Performing Complementary Therapies. Online Journal of Issues in Nursing. August

13. Retrieved October 2002 from http://www.nursingworld.org/ojin/topic15.

Sturn R, Unutzer J. 2001. State legislation and the use of complementary and alternative

medicine. Inquiry 37:423-429.

398 Appendix III The White House Commission

Appendix IV

Recommended Essential-Oil

Distributors

here are many essential oil distributors that sell good essential oils, and it

would be impossible to list them all. Instead I have listed a few companies

I have used for many years. There are the ﬁve companies I use in my cer-

tiﬁcation program and others I use for my courses.

Companies Used in Certiﬁcation Program

Florial France

42 Chemin Des Aubepine

06130 Grasse, France

www.ﬂorihana.com

US Distributors:

Lisa Roth

2653 Blackhoof Train

Milford, OH 45150

Tel: 513-576-9944

Email: danannscrossing@yahoo.com

and

Kari Morford

9418 14th Avenue SW

Seattle, WA 98106

Tel: 206-768-2568

Email: [email protected]

Fragrant Earth Ltd.

Orchard Court, Magdelene Street

Glastonbury, Somerset BA6 9EW UK

www.fragrant-earth.co.uk

Northwest Essence

Director: Cheryl Young

PO Box 428

Gig Harbor, WA 98335 USA

Tel: 253-858-0777

Email: [email protected]

Scents & Scentsibility Ltd.

Director: Debbie Freund

PO Box 8013

Bridgewater, NJ 08807 USA

Tel: 908-369-4537

www.scentsibility.com

Nature’s Gift

1040 Cheyenne Boulevard

Madison, TN 37115 USA

Tel: 615-612-4270

www.naturesgift.com

Companies Used for Other Courses

Essentially Oils Ltd.

8-10 Mount Farm, Junction Road

Churchill, Chipping Norton, OX7 6NP UK

www.essentiallyoils.com

Elizabeth Van Buren, Inc.

PO Box 7542

Santa Cruz, CA 95061 USA

Tel: 800-710-7759

www.evb.aromatherapy.com

Therapeutic Essentials

5 Michelle Court

Edgewood, NM 87015

Tel: 505-281-9547

Email: [email protected]

Springﬁeld Aromatherapy

Unit 2, 2 Anella Avenue

Castle Hill, NSW 2154

Australia

(2)9894-9934

www.springﬁeldsaroma.com

Enﬂeurage

321 Bleeker Street

New York, NY 10014 USA

888-387-0300

www.enﬂeurage.com

400 Appendix IV Recommended Essential-Oil Distributors

401

Appendix V

Useful Addresses, Databases,

and Web sites

search on www.google.com or using one of the following databases is a

great way to begin a search for studies on aromatherapy. For botanical

sites, use an individual essential oil, either botanical or common name, as

your search term is likely to bring up more studies than using aromatherapy. For

more information on databases please see Wootton’s Directory of databases for

research into alternative & complementary medicine (1997) in the Journal of Al-

ternative & Complementary Medicine. One of the best places to start for aro-

matherapy searches is Bob Harris’s database, www.aromatherapy.database.com.

This is a privately owned database you can subscribe to that has abstracts of over

800 studies and is excellent value.

Databases

Agricola (National Agricultural Library database) www.nal.usda.gov

American Indian Ethnobotany Database www.umd.umich.edu

Biosciences Information Service of Biological Abstracts www.csfs.ca

Current Awareness Topics/Alternative & Allied Medicine Database

(CATS/AMED) www.bl.uk

Cumulative Index to Nursing and Allied Health (CINAHL) www.cinahl.

com

EMBASE/Excerpta Medica Secondary Publishing Division http://library.

dialog/bluesheets/html

EthnobotDB (Dr. Duke’s Phytochemical Ethnobotanical database) www.

ars.grin.gov

Focus on Alternative & Complementary Therapies (FACT); follow links

through www.pubmed.com

Food Science & Technology Abstracts www.iﬁs.org

Herb Research Foundation www.herbs.org

IBIS: The Interactive BodyMind Information Service www.ibismedical.com

The Indian Medicinal Plant Distributed Database Network (INMED-

PLAN); access through www.rosenthal.hs.columbia.edu/databases

International Pharmaceutical Abstracts (IPA) www.csa.com/csa

Journal of National Herbalists published by the National Institute of Med-

ical Herbalists www.ejhm.co.uk

Medline National Library of Medicine www.ncbi.nim.nih.gov/PubMed

Medicinal Plants of Native America Database (MPNADBP) www.ars-grin.

gov/duke

NAPRALERT (NAtural PRoducts ALERT) www.ag.uiuc.edu/~ffh/

rapra.html

National Library of Medicine www.nim.nih.gov

Occupational Therapy Index/AMED www.bl.uk/services/information/

amed.html

Phytodok (index of worldwide scientiﬁc journals) www.phytopharm.org/en/

science.html

Pubmed www.ncbi.nim.nih.gov/PubMed

Review of Aromatic & Medicinal Plants Journal www.cabi-publishing.org

Science Citation Index; follow links from www.isinet.com

Social Science Citation Index; follow links from www.isinet.com

World Research Foundation www.wrf.org

Planetree Medical Centers and Facilities

Planetree facilities are patient-centered and use complementary therapies includ-

ing aromatherapy in all their facilities. My company, R J Buckle Associates, is an

approved educational provider in aromatherapy and the “m” technique for the

Planetree Hospitals. For a list of their 45 facilities in the United States, go to

www.planetree.org.

REFERENCES

Wootton J. 1997. Directory of Databases for Research into Alternative & Complemen-

tary Medicine. Journal of Alternative & Complementary Medicine. 3(2) 179-190.

402 Appendix V Useful Addresses, Databases, and Web sites

403

Appendix VI

Hospitals and Other

Institutions Employing

Aromatherapy in Treatment

USA

Desert Samaritan Medical Center,

Mesa, Arizona

Fountain Valley Hospital, Fountain

Valley, California

Orange Coast Memorial Hospital,

Fountain Valley, California

Saddleback Medical Center, Laguna

Hills, California

Midway Hospital, Los Angeles, Cali-

fornia

Children’s Hospital and Health Cen-

ter, San Diego, California

San Diego Hospice, San Diego, Cali-

fornia

California Paciﬁc Medical Center,

San Francisco, California

O’Connor Hospital, San Jose, Cali-

fornia

Aspen Valley Hospital, Aspen, Col-

orado

Memorial Hospital, Colorado

Springs, Colorado

St. Anthony Hospitals, Centura

Health, Englewood, Colorado

Gunnison Valley Hospital, Gunni-

son, Colorado

Grifﬁn Hospital, Derby, Connecticut

St. Francis Medical Center, Hartford,

Connecticut

Windham Community Memorial

Hospital, Willimantic, Connecti-

cut

Holy Cross Hospital, Sunrise,

Florida

Northside Hospital, Atlanta, Georgia

North Hawaii Community Hospital,

Kamuela, Hawaii

Advocate Good Shepherd Hospital,

Barrington, Illinois

St. James Health and Wellness Insti-

tute, Chicago, Illinois

Advocate Heathcare, Oakbrook, Illi-

nois

Deaconess Hospital Evansville Indi-

ana

Riverview Hospital, Noblesville, In-

diana

Memorial Health System, South

Bend, Indiana

Charlton Health System, Fall River,

Massachusetts

St. Luke’s Health Care System, New

Bedford, Massachusetts

Morton Hospital and Medical Cen-

ter, Taunton, Massachusetts

Tobey Health Systems, Wareham,

Massachusetts

Barbara Ann Karmanos Cancer In-

stitute, Detroit, Michigan

Bronson Methodist Hospital, Kala-

mazoo, Michigan

Mercy Hospital Group, Port Huron,

Michigan

St. John’s Health, Warren, Michigan

Children’s Hospital, St. Paul, Min-

nesota

Regions Hospital, St. Paul, Min-

nesota

St. Peter Community Hospital St Pe-

ter, Minnesota

Woodwinds Health Campus, Wood-

bury, Minnesota

Barnes-Jewish Hospital, St. Louis,

Missouri

St Luke’s Hospital. Chesterﬁeld,

Missouri

Bergen Mercy Medical Center, Om-

aha, Nebraska

St Rose Dominican Hospital, Hen-

derson, Nevada

Wentworth-Douglas Hospital,

Dover, New Hampshire

Cooper Hospital/University Medical

Center, Camden, New Jersey

St. Barnabas Health Care System,

Hackensack, New Jersey.

Mountainside Medical Center,

Montclair, New Jersey

Bellevue Women’s Hospital. Albany,

New York

St Peter’s Medical Center, Albany,

New York

Northern Westchester Hospital Cen-

ter, Mount Kisco, New York

Columbia Presbyterian Medical Cen-

ter,New York,New York

Bellevue Women’s Hospital,

Niskayuna, New York

Morgan Stanley Children’s Hospital,

New York, New York

New York-Weill Cornell Children’s

Hospital, New York, New York

Hugh Chatham Memorial Hospital,

Elkin, North Carolina

Iredell Memorial Hospital,

Statesville, North Carolina

Children’s Hospital Medical Center,

Akron, Ohio

Alliance Community Hospital, Al-

liance, Ohio

Cleveland Clinic Health System,

Chagrin Falls, Ohio

UHHS Bainbridge Health Center,

Chagrin Falls, Ohio

University Hospitals’ Health System,

Cleveland Ohio

Mercy Health Center, Oklahoma

City, Oklahoma

St. Charles Medical Center, Bend,

Oregon

Mid-Columbia Medical Center, The

Dalles, Oregon

Elk Regional Health Center, Elk,

Pennsylvania

St. Peter’s Hospital, Jeanette, Penn-

sylvania

Windber Medical Center, Windber,

Pennsylvania

404 Appendix VI Hospitals Employing Aromatherapy

Highline Community Hospital

Burien, Washington

Elmbrook Memorial Hospital, Brook-

ﬁeld, Wisconsin

St. Michael Hospital, Milwaukee,

Wisconsin

Shawano Medical Center, Shawano,

Wisconsin

Canada

Children’s Hospital of Western On-

tario. London, Ontario

Toronto Hospital, Toronto, Ontario

Trinity Health Center, Windsor, On-

tario

BUPA Hospital Group, nationwide

London

Edgware Hospital, Edgware, London,

Guy’s and St Thomas’ Hospital NHS

Trust London

Hammersmith Hospital NHS Trust

London

King’s College Hospital Caldecot

Centre, London

London Bridge Hospital, London

The Royal London Homoeopathic

Hospital, London

St George’s Hospital, London

St Thomas’ Hospital, London

University College Hospital NHS

Trust, London

Northern England

Bolton NHS Trust, Bolton, Lan-

cashire

Bridlington Hospital, Bridlington,

East Yorkshire

Hereford Hospitals NHS Trust,

Hereford, Herefordshire

Leeds General Inﬁrmary, Leeds,

Yorkshire

Liverpool & Broadgreen University

Hospitals NHS Trust, Liverpool

Newcastle General Hospital, Newcas-

tle, Durham

Nottingham City Hospital NHS

Trust, Nottinghamshire

Smallwood Day Hospital, Redditch,

Worcestershire

The Queen Elizabeth Hospital, Birm-

ingham

Southern England

Crowborough War Memorial Hospi-

tal, Crowborough, Sussex

Heatherwood Hospital, Ascot, Berk-

shire

Moorgreen Hospital, Southampton,

Hampshire

Mount Vernon Hospital, Northwood,

Middlesex

Musgrove Park Hospital, Taunton,

Devon

Poole Hospital, Poole, Dorset

Royal Surrey Country Hospital NHS

Trust, Guildford, Surrey

Royal South Hants Hospital,

Southampton, Hampshire

Southend Hospital NHS Trust,

Southend, Essex

Swanage Hospital, Swanage, Dorset

West Suffolk Hospital HNS Trust,

Suffolk

Dorset Cancer Centre, based at Poole

Hospital, Dorset

Queen Victoria Hospital NHS

Chartham, Kent

Scotland

Borders Community Hospital Group

thru-out Scotland

Western General Hospital, Edin-

burgh,

Appendix VI Hospitals Employing Aromatherapy 405

Western General Hospital in Edin-

burgh

Northern Ireland

Thompson House Hospital, Lisburn,

Antrim, Northern Ireland

St Francis Private Hospital,

Mullingar, Co Westmeath,

Northern Ireland

Ireland

Galway University College Hospital,

Galway

Stewarts Hospital, Dublin

Australia

Calvary Health Care, Kogarah, New

South Wales

Prince of Wales, Randwick, New

South Wales

St Vincent’s Hospital, Sydney, New

South Wales,

Mater Private Hospital, Brisbane,

Queensland

Royal Brisbane Hospital, Brisbane,

Queensland

St Andrew’s Hospital, Toowoomba,

Queensland

Cabrini Hospital, Malvern, Victoria

Myrtleford Hospital, Myrtleford, Vic-

toria

St. Vincents & Mercy Private Hospi-

tal, Melbourne, Victoria

Swinburne Hospital, Swinburne, Vic-

toria

406 Appendix VI Hospitals Employing Aromatherapy

407

Index

Abies balsamea, 17

Abortiﬁcant, pennyroyal as, 80

Abortion, 323

Abuse, substance, 357-359

Acetaminophen, 93, 215

Achilla millifolium, 42t

Acquired immunodeﬁciency disease (AIDS), 315-316

Active ingredient, isolation of, 18

Acute pain, 214

Acyclovir for herpes, 287

Addiction, 356-359

Adenosine triphosphate, 67

Adrenaline, 233

Aging, 107, 270

Alantolactone, 52, 52t

Alcohol abuse, 359

Alcohol of essential oil, 46, 47t, 48, 48t

Aldehyde of essential oil, 49-50, 49t

Allelopathy, 70

Allergic reaction, 85-87

Alpha-bisabolol, 47t

Alpha-eudesmol, 48

Altered comfort as nursing diagnosis, 121-125

Alzheimer’s disease, 261

Amygdala, 30, 111

Analgesic essential oil, 151t, 314t, 331t

Androsterone, 111

Anemia, sickle cell, 223

Anethole, 53-54

Anethum graveolens, 45

Angelica archangelica

dreaming and, 111

for nicotine withdrawal, 357

Animal testing of essential oil, 80-81

Anosmia, 31

Anthemis nobilis for inﬂammation, 223

Antibacterial essential oil, 130-131, 172-178

aromatogram for, 179-180, 179f

for lymphedema, 341t

research on, 173-178

Antibiotic, 167, 169-172

resistance to, 169, 170f, 171-172

in tuberculosis, 370

Anticarcinogenic essential oil, 335, 342t

Anticholinergic drug, 208

Anticholinergic essential oil, 211

Anticoagulant, 90-91, 256

Antidepressant drug, 361

Antifungal agent, 289-291

essential oils as, 317-319, 318t

Eucalyptus globulus as, 122

for lymphedema, 341t

Antiinﬂammatory agent

chamazulene as, 41

eczema and, 285-286

essential oils as, 223-224, 314t

for low back pain, 151t

for pain, 215-216

for postradiation burn, 339

Antimicrobial essential oil, 281t

Antiparasitic essential oil, 190-192

Antipsychotic drug, 360-361, 360t

Antiretroviral therapy, 182

Antispasmodic essential oil, 222t, 300t, 330

Antiviral agent, synthetic, 181-182

Anxiety

aromatherapy and, 242-243

in child, 346-347

myocardial infarction and, 250-251, 251t

Apium graveolens, 189

Arabia, 15-16

Aroma, 64-65, 70, 73

Aromatherapy Organisation Council, 75

Aromatherapy Registration Council, 137

Aromatogram, 177-178, 179-180, 181f

Artemisia dracunculus, 42t, 175

Artemisia parviﬂora, 187

Artemisia, 190-191

Artemisia annua, 70

Artemisia caerulescens, 219

Artemisia cina, 192

Arthritis

osteoarthritis, 152, 269-271

rheumatoid, 313-315, 314t

Aspergillosis, 185, 187-188, 189

Asthma, 365-369, 368t

Athlete’s foot, 289-291

Attention deﬁcit/hyperactivity disorder, 348-351

Autoimmune disorder, 313-315

Avicenna, 15-16

AZT, 180, 182

Note: Page numbers followed by f indicate ﬁgures; those followed by t indicate tables.

B-asarone, 91

B-mycene, 90

Bacilli, 166f

Bacillus subtilis, 174

Bacterial vaginal infection, 329

Barbiturate

b-myrcene interacting with, 90

for insomnia, 202-203

Bark, cinnamon, 95

Barrier to pain management, 216-217

Bay laurel, 183

Bedsores

in critical care patient, 279-281, 280t, 281t

in elderly, 267-269

essential oils for, 178

Benzaldehyde, 189

Benzene ring in phenol, 48-49

Benzodiazepine, 202, 208, 357t

Benzoin, skin reaction to, 85

Bergamot, 39, 87-88, 254

Beta-caryophyllene, 46t

Bilharziasis, 191

Binding of drug, 90

Biosynthesis, 43f, 65-71, 67t

Bipolar disorder, 359-363, 361t, 362t

Bitter fennel, 95

Black cumin, 172, 204

Black pepper oil, 152

Blood pressure, 95, 105

Blue gum eucalyptus, 92

Boldo leaf, 95

Bone marrow transplant, 334-335, 338

Borderline hypertension, 247-250

Borneol, 221-222

Boswellia carteri

for cryptococcosis, 318

for eczema, 286

for low back pain, 150

Bronchitis, 365-369, 368t

Bulinus truncatus, 191

Burn

essential oil for, 173

phototoxicity and, 87

postradiation, 338-339

Bypass surgery, depression after, 252-255, 253t

Calamus, 95

Calophyllum inophyllum, 279

Camphene, 366-367, 367t

Camphor, 50, 70, 95

Campylobacter enteritis, 164

Cananga odorata, 46t, 358-359

Cancer

end-of-life care in, 303-307

essential oils in, 341-342, 342t

contraindicated, 95, 342-343

for treatment side effects, 336-341

hair loss in, 339-340

lymphedema in, 340-341

“m” technique for, 153-154

nausea in, 337-338

postradiation burn in, 338-339, 339t

Candida albicans, 185

antifungal essential oils for, 188-189

nail infection with, 189

vaginal infection with, 124, 327-328, 328t

Cannabinoid, 208

Capsaicin, for pain, 221

Carbamazepine, 360t

Carbon dioxide extraction, 60t, 63-64

Carbon dioxide in photosynthesis, 67

Cardamom, 209

Cardiac surgery, 236, 255

Cardiology, 247-256, 251t, 253t

Carrier for lymphedema, 341t

Carvacrol, 48t, 49

Carvone, 25

Cassia, 95

Catharanthus roseus, 335

Catnip, lactones of, 52, 52t

Cedar for eczema, 286

Cedarwood, 93

Cedrus atlantica, 286

Cellulitis, 141

Centella asiatica, 335

Central nervous system disorder, 207-208

Ceylon cinnamon, 183

Chamaemelum nobile

allergy to, 86

drug interactions with, 92

for eczema, 286

for insomnia, 204-205

for pain, 220

taxonomy and properties of, 40-41, 40t

Chamazulene, 41, 46t

Chamomile

German. See German chamomile

for inﬂammation, 223

for insomnia, 204-205

Moroccan, 40-41, 40t

for postradiation burn, 339

for pressure sore, 279

properties of, 40

Roman. SeeRoman chamomile

taxonomy of, 40-41

Chemistry of essential oils, 43-54. See also Essential

oil, chemistry of

Chemoreceptor trigger zone, 208

Chemotherapy

nausea and vomiting in, 209-211, 337, 338t

study on, 140

Chemotype, 42

Chenopodium ambrosioides, 191-192

Children

cellulitis in, 141

diarrhea in, 141

essential oil doses for, 347t

hyperactive, 348-351

overdose of essential oil in, 79

pediculosis in, 351-352

China, 13

Chiropractic, 149-152, 151t

Chronic bronchitis, 365-369, 368t

Chronic pain, 127, 214

Chronic pain syndrome, 217

Chronic stress, 230-231, 231f

Chronic toxicity, 88

Cigarette smoking, 357

408 Index

1,8-Cineole

as antiviral, 182-183

properties of, 51, 51t

in transdermal therapeutic system, 283

Cinnamaldehyde, 49, 49t

Cinnamomum zyelanticum, 49, 49t

Cinnamon

as antiviral, 183

drug interactions with, 93

overdose of, 78

trichlorophenol and, 85

Cinnamon bark, 42, 95

properties of, 42

Ciproﬂoxacin, resistance to, 171

Citral, 86

Citronella, 78t, 80, 105

Citronellal, 49, 49t. 204

Citrus aurantium, 275

Citrus bergamia, 39

Citrus limon, 254

Citrus peel oil, 85

Clary sage, 299, 300, 325-326

Closed ventilation system, 130-131

Clostridium, 178

Clove

contraindicated, 95

for herpes, 289

for nausea and vomiting, 211

overdose of, 78t

Clove bud oil, 183, 221-222

Cocaine abuse, 359

Cocoa, 17

Codeine, 215

Cohobation, 62

Commiphora momol

as antiparasitic, 190

for pain, 220-221

Common thyme, 42

Complementary and alternative medicine, 4-6

Compress, 178, 314-315, 330-331

Conduction, galvanic skin, 105

Constipation in elderly, 267, 267t

Contact dermatitis, 85-87

Contraindications for essential oils, 94-96

Coriandrum sativum, 223

Coronary artery bypass surgery, 252-255, 253t

Corticosteroid for nausea and vomiting, 208

Cotton ball, direct inhalation via, 32

Coumarin, 52-53, 53t, 256

Cramp, menstrual, 329-330

Critical care, 274-281

Cross-infection, 193

Cryptococcosis, 185

essential oils for, 186-187, 317-319, 318t

in HIV/AIDS, 316-319, 318t

Cupressus sempervirens, 183

Cymbopogon citratus, 45

aldehydes of, 49, 49t

as antibacterial, 176

for low back pain, 150

for onychomycosis, 290-291

for osteoarthritis, 270

Cymbopogon martini, 47t, 50, 50t

Cymbopogon nardus, 219

Cyperus scariosus, 286

Cypress, 183, 299

Cystic ﬁbrosis, 368

Cystitis, study on, 140-141

d-pulegone, 91

Decubitus ulcer

in critical care patient, 279-281, 280t, 281t

in elderly, 267-269

essential oils for, 178

Degenerative joint disease, 269-271

Dementia, 261, 264-266, 266t

Depakote, 360t

Depression, 108-111

bergamot for, 254

postpump, 252-255, 253t

Dermal lethal dose of essential oil, 81

Dermatitis, contact, 85-87

Dermatology, 283-291, 285t, 287t, 288t

Dermatophyte infection, 289-291

Detoxiﬁcation, 356-357, 357t

Diabetes, 300

Diagnosis, nursing, 119-122

Diazepam, 30, 31

Dicoumarol, 53, 93

Dilution, 25, 74, 138

Distillation, 59, 60t, 61-62, 61f, 84

Diterpene, 46

Drainage, lymphatic, 340

Dressing, 26

Dronabinol, 208

Drop, size of, 138

Drug interaction with essential oil

cellular receptors and, 89-90

changing action or potency, 90-94

pharmacokinetics and, 88-89

taking multiple drugs and, 86

Drug-resistant bacteria, 177-178, 370

Duct, secretory, 69

Dysmenorrhea, 329-331, 330t, 331t

Eczema, 284-286, 285t

Egypt, 12-13

Elderly, 260-271

constipation in, 267, 267t

dementia in, 264-266, 266t

insomnia in, 262-264

mood and, 110

osteoarthritis in, 269-271

wound healing in, 267-269, 268f, 269t

Elettaria cardamomum, 209

Elimination, drug, 89

Emergency room, 130

Emmenagogic agent, 324

End-of-life care, 305-307

Endocrine system, 294-300, 295t, 298t, 299t

Endorphin, 239-240

Enﬂeurage, 60t, 63

English approach to aromatherapy, 77

Enzyme, drug interactions and, 92

Epidermal absorption, 26-27

Epidermal cell, 69

Epilepsy, 95

Index 409

Essential oil

absorption of, 22-23, 24f, 25-28

for aging, 270

in Alzheimer’s disease, 264-265

antibacterial, 130-131, 172-178

anticarcinogenic, 342t

antimalarial, 190-191

antimicrobial, 281t

antiparasitic, 190-192

aroma intensity of, 64-65

in asthma, 366

availability of, 137

biosynthesis of, 65-71, 67t

in bipolar disorder, 361-363, 362t

blood pressure and, 248-249

for burn, 173

buying of, 73-75

camphene in, 366-367, 367t

chemistry of, 43-54

chemotypes of, 42t

in chiropractic, 149-152

for constipation, 267

contraindications for, 94-96

in critical care, 275-277

for depression, 109

for diarrhea, 319

dilution of, 138

drug interactions with, 88-94

for dysmenorrhea, 330, 330t

electroencephalography and, 236-237

expression of, 60t, 62

extract versus, 60f

extraction of, 59-62

for extubation, 277-278

for herpes, 122

homeopathy and, 94

for hyperactive child, 348t

immune function and, 312t

for inﬂammation, 223-224

inhalation of, 29, 32-33

for insomnia, 203-205, 262-264, 263t

in labor and delivery, 325-327, 326t

for lice, 351-352

for lymphedema, 341t

“m” technique with and without, 153

material safety data sheet for, 74

in menopause, 298-300, 298t

for muscle spasm, 222, 222t

for nausea and vomiting, 209-211

olfaction and, 29-32

oral administration of, 28-29

overdose of, 78t

for pain, 218t

for postpump depression, 253t

for premenstrual syndrome, 297-298, 297t

for pressure sore, 279-281, 280t

purity testing of, 72-73

quality of, 71, 71t

for rheumatoid arthritis, 313-315, 314t

skin reaction caused by, 85-88

storage of, in plant, 68-70

toxicity of, 76-98. See also Toxicity

for tuberculosis, 370-371

uses of, 7-8, 71, 72t

Essential Oil Safety, 95

Essential Oils Trade Association, 74-75

Ester, 41, 50t

Estragole, 53-54

Estrogen, forms of, 296

Estrogen-like effect, 342-343

Ether, 53-54, 54t

Ethical issues, 132

Eucalyptol, 87, 92, 182-183

Eucalyptus, 78t, 79-80, 174, 183

Eucalyptus citriodora, 49t, 291, 300

Eucalyptus globulus

in cystic ﬁbrosis, 368

for extubation, 277-278

for herpes, 122

oxide of, 51t

in tuberculosis, 371

Eugenia caryophyllata, 189, 211

Eugenol

in cinnamon bark, 42

for cryptococcosis, 318

drug interactions with, 93

for herpes, 289

properties of, 48t, 49

Euglobal III for rheumatoid arthritis, 313-314

Europe, aromatherapy in, 16, 17-19

Evening primrose oil for wound healing, 268

Expectorant, 366, 369

Expression of essential oils, 60t, 62

External method of aromatherapy, 77

Extraction, 63-64, 85

Extubation, 277-278

Farnesol, 47t

Fatty acid, polyunsaturated, 270

Fear

amygdala and, 111

in critical care, 278

in extubation, 277-278

Female reproductive system, 294-300, 299t

Fennel, 54t, 95, 223

Fetal abnormality, 323-324

Fibromyalgia syndrome, 146-149, 148t, 149t

Fibrosis, cystic, 368

Flavonoid, plant, 223

Floral waters267-268, 280t, 306

Florasol process, 64

Foeniculum vulgare, 54t, 223

Fragrance, allergy to, 85, 87

France, 12

Frankincense

in asthma, 367

for cryptococcosis, 318-319

dreaming and, 111

for eczema, 286

in labor, 325-326

for low back pain, 150

French approach to aromatherapy, 77

French marigold, allergy to, 86

Fungal infection, 184-189

Fungus, plant metabolites and, 70

Furanocoumarin, 53, 87-88

phototoxicity of, 87-88

Gamma-aminobutyric acid, 202

Garlic, 184

410 Index

Gas chromatography of essential oil, 72-73

Gastrointestinal disorder, 207

Gastrointestinal worm, 191-192

GCMS, 72-73

Gelatin capsule, 77, 139, 140

Gentamicin, resistance to, 171

Geraniol, 47t, 49t, 289

Geranium

for diarrhea, 141

for dysmenorrhea, 330

in labor, 325-326

in menopause, 300

Geranyl acetate, 50, 50t

German chamomile

allergy to, 86

in bipolar disorder, 361-362

for eczema, 285-286

for inﬂammation, 223

taxonomy and properties of, 40-41, 40t

Ginger, 210, 221

Glandular trichome, 69

Glucose-6-phosphate dehydrogenase, 93

Glutathione, 93

Gram-negative cocci, 166, 166f, 167

Gram-positive cocci, 166, 166f, 167

Greece, 14-15

Griseofulvin, 289-290

Group A Streptococcus, 164-165

Guaiacwood oil, 87

Guba’s wound-healing cream, 268-269, 269t

Gully gum oil, 182

Gynecology, 327-331

Hair loss, 339-340

Head lice, 351-352

Healing in elderly, 267-269, 268f, 269t

Heart disease, 247-256, 251t, 253t

Heart surgery, 236

Hedonic mechanism, 102

Helichrysum picardii, 175

Helichrysum italicum, 270, 357

Heliotropin, 106

HELLP syndrome, 325

Helminth infestation, 191-192

Herbal medicine, 7, 77-78, 359

Heroin addiction, 359

Herpes infection

antiviral essential oils for, 184

case study of, 122

essential oils for, 286-289, 287t, 288t

Hexose, 67t

Hibi oil, 110

HIV infection, 315-316

Holism, 118-119

Holistic aromatherapy, 11

Holy basil, 188

Homeopathy, 94

Honey, 140

Hood, direct inhalation via, 32

Hormone replacement therapy, 298

Hospice, 303-307

Hospital-acquired infection, 162-166, 163f, 163t, 176

Hospital staff, stress and, 237

Hot-pepper cream for pain, 221

Houttynia cordata, 184

Human study of antibacterial essential oils, 177-178

Hybrid, antibacterial, 175t

Hydrocortisone, 93

Hyperactivity, 348-351

Hypericum perforatum, 316, 363

Hypertension

borderline, 247-250

essential oils contraindicated in, 95

pregnancy-induced, 325-327, 326t

Hyssop, 78t

Immune system, 311-313, 312t

Immunoglobulin G, 312

Immunology, 234-235, 310-319

Incense, 110

India, 13-14

Indirect inhalation, 32-33

Infection

antibiotics for, 167, 169-172

aromatogram and, 179-180

bacterial classiﬁcation of, 166-167, 166f, 167f

cross-infection, 193

essential oils for, 172-178

fungal, 184-189

in HIV/AIDS, 316

hospital-acquired, 162-166, 163f, 163t

parasitic, 189-192

spread of, 163t

vaginal, 124-125, 327-328, 327-329, 328t

viral, 180-184, 181f

Inﬂammation, 222-224

Informed consent, 132

Infrared test, 73

Ingestion, 7, 78-80

Inhalation

direct, 31-32

of essential oils, 29, 32-33

for insomnia, 204

for sinusitis, 368

toxicity of, 82

Insect, plant metabolites affecting, 69-70

Insomnia, 201-205

in elderly, 262-264, 263t

Insurance, 139

Integrative medicine, 5-6

Internal administration of essential oils, 28-29, 77,

136-144

anomalies about use of, 137-138

oral use versus, 137-138

Inula graveolens, 52, 52t

Iraq, 12

Irrigation, wound, 267-268, 268t

Irritation, 84-85

Isoborneol, 184

Isoprene unit, 44-45

Jasmine, 104

Joint Commission on Accreditation of Healthcare Or-

ganizations, 214-215

Joint disease, degenerative, 269-271

Juniper, 85-86, 183, 223

Juniperus communis, 223

Index 411

Kallmann’s syndrome, 31

Kanuka, 176

Ketoconazole, 289

Ketone, 50-51, 51t

Ketosis, 50

Khella, 53

Khellin, 52-53

Killer T cell, 311

Klebsiella, 164-165

Kunzea ericoides, 176

Labeling, 74-75, 85

Labiatae, 39-40

Labor and delivery

aromatherapy for, 242-243

essential oils in, 96, 325-327, 326t

Lactone, 52-53, 52t, 53t

Lamiaceae family, 39-40, 70, 176

Lavandin, 39-40, 275-276

Lavandula, 39-40, 40t, 175t

Lavandula angustifolia, 39-40

alcohols of, 47t

in Alzheimer’s disease, 265

as antiparasitic, 192

in chiropractic, 150

in critical care, 276

drug interactions with, 91

eczema and, 285

in end-of-life care, 307

esters of, 50, 50t

examination stress and, 106-107

for extubation, 278

for insomnia, 203, 262-263, 263t, 264

for nicotine withdrawal, 357

in pregnancy-induced hypertension, 325

quality of essential oil of, 71

sedative effect of, 30

toxicity of, 79

in tuberculosis, 371

for vaginal yeast infection, 328

for wound healing, 268

Lavandula intermedia, 210, 275-276

Lavandula latifolia, 39-40

as antiparasitic, 192

blood pressure and, 249

for extubation, 277-278

toxicity of, 79

Lavandula spicas, 40

Lavandula stoechas, 40, 79

Lavender. See also Lavandula entries

absorption of, 22, 25

in Alzheimer’s disease, 264-265, 265

as antibacterial, 172, 175t

as antiparasitic, 192

in asthma, 367

blood pressure and, 248-249

in chiropractic, 150

contingent negative variation and, 31

in critical care unit, 275

in drug detoxiﬁcation, 358

drug interactions with, 91

eczema and, 285

examination stress and, 106-107

for hospitalized child, 346-347

Lavender (Continued)

for insomnia, 203, 262-263, 264t

in labor, 325-326

“m” technique with, 153

memory test and, 107

mood and, 110

for nausea and vomiting, 210

in nicotine withdrawal, 357

for osteoarthritis, 152

overdose of, 79

physiologic changes with, 105

psychological associations of, 104

for skin condition, 123

taxonomy of, 39-40

in tuberculosis, 371

for vaginal yeast infection, 328

for wound healing, 268

Lemon, 110

Lemon balm, 182

Lemon oil for postpump depression, 254

Lemongrass

as antibacterial, 176

as antifungal, 187

for cryptococcosis, 317

for low back pain, 150

for onychomycosis, 290

for osteoarthritis, 270

Leptospermum ﬂavescens, 327

Leptospermum scoparium, 176

Lethality of essential oil, 28-29, 80-81

Lice, 351-352

Limbic system, 30-31

Lime blossom, 204

Limonene, 45, 283, 335

Linalol, 47t, 80

Linalyl acetate, 50, 50t

Lipid solubility, 25, 89

Lippia alba, 188

Lippia citriodora, 188-189

Lippia multiﬂora, 351-352

Lippia sidoides, 48t

Lithium, 360t

Litsea cubeba, 285

Liver disease, 80, 191

Long pepper, 188

Low-back pain, 149-152, 151t

Lupulon, 173

Lymphedema, 340-341

“m” technique, 131, 132, 152-154, 254

for cancer patient, 336

in critical care, 276-277

in end-of-life care, 307

for extubation, 276-277

fear and, 278

in pregnancy-induced hypertension, 325

Madagascan periwinkle, 335

Magnetic resonance imaging, 337, 359-360

Malaria, 48, 190-191

Manic-depressive disorder, 359-363

Manipulation, chiropractic, 149-152

Manual therapy, 145-154

Manuka, 176

Marigold, French, 86

Mass spectrometry, 72-73

412 Index

Massage, 145-146

aromatherapy linked with, 7

cancer and, 336

chiropractic and, 149

for constipation, 267

foot, in critical care unit, 275

“m” technique versus, 152-153

Material safety data sheet, 74

Matricaria recutita

allergy to, 86

in bipolar disorder, 361-362

chemotypes of, 42t

eczema and, 285-286

for inﬂammation, 223

for pressure sore, 279

properties of, 46t

taxonomy and properties of, 40-41, 40t

Melaleuca alternifolia

alcohols of, 47t

for cystitis, 140-141

for vaginal yeast infection, 124, 327-328

for vaginosis, 329

Melissa, 265, 287-288

Melissa ofﬁcinalis, 182, 261

Memory, 104-107, 254

Menopause, 298-300

Menstrual period, 296-298, 297t, 324

Mental illness, 354-355

Mentha longifolia, 91, 249

Mentha piperita, 51t, 209, 314-315, 368

Mentha rotundifolia, 91, 220, 249

Menthofuran, 80

Menthone, 51t

Mesopotamia, 12

Metabolic disorder, 208

Metabolism, drug, 89-91

Metabolite68, 69

Metastatic cancer, 153-154

Methicillin, resistance to, 171

Methicillin-resistant Staphylococcus aureus, 164, 176-178

Methyl salicylate, 90-91

Metronidazole for vaginosis, 329

Mevalonic pathway, in essential oils, 44

Mind/body connection, 106-108

Mint, drug interactions and, 91

Monarda didyma, 39

Monoterpene, 45

Monoterpenic alcohol, 46

Mood, odor affecting, 109-110

Moroccan chamomile, 40-41, 40t

Mourning, 304

Mugwort, 95

Multiple-drug resistant tuberculosis, 370

Muscle spasm, 150, 222, 222t

Mustard, 94, 95

Mycobacterium avium, 174

Myocardial infarction, 250-251

Myrcene, 45, 222

Myristica fragrans, 174, 223

Myrrh, 220-221

Myrtol, 368-369

Nail infection, 189, 289-291

Nardostachys jatamansi, 263

National Association for Holistic Aromatherapy, 75

Native American medicine, 17

Nausea and vomiting, 207-211

in cancer patient, 337-338, 338t

central nervous system causes of, 207-208

conventional approaches to, 208-209

essentials oils for, 209-211

gastrointestinal causes of, 207

metabolic causes of, 208

Nebulizer, 33

Nepeta caesarea, 52, 52t, 219

Nepetalactone, 52, 52t

Neral, 49, 49t

Neroli, 204, 275

Nerolidol, 48

Neurologic disorder, 207-208

Neuropathic pain, 213

Nicotine withdrawal, 357

Nigella sativa, 172, 174, 204

Night sweats, 299

Non-insulin-dependent diabetes, 300

Nonopioid analgesic, 215

Nonphysician clinician, prescriptive license for, 142-

144, 143t

Nonsteroidal antiinﬂammatory drug, 215-216

Nontoxic ketone, 51

Noradrenaline, 233

North American Nursing Diagnosis Association, 119-

120

Nucleoside analogue for herpes, 287

Nursing practice, 116-133

case study of, 122-129, 126f

nursing diagnosis in, 119-121

Nursing shortage, 116, 117

Nutmeg, 223

Obstetrics and gynecology, 323-329, 328t

Occlusive dressing, 26

Ocimum basilicum, 42t

Ocimum sanctum, 188

Odor

brain mapping and, 31

of essential oil, 64-65

pheromones and, 103

pollination and, 70

relaxing versus stimulating, 104

Olfaction, 29-32

Olfactory dysfunction, 264, 359

Olfactory response, 102

Oncology, 334-343

end-of-life care, 303-307

essential oils in, 341-342, 341t

contraindicated, 95, 342-343

for treatment side effects, 336-341

hair loss in, 339-340

lymphedema in, 340-341

“m” technique for, 153-154

nausea in, 337-338

postradiation burn in, 338-339, 339t

Onychomycosis, 289-291

Open-heart surgery, 236

Operating theatre, 130-131

Oppor

tunistic infection in HIV/AIDS,

316

Oral administration, 136-144

of essential oil, 28-29, 77

Oral lethal dose of essential oil, 80-81

Index 413

Oregano, 95, 183, 193

Oregano ofﬁcinalis, 176

Organ transplant, 236

Origanum majorana, 178, 265

Origanum tyttanthum, cross-infection and, 193

Origanum vulgare, 48t, 174, 193

Ormenis mixta, 40-41, 40t

Ormenis multicaulis, 40-41, 40t

Osteoarthritis, 152, 269-271

Osteomyelitis, 177

Overdose of essential oil, 78t

Overgrowth, Candida, 185

Oxide of essential oil, 51-52, 51t

Pain, 213-222

aromatherapy for, 217-222

chronic, case study of, 127

in labor and delivery, 327

“m” technique for, 154

orthodox approach to, 214-217

physiology of, 213-214

relaxation and, 239-240

Palliative care, 304-305

Panic attack, 106

Parasitic infection, 189-192

Parsley seed, abortion and, 323-324

Patch test, 84

Patchouli, 47t, 317

Pathogen, classiﬁcation of, 168f

Pediculosis, 351-352

Pelargonium graveolens, 39, 174, 330

Penicillinase-resistant Staphylococcus, 171

Pennyroyal, abortion and, 80, 323-324

Pentobarbital, 90, 91

Pentose, 67t

Pepper

black, 152, 174

long, 188

Peppermint

blood pressure and, 249

in menopause, 299

for muscle spasm, 222

for nausea and vomiting, 209-210

for pain, 221

for rheumatoid arthritis, 314-315

sleep and, 111

Peppermint oil, 88, 140

Pharmacokinetics, 25, 88-89

Phenol, 48-49, 48t, 81-82

Phenylethyl acetate, 204

Phenylpropane, 43-44, 43f

Pheromone, 103

Phototoxicity, 53, 87-88

Physical symptoms of stress, 233-234

Phytoestrogen, 342

Phytol, 280t

Picea glauca, 17

Pigmentation, 53

Pine, Scotch, 107-108

Pink root, 192

Pinus pumilio, 92

Piper longum, 188

Piper nigrum, 174, 270

Plant ﬂavonoid, 223

Plasma protein, 90

Pleasure memory, 254

Pneumococcus, 167

Poisoning, 78-80. See also Toxicity

Polymyxin B nonapeptide, 174

Polyunsaturated fatty acid, 270

Portable distillation of essential oils, 62

Postpump depression, 252-255, 253t

Postradiation burn, 338-339

Potency, drug, 90-91

Povidone spray, 337

Pregnancy, 95-96, 210, 323-327

Premenstrual syndrome, 296-298, 297t

Prescriptive license, 142-144, 143t

Pressure sores

in critical care patient, 279-281, 280t, 281t

in elderly, 267-269

Prostaglandin, 216, 294-297

Protein binding in drug interaction, 90

Protocol in bipolar disorder, 361

Pseudomonas aeruginosa, 164, 174

Psoriasis, 123

Psychiatric care, 354-363

Psychoaromatherapy, 103-105

Psychological stress, 233

Psychology, 102-112

Psychoneuroimmunology, 240-244, 311-312

Pulegone, 50-51

Purity of essential oil, 72-73

Quasipharmacologic mechanism, 102

R-R interval, changes in, 105

Radiation burn, 338-339

Rapid eye movement sleep, 111-112, 201-202

Red thyme, 95

Refractive index, 73

Relaxation, 7, 238-244

Remission, spontaneous, 243-244

Reproductive system, female, 294-300

Resinoid, 65

Resistance, antibiotic, 169, 170f, 171-172

Respiratory care, 365-371, 372t

Rheumatic disease, 150

Rheumatoid arthritis, 313-315, 314t

Ritalin, 349

RNA virus, 180

Roman chamomile

allergy to, 86

drug interactions with, 92

for dysmenorrhea, 330

for eczema, 286

for inﬂammation, 223

for insomnia, 204-205

taxonomy and properties of, 40-41, 40t

Root, valerian, 362-363

Rosa damascena, 127

Rosa rubiginosa,

268, 279

Rose oil,

107

for insomnia, 205

in menopause,

299

for pain, 127

for spiritual distress, 128

Rosehip for pressure sore, 279

414 Index

Rosemary

in Alzheimer’s disease, 266

as antifungal, 187

blood pressure and, 248-249

for cryptococcosis, 318-319

in diabetes, 300

drug interactions with, 93

examination stress and, 106-107

for hyperactive child, 350

memory test and, 107

physiologic changes with, 105

Rosmarinus ofﬁcinalis

in Alzheimer’s disease, 266

blood pressure and, 248-249

for cryptococcosis, 319

in diabetes, 300

examination stress and, 106-107

for hyperactive child, 350

Royal College of Nursing, 137

Rue, 95

Sabinyl acetate, 324

Safety, of essential oils, 96

Safety labeling, 75

Sage

as antibacterial, 175t

clary

in labor, 325-326

in menopause, 299, 300

St. John’s wort, 316, 363

Salmonella, 174

Salvia elegans, 261

Salvia ofﬁcinalis, 42t, 174

Sandalwood, 87, 183-184

Santolol, 48

Sassafras, 95

Satureja, 175t

Satureja hortensis, 270, 319

Savory, 175t

Scabies, 191

Sarcoptes scabii, 191

Sclareol, 48, 335

Scopolamine, 208

Scotch pine, 107-108

Secondary metabolite, 69-70

Secretory structure of plant, 69-70

Sedative, 201-205, 357t

Sedative essential oil for hyperactive child, 350

Selective serotonin reuptake inhibitor, 296-297

Semantic mechanism, 102

Sensitivity, 85-87

Serotonin agonist, 209

Serratia marcescens, 164-165

Sesquiterpene, 45-46

Sesquiterpenol, 4, 47t, 48

Sexually transmitted disease, drug resistant, 172

Shigella, 172, 174

Shikimic pathway, 44

Sickle cell anemia, 223

Sinusitis, 366-369, 368t

Skin

absorption of essentials oils from, 23, 24f, 25-28

lavender for, 123

Skin disorder, 283-291, 285t, 287t, 288t

Skin reaction, 81-82, 85-88

Skin ulcer

in critical care patient, 279-281, 280t, 281t

in elderly, 267-269

essential oils for, 178

Sleep

aroma affecting, 104

in elderly, 262-264, 264t

insomnia and, 201-205

rapid eye movement, 111-112

Smell, sense of, 29-32. See also Odor

age affecting, 107

in Alzheimer’s disease, 264

in child, 347

loss of, 359

pheromones and, 103

psychologic effects of, 354-355

as purity test, 73

Smoking cessation, 357-358

Solubility in drug interactions, 88

Solvent, irritation caused by, 85

Solvent extraction of essential oils, 60t, 63

Spearmint, 210

Spigelia marylandica, 192

Spike lavender

in asthma, 367

blood pressure and, 249

for eczema, 285

properties of, 40t

taxonomy of, 40

Spray, povidone, 337

Spritzer for postradiation burn, 338-339, 339t

Staphylococcus, 167, 171

Staphylococcus aureus, 164, 174

Steam, direct inhalation via, 32

Steam distillation, 59, 61, 62, 84

Steam inhalation for sinusitis, 368

Steroid, antiinﬂammatory, 216

Stimulant essential oil for hyperactive child, 349-350

Stoechas, 40

Storage of essential oil, 68-70, 96-98

Stratum corneum, 25-26

Streptococcus, 164-165, 167

Streptomyces, 173

Stress, 228-244

aroma affecting, 106-107

deﬁnition of, 229

immunology and, 234-235

physical responses to, 232-233

psychoneuroimmunology and, 240-244

Selye’s list of, 230-232, 231f

topical absorption and, 26

Substance abuse, 357-359

Substance P, 214

Sugar, types of, 67t

Summer savory, 270

Suppository, 141

Suppressor cell, 311

Susceptibility, antibacterial, 170f

Sweet birch, 90

Sweet marjoram, 178, 188, 204-205, 265

Synthetic antiparasitic, 190

Synthetic antiviral, 181-182

Synthetic fragrance, allergy to, 85

Synthetic oil, concern about, 132

Syzgium aromatica , 48t, 289

Index 415

Tagetes patula, 86

Tanacetum, 338

Tansy, 95

Tarragon, 175

Taxonomy, 39-41, 40t

Tea, pennyroyal, 80

Tea tree

as antibacterial, 176, 177

as antifungal, 189

as antiparasitic, 192

for bacterial vaginosis, 329

for cancer patient, 337

for onychomycosis, 290

for vaginal yeast infection, 327

Tea tree oil

allergic reaction to, 87

for cystitis, 140-141

overdose of, 79

Pseudomonas aeruginosa and, 174

for vaginal yeast infection, 124

Teratogen, 323-324

Terminal patient, 303-307

Terpene, 43-46, 44t, 45t, 70

Terpenic alcohol, 4, 47t, 48

Terpenoid, deﬁnition of, 44-45

Terpinen-4-ol, 47t

Terpineol, 93

Testosterone, methol and, 93

Theobroma cocao, 17

Thujopsis dolabrata, 110

Thyme, 42, 95, 175t

Thyme oil, sensitivity to, 87

Thymol, 48t, 248

Thymus vulgaris

as antibacterial, 174

blood pressure and, 248

chemotypes of, 42

thymol in, 48t

Tibet, 14

Tinea ingium, 289-291

Tinea pedis, 289-291

Toenail infection, 289-290

Tonsillitis, 141

Topical application, of essential oils, 23-28

Touch

aromatherapy with, 131

for child, 349

for hospitalized patient, 238

in palliative care, 304

relaxation and, 239

Toxicity

chronic, 88

ingestion reactions in, 78-80

inhalation, 82

of ketones, 50-51

measuring of, 80-81

skin reaction in, 81-82

Trachyspermum ammi, 188, 248

Transanethole, 54t

Transdermal therapeutic system, 289

Transplant, organ, 236

Trichlorophenol, 85

Trichome, glandular, 69

Trichomonas vaginalis, 191, 329

Trichophyton mentagrophytes, 188, 290-291

Triose, 67t

True lavender, 40. See also Lavandula angustifolia

Tuberculosis, 370-371, 372t

Ulcer, skin, 267-269, 279-281, 280t, 281t

essential oils for, 178

United Kingdom, 19

Urticaria, 87

Vaginal infection

bacterial, 191, 329

yeast, 124-125, 327-328, 328t

Vaginosis, bacterial, 191, 329

Valerian root, 362-363

Valeriana ofﬁcinalis, 263, 362-363

Valve repair, cardiac, 255

Vancomycin, resistance to, 171

Vaporized essential oil, antibacterial, 193

Vedic medicine, 13

Ventilation system, closed, 130-131

Ventilator-dependent patient, 153-154

Ventilatory weaning response, dysfunctional, 125, 126f

Virola surinamensis, 48

Virus, plant metabolites and, 70

Visitor, stress and, 237-238

Visnagin, 52-53

Vomiting. See Nausea and vomiting

Warfarin, 53t, 90-91

Water-and-steam distillation, 59

Water distillation, 59

Weaning response, dysfunctional ventilatory, 125, 126f

Wintergreen, 90-91, 95

Worm infestation, 191-192

Wormseed lavant, 192

Wormwood, 95

Wound healing in elderly, 267-269, 268f, 269t

Wound infection, 178

Yeast infection

Candida albicans, 185

cryptococcosis, 185

essential oils for, 186-187, 317-319, 318t

in HIV/AIDS, 316-319, 318t

vaginal, 124-125, 327-328, 328t

Ylang ylang, 250, 358-359

Zidovudine, 180, 182

Zingiber ofﬁcinale, 210-221

416 Index