The medicinal legacy also included knowledge of the classical humoral system of the Greeks, which spread into the wider population. We have glimpses of Roman medicine even from a Celtic temple of healing at Lydney where one of several stone stamps used to label eye ointments was found (3).  These gave the name of the Roman oculist (eye doctor) and of the salve, including ingredients, such as frankincense (Boswellia sacra), quince (Cydonia oblonga), myrrh (Commiphora molmol), opium poppy (Papaver somniferum), fennel or saffron (Crocus sativus) (4). The Roman trade routes covered the known world, and spices as well as more exotic herbs were sold in shops that appeared in the towns that became Roman civitas. Recent archaeology has added greatly to our knowledge of the integration of Romano British life (5).

We have knowledge of medical recipes from the collection of Scribonius largus, a surgeon who spent time along Hadrian’s Wall in the first century (6). Having made a number of these in historical workshops, there are some surprising inclusions of ingredients that are backed by modern research; one being  The most surprising pine nuts ground with rose petals and poppy seeds to treat an ulcerated kidney. We have made this recipe several times and I was intrigued and followed up on why the pine nuts. Modern research I found supported it (7). 

Similar recipes appear in Celsus De Medecina written in Rome at the same period (8). Lastly, herbs continued to grow near the Roman forts as we find mentions of herbalists still gathering them centuries later from along the wall.

The legacy of Roman introductions of herbs, vegetables and trees is possibly the only Italian influence most people are aware of. There is so much more. Christianity also came with followers among the multicultural Roman army, but the real influence of the Church of Rome begins with the conversion of King Aethelbert of Kent in 597 CE. The first monastery was built in the following year and a school established in 670 CE in Canterbury.

There is evidence from some of the later pupils that medicine was one of the subjects taught there (9). Although the Church subsequently put care of the soul before care of the body in disease, there was ecclesiastical copying and exchange of medical manuscripts and exotic herbs during the Anglo-Saxon period. As a consequence, we find references to Roman and Greek sources being consulted in the Leechbooks (10).

In 1095, a long-established teaching hospital with an already high reputation in the busy port of Salerno, Italy, became the base hospital for crusaders. Some men returned home to England with prescriptions, and new herbal knowledge. Others with a taste for oranges experienced at Jaffa, also sugar and Asian spices, which were then increasingly imported often on Venetian galleys into Southampton (11). 

Many years ago, I visited Salerno, where among other English students, Gilbertus Anglicus, mentioned in Chaucer,’s Canterbury Tales, trained as a physician (12). There, in the museum, is a manuscript, copies of which were kept in Cathedral libraries in England, the Antidotarium of Nicolai. Salerno is associated with the translations of Greek, Jewish and Arabic medical texts by Constantine the African, a monk at the nearby Abbey of Montecassino in the 11^th century. 

Following his work, it was to be Avicenna’s interpretation of Galen that would be taught to physicians in the Universities of Europe (8). The Medieval Health Handbook, the Tacuinem Sanitatis, is adorned with vivid Italian illustrations. The original manuscript is thought to have been translated into Latin based on the work of an Arabian physician, Ibn Botlan who lived in the 11^th century. There are several copies held in different European countries. 

The brightly coloured illustrations accompany the slightly adapted Arabic Tacquim or tables of humoral advice. Fennel is listed as warm and dry, as useful for eyesight, milk and urine flow, and flatulence. Cautions are given  of danger from slow digestion, which is remedied by chewing slowly and informed that fennel is suited to be eaten in winter — for those who are old, or have cold temperaments. This pattern of advice is followed for herbs, such as sage (Salvia officinalis), marjoram (Origanum majorana), mandrake (Mandragora officinarum), dill (Antheum graveolens), garlic (Allium sativum) and elecampane (Inula helenium). The illustration of mandrake inevitably includes a dog, supporting the caution that it was not safe for a person to dig the plant out of the soil, a dog must be used. Other illustrated features included foods — such as eggs, wheat, dates, pasta, olive oil and meats — clothing fibres, activities, people chatting and expressing strong emotions s, as well as environmental influences — the winds from south, east, west or north (13).

Advice on how to live a healthy life was brought back to England also by pilgrims and in the time of Elizabeth I, her godson, Sir John Harington translated the Regimen Sanitatis   into English (14). His love of fun shows brilliantly in the playful poetic presentation of the different humoral types of person and medicinal properties of foods and herbs. It is an excellent aid to herbal students learning healthy living in the humoral system. 

Avicenna’s interpretation of Galen was used in Continental Universities. This also informed the training of English and Irish physicians as there seems to have been little enthusiasm for the subject of medicine at Oxford, where in 1303 there was one master with a handful of students (9). More went to Montpellier, Padua or Bologna. In Italy, where there had already been close ties to Arabic ways when the first official European formulary, the Florentine Nuovo Receptario Composito of 1498, was compiled (15). This was by a committee of physicians who co-operated with apothecaries in Florence in producing this work, as they both belonged to the same guild, the arte dei medici e speziali. Many Italian states followed (15).^. 

Italian regulation of medicine then was far more developed than the confused multiplicity of practices and freedoms in England. Henry VIII came to the throne in 1509. He was very interested in medicine and formulated his own herbal recipes to treat his chronic leg condition. One of his physicians, Thomas Linacre had graduated in Padua and been impressed by the control exercised by the Collegium of Physicians and training of apothecaries, who took examinations set at Salerno in order to practice. Although Henry VIII signed the letters patent, Thomas Linacre has been seen as the real founder of the Royal College of Physicians (9).

The London Pharmacopoeia was still a century away, but again the trail of inspiration has taken us back to Florence. The power of physicians to repress unlearned practitioners and examine stocks of apothecaries and druggists relates to herbs, yet Thomas Linacre and others learned of herbs from Dioscorides Materia Medica. Their physical contact with plants was limited to their dried state in the apothecary shop. Luca Ghini, who had previously taught practical medicine at Bologna, promoted the idea of a separate lectureship of materia medica. 

Invited by Cosimo I, grand duke of Tuscany to Pisa, he was appointed to teach and demonstrate medicinal simples in 1539. At Pisa he founded the first botanic garden there for direct observation and perfected the hortus siccus of pressed, dried specimens of plants as a teaching aid (16).

The hortus siccus was later known as the herbarium, an aid to plant identification which I teach herbal students today at the School of Herbal Medicine in pharmacognosy class. I also take them annually to the herbarium founded in 1621 at the University of Oxford, to see early samples of herbs from the botanical garden. Some are still with fresh colours, from the hills around Bologna, capturing how the Italian herbal influence lives on. 

1. Alcock JP. Food in Roman Britain. Tempus; 2001.
2. Bowman AK. Life and Letters on the Roman Frontier. The British Museum Press; 2003.
3. Wilson R. A Guide to the Roman Remains in Britain. Constable; 2002.
4. Scullard HH. Roman Britain Outpost of the Empire. Thames and Hudson; 1979.
5. Bedoyere G. Roman Britain A New History. Revised edition. Thames & Hudson; 2013.
6. Bernhold JM, editor. Scribonii Largi Compositiones Medicamentorum. Scholar Select; originally 1786.
7. Takala R, Ramji DP, Choy E. The Beneficial Effects of Pine Nuts and Its Major Fatty Acid, Pinolenic Acid, on Inflammation and Metabolic Perturbations in Inflammatory Disorders. Int J Mol Sci. 2023;24(2):1171. Published 2023 Jan 6. https://doi.org/10.3390/ijms24021171 
8. Spencer WG, translator. Celsus De Medecina II Books V-VI. Harvard University Press; 1989.
9. Stapley C. A History of Plant Medicine. Ancient Greeks to the Modern Day. Aeon Books; 2024.
10. Pollington S. Leechcraft. Anglo Saxon Books; 2000.
11. Labarge MW. A Baronial Household of the Thirteenth Century. Eyre & Spottiswoode; 1965.
12. Chaucer’s Canterbury Tales. Penguin Classics; 1975.
13. Arano LC, editor. The Medieval Health Handbook. Tacuinem Sanitates. George Braziller; 1976.
14. Harington SJ. The School of Salernum. Regimen Sanitatis Salerni. Edizioni Saturnia Roma; 1957.
15. Nuovo Receptario Composto Dal Famossisimo Chollegio Degli Eximii Doctori Della Arte. Firenze. Facsimile. Gyan Books (distributor).
16. Bellorini C. The World of Plants in Renaissance Tuscany. Routledge; 2016.

Founded in 2009 by a small group of professionally trained medical herbalists, the HHRN aims to promote further research through its blogs, seminars and study groups. It continues to be run today by a small voluntary group of medical herbalists and humanities researchers. In 2024 we celebrated our 15^th anniversary, quite an achievement and we are looking ahead to the next decade. The group’s mission is to promote a scholarly approach to understanding historic herb uses and practices by bringing together interdisciplinary practices actively involved in using and applying herbal knowledge around the globe.

Published research 

For the 5th anniversary of the network in 2014, founding members Anne Stobart and Susan Francia co-edited Critical Approaches to the History of Western Herbal Medicine (see Figure 2)​. The text is now freely available online via Bloomsbury Press​ and is an excellent starting point for anyone interested in researching herbal history.

In addition to this landmark publication, the group regularly publishes blogs authored by researchers from a variety of disciplines: Curator John Hunnex recently wrote about The Botanical Collections of the Natural History Museum and botanical artist, ​Christina Hart-Davis shared stories of painting her favourite herbs in the context of their history and traditional uses as discussed in her latest book, The Herbal Year​. 

The top two of our most visited blog posts over time are both about herbal remedies in Old English early medieval medical manuscripts — The Nine Herbs Charm: Plants, Poisons and Poetry and Medieval herbal manuscripts. ​Philologists in the early 20th century denigrated the value of these remedies and subsequently labelled them as charms. On reading these texts aided with the experience of a contemporary herbalist, it becomes apparent that they are wound healing remedies with prayer intention introduced during the remedy making process and application to the patient. Herbalists reading these texts will find a familiarity, a homecoming reminiscent of a healing tradition that has been passed down for millennia.

​Among the many blog posts that include recipes with botanical ingredients is Claire Burridge’s article on incense in early medieval medical recipes — it seems it was not only the sensory benefits of incense (derived from the tree resin and scented woods) that were purposed, but also mixed with antidotes to be given to asthmatics in drinks according to Dioscorides​. And, if you are interested in the Early Modern period, Anne Stobart’s Handy guide to deciphering 17th century domestic recipes includes an index to handwriting styles, methods of interpretation, spellings and abbreviations.​

Research interest

It may, therefore, come as no surprise that there is a breadth of research interest across the network. Academics, herbalists and students of herbal medicine and herbal history engage with the HHRN across disciplines such as classical and ancient medicine, 17th century domestic medicine, historiography, manuscripts, critical editions and formulations.​
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From an herbal practitioner’s perspective, it is comforting to know the skills taught in practitioner training schools and colleges today are rooted in traditional practices and that many of those practices haven’t changed for thousands of years. 

Seminars

Seminars have been a key way to reach out to existing and new researchers​. There have been 10 seminars since the group’s foundation in 2009. Different perspectives have been platformed in each case — starting with appraising methods and sources in the first seminar in 2010, exploring the relationship with pharmacology in 2011, outlining the association with gardens in 2013, uncovering illustration as a means of identification at Kew in 2014 and considering the role of herbs and herbal medicine in trade routes at Wellcome in 2015. In 2017, we focused on the preservation of herbs at the Birmingham Botanic Garden, and in Bath in 2019, our last in-person seminar before the pandemic, we explored botanical knowledge and discovery. ​

COVID gave us the opportunity of conducting our seminars online, increasing the group’s global reach​ and the first of these discussed the theme of cough and lung disease in 2021 featuring Anne Van Arsdall, Valerie Thomas and Frances Watkins (Treasurer of the HHRN).  In 2022 we observed the transition of herbal medicine cultures with a range of speakers  including Diana Luft, Julian Barker, Siobhán Barrett and Professor Toine Pieters.​ And most recently, we explored Evolving Traditions: Influences on Western Herbal Practice in 2025 (See Figure 3) with an array of speakers from diverse disciplines and our best ever event with over 133 attendees.​

Workshops

We have previously also offered small study groups or practical workshops for up to 30 delegates. The last one was held in London in 2019 with Joe Nasr, founder of Avicenna. He discussed distilled and spiritous waters in early Arabic medicine following Avicenna’s 10th century innovation of the ‘worm’ to advance the development of distillation.  On the same day Christina Stapley discussed considerations for interpreting stillroom recipes and comparisons made between distilling practice by the apothecary versus methods followed in stillrooms. Details of past events can be found on the HHRN website.

Working groups

Following on from the online seminar in May 2021 Anne Van Arsdall and Frances Watkins discussed how best we could collaborate and explore the tacit knowledge required for making herbal remedies and this developed into them participating in a Decoding Remedies workshop at Sheffield University in October 2023. ​This resulted in a paper titled: Tacit knowledge behind the words in early medical texts: A collaboration to decode the remedies, which has been accepted for a forthcoming publication. The paper discusses several remedies from Harley MS 585.

Resources

In addition to publishing blog posts and creating seminars, the HHRN maintains a resource list on the website providing a handy guide to herbal history. Communication between academics, herbal practitioners and students of herbal medicine is encouraged through our Hist-Herb-Med JiscMail. It is an invaluable resource for locating knowledge of manuscripts, historical uses of medicinal plants, plant names (always a hot topic) and of course, the art and skill of making and taking herbal medicines.​

​If you are actively involved in research, please consider joining the HHRN mailing list. Join to be part of sharing the dialogues helping researchers better understand the enormous variety of skills we have as herbal practitioners and makers of herbal medicines — using traditional skills and knowledge passed down from our teachers.

The HHRN bulletin is emailed after each new blog post is published on the website and includes news of forthcoming seminars and herbal history events. Currently, we have over 700 subscribers and moving forward, we would be delighted to hear from anyone interested in working with the team to edit future blogs and/or write the bulletins which are published 4–6 times per year.​

Following on from the Decoding Remedies workshop, a Heritage Remedies Working Group was established by HHRN, and we’d like to hear from you if you would like to be involved. Our aim is to support herbal practitioners willing to share their tacit knowledge in collaborating with historians and philologists as to what is meant by the terse instructions often found in medical manuscripts describing recipes and remedies. ​ 

In addition to the blog posts, seminars and workshops planned in the future, the group aims to become a hub for herbal history research. With a growing social media presence (Instagram, X and Facebook) it is hoped that we will garner more attention nationally and internationally. A recent appearance at the Power of Plants festival organised by the National Institute for Medical Herbalists (NIMH) generated a considerable amount of interest.  ​

To join our network, please visit the contact us page on our website

Most of us are already likely to be familiar with the qualities and names of these four Humours:

• Air: Sanguine or blood humour — hot and wet
• Fire: Choleric humour — hot and dry
• Earth: Melancholic humour — cold and dry
• Water: Phlegmatic humour — cold and wet

Perhaps the first guiding concept of humoral theory that we have not retained in the Western biomedical model is the role of cycles in health and disease.

In all ancient medical systems and traditions, rhythm and cycles are understood as the core expression of life, and the loss of cycle is associated with sickness and ill health.

We frequently find the ancient concept of dynamic cosmic change and repetitive cycles expressed through the symbol of a circle; it has no beginning, no end, it is in continual motion. It also corresponds to the world around us; the circular and cyclical nature of the sun and moon, the circle and cycle of the continual dance of day and night, the cycle of the four seasons coming, going and returning, the circle and cycle of being born from the earth and returning to the earth at death.

The humours themselves are bodily manifestations of the phases of movement in this cycle, a movement we see reflected in the seasonal cycle; winter — cold and wet, through spring — hot and wet, to summer — hot and dry, and back again through autumn — cold and dry. This humoral cycle is seen in the life cycle with spring being birth and youth, summer adulthood, autumn middle age, and winter old age and death. 

The activity of the humours in the body is likened to the seasonal changes that make up the annual cycle of growth and regeneration in the world around us. If the seasonal temperaments are in balance and there is a year without extreme heat and drought, or without extreme cold and wet flooding the land; everything grows well, and there will be a plentiful harvest. 

Similarly, if the humours are well balanced like good seasons, the vitality of the body is nourished. This living vitality then manifests in the body as healthy and strong ‘spirits’. Loss of health arises when one aspect of the cycle becomes excessive and overwhelms the body. 

A fever may be likened to a heat wave in the summer, which although can be made easier by finding a cool breezy place offering instant respite, it will only properly resolve when the balancing coolness of autumn arrives. 

When treating a fever, we must first address the excess temperature by using cooling strategies, such as swabbing with a tepid cloth and giving antipyretics, such as willow (Salix alba). But, we also need to find a way to move things on to the next cooler phase, for instance using sweat inducing and immune stimulating diaphoretics (traditional cleansing cathartic herbs) such as vervain (Verbena officinalis) or elder (Sambucus nigra). This is like moving the fever cycle from being stuck in summer heat into the cooler days of autumn. 

It is then important to consider what excess humour initially overwhelmed the system and lead to the depletion of the vital spirit and its innate heat, as it is this heat that confers protection against any ‘invasion of poisons’ (infection and fevers).

When the underlying temperamental balance is lost, the most powerful way of bringing the balance back is through using sympathetic supportive strategies, even if we have to initially respond with countering ‘antipathetic’ interventions to address the immediate imbalance.

Sympathetic supportive strategies consist of:

• Restoring and nourishing weakened tissues and organs ensuring that their temperament is returned to normal.
• Supporting any weakened ‘spirits’, including the organs that they reside in — the heart, the head, the liver, the reproductive organs.
• Using constitutional medicines that help to balance the individual’s dominant humour, or effects of their stage of life.

Even today when we ask someone if they are in ‘good spirits’, or if they are feeling ‘dispirited’ we are continuing the use of these ancient humoral concepts in our language.

In humoral physiology there are four spirits which arise in the body.

• The vital spirit resides in the heart and consists of the innate heat and radical moisture. It activates all the bodily functions, gives the body its vitality, and protects it from infection.
• The natural spirit resides in the liver, it enables digestion and the dispersal of the humours in healthy blood.
• The animal spirit resides in the head, corresponds to the element ether, and initiates motivation, movement, and sensory perception.
• The procreative spirit resides in the testes, ovaries and womb. It arises as desire and provides the ability to conceive and procreate.

As the loss of correct temperament is the main underlying cause of sickness, we need to look at its main possible causes.

1. Life stage
2. Constitution
3. External influences

Lifecycle 

Each stage of life is dominated by a particular humour, during each phase it is more likely that a loss of temperament will be caused by the dominant humour of that stage becoming an overwhelming influence: 

• Youth: Sanguine / air 
• Adulthood: Choler / fire 
• Middle age: Melancholic / earth 
• Old age: Phlegm / water

Individual constitution 

Each person is born with a constitutional temperament, and this remains the same throughout life. We can quickly recognise the dominant temperament of some people, in others it may be a bit more subtle. We automatically recognise ‘warm’ people and ‘hot’ fiery people, as well as those who are ‘cool and chilled’, or perhaps even ‘cold’.

Determining a person’s constitution is important, as the temperament that dominates is always most likely to be the underlying cause of an imbalance for any individual. Having this temperament as a dominant influence in our bodies makes it always most likely to be the one which will become excessive.

Sanguine / air constitution 

We all know the energetic, explorative, creative, embracing but slightly flighty types, the ones who can’t stay still for too long, who being similar to an energetic youngster have an exuberant sanguine/air temperament.

Choleric / fire constitution

These are those with a strong personal drive, focus, high motivation, and often low tolerance of failure and a short temper, this typifies the time of our lives when we are working toward goals as adults and corresponds to the choleric/ fire temperament. 

Melancholic / earth constitution

We expect these types to be more introverted, solitary and studious, also reliable and trustworthy, often going deeply into ideas, but often prone to getting a bit stuck. This corresponds to middle age, when we slow down, become steadier and more anchored in our lives. This more grounded energy is the melancholic/earth temperament.

Phlegmatic / water constitution

Like the water element that rules them, phlegmatics are more likely to accommodate and flow with others, being more tolerant, but also a bit dreamy, and prone to getting overwhelmed. This corresponds to becoming an elder, with the wisdom of age making one more tolerant, and being able to let go of fixed ideas and attitudes. This softer gentler energy corresponds to the phlegmatic/water temperament.

Each of these four temperaments may manifest in combination with another, one still being the dominant aspect and one being secondary. 

External factors affecting the temperament

In humoral medicine, there is a recognition that external factors have a very important influence on health and disease. These are seen as influences that arise from outside of the body rather than from its own nature, thus they are named the ‘six non-naturals.’ 

Air

The natural temperament of air is cold and moist like the lungs. When hot it may irritate the naturally damp lungs and blood, and when too cold and moist it may add to excess moisture causing putrefaction and infection. Each constitution is balanced by air of the opposite temperament — cool air for hot people, etc. Purity of air is of utmost importance.

Diet

Foods all have an intrinsic heat or cold, and each of the different constitutions are challenged or benefitted by them. In summer, the digestive heat is more dispersed due to the summer heat, and in winter, digestive heat is concentrated in the body. This corresponds to us eating more lightly in the summer with a preponderance for cooling foods such as lettuce, chicory and cucumber. Hotter people have stronger digestive heat and better digestion than cool phlegmatics, who benefit from always adding warming herbs, spices and pepper to their food.

Exercise and rest

Exercise activates innate heat and energises the body. The heat of excess exercise damages the body, and lack of exercise leads to stagnation and congestion.

Sleep and wakefulness

Sleep is brought on by the rising upwards of a sweet calming restoring vapour from the heart to the head. It has a moistening and refreshing effect on the brain and the nerves. During sleep the innate heat settles in the liver completing digestion and the production of the humours. Insomnia dissipates the spirits and dries the brain.

Retention and evacuation

The body has a retentive faculty associated with the Earth element and the spleen, and an expulsive faculty associated with the Water element, the bowels and bladder. If either faculty is lowered through disease, an excess of the retentive melancholic humour, or inadequate innate heat or moisture to activate the expulsive faculty then blockage occurs. This kind of congestion can lead to melancholic vapours rising up from the spleen effecting the heart, stomach and head.

Perturbations of the mind and emotions

The maintenance of a calm state throughout the body and mind is beneficial to health. Reducing stress and releasing extreme emotions through cathartic activities is very helpful.  Singing, dancing, and expressing emotions in a healthy way are all considered very important, especially to the health of the vital spirit. Activities that promote joyfulness and practicing kindness are as important as any other measure we may take to maintain health.

Although the physiological and anatomical descriptions that underpin the historic humoral model now seem to be redundant due to our advances in the understanding of human biology and physiology, we shouldn’t discount the many important insights it can offer which have been drawn from millennia of medical observation and practice. Through embracing the humoral system, we gain a therapeutic model with which we can anchor our herbal practice to a holistic core.

Many are familiar with Hippocrates being considered the ‘father’ of medicine, and with his aphorisms such as ‘Let your food be your medicine and your medicine be your food’ or ‘Nature knows best’. But in fact Hippocrates and his fellow physicians have much more to impart.

I discovered this when I read their writings in detail in the English translation of the Hippocratic Corpus, and strove to understand the milieu in which they were written. The Corpus comprises roughly 60 treatises written by different physician-healers in the late 5^th century and the early decades of the 4^th century BC.

Written texts on this scale were a recent development. The texts include a diverse range of topics and reflect differing, sometimes even contradictory theories, as the authors explored and tried to establish just what the best approach is for discovering the causes of disease, and what are the best methods and medicines to relieve suffering.

They detail the powers of botanical medicines and how to apply them, based on insights into how the body in a holistic sense is constituted and responds to disease as well as lifestyle and environmental factors.

Practical, theoretical and philosophical insights are evidenced in ancient medical texts. The physicians’ experience and their writings were so transformational that they were collected together, studied and revered from that era and on into the next 2000 years.

What is not often appreciated is the conceptual background amongst Greeks of this time. From about the 6^th century BC, Greeks in both a practical and a philosophical sense innovatively began to explore the origins of human existence, of the universe, the phenomenal world and the human body in radical new ways.

Their insights contrasted with the traditional gods-centred view of their societies, in which certain gods were associated with healing and teaching medical skills – e.g. Apollo, Artemis, Aescleplius. Instead these early thinkers conceived unifying eternal principles.

The Kosmos is the divine ultimate source and sustainer of everything. The Kosmos was also spoken of as the “Holos” or Whole – a term often found in the medical writings and from which we derive the word ‘holistic’.

Some writers particularly emphasised Nature (in Greek physis from which we get the words physician, physics) itself as the divine principle in the phenomenal realm. Nature is a universal force combining elements of fire, water, earth and air, and including a fifth element aither, which regulates their qualities of heat, cold, moisture and dryness in the world of living things, the earth, climate, weather and so on.

For example, Empedocles (c 494-434 BC) describes the workings of Nature in terms of the divine Sphere, within which the forces of Love and Strife attract or disrupt the harmonious “mixture” of the elements, and qualities and forms which derive from them.

The medical authors sought to understand the individual constitution – how the elements and qualities expressed themselves in the body, how the parts of the body are all interconnected and sensitive to one another.

Human existence is a microcosm of the universal macrocosm, so understanding and living according to the laws of Nature fosters harmony both with the phenomenal world and with our best self. Some thinkers describe the ultimate purpose of humans is to find their true nature by returning to union with the Divine principle within.

That there was a close relationship between Greek philosophical ideas and medicine is revealed in Plato’s Symposium. Each guest at the dinner is invited to speak on Love. Plato (c 427-347 BC) includes a physician, Erixymachus, as one of the guest, whose words echo the themes above:

“The business of what we call medicine, which is, in a word, the knowledge of the principles of love at work in the body in regard to repletion and evacuation. The most skilful doctor is the doctor who can distinguish between noble and base loves in this sphere, and the man who can cause a body to change the latter for the former and can implant love in a body which lacks but needs it, and remove it where it already exists, will be a good practitioner. He must be able to bring elements in the body which are most hostile to one another into mutual affections and love; such hostile elements are the opposites hot and cold, wet and dry and the like; it was by knowing how to create love and harmony between these that our forefather Asclepius, as our poets say and as I believe, founded our craft.” (1)

This world view is amply reflected in the writings of Hippocratic physicians who endeavoured to follow the ‘healing power of Nature’ as guide in medical practice, by which they meant a scrupulous, rational study of the natural world and human body in order to derive knowledge and the skills with which to both to maintain health and treat diseases. This continued to form the background to subsequent medical practices and texts in subsequent centuries.

Ancient medicine recognised the importance of foods and dietary regimens for both health and in treating disease. This was combined with exercise, rest and therapeutic baths and amplified with a pharmacy of medicinal herbs, and the therapeutic uses of oils, waxes, wines, waters, clays and minerals (blood-letting is evidenced but not routine).

In the Hippocratic work Regimen II. LIV. (2), the author describes the qualities of many herbs and foods, along with their effects on the body: “Purslane when fresh cools, when preserved it warms… Mint warms, passes easily by urine, and stops vomiting” – an effect we still observe today (2).

The Hippocratic physicians were the first to practise recording the case histories of individual patients and the outcomes of their treatments. These can be read in the work of several Epidemics treatises where we find individually named persons, with their addresses recorded. This invaluable approach has continued through the centuries to be a feature of Western medicine.

We learn more of early herbal pharmacy, the way the actions of herbs were understood, how they were sourced and applied from the writings of Theopharastus (c317-287 BC) and Dioscorides (c40-90 AD).

Theophrastus was a pupil and later the successor to Aristotle in the Lyceum school in Athens. Inspired by Aristotle’s systematic investigative approach to nature, he focused on the plant kingdom and is credited with being the first botanist, although he also thought and wrote about many other topics. He left two surviving works on plants, Enquiry into Plants and On the Causes of Plants.

These include many medicinal herbs with details of how they were gathered or cultivated, and used practically. He carefully observed plants in terms of their forms, and modes of reproduction, for which he is credited with being the first botanist. These works later became inspirational to the renewal of learning during the Renaissance, and for Linnaeus himself.

Dioscorides’s De Matiera Medica – On the Materials of Medicine – is a Greek text of five volumes which includes about 850 medicinal substances, the majority of which are herbs. It survived into the early modern medicine via translations in Aramaic, Arabic, and then Latin, becoming accessible in English with a first inclusion of his information in Henry Lyte’s A Niewe Herbal, 1578, which itself was based on Flemish and French translations. Take a look at Dioscorides’s text (3).

Fast forward to the 1980s when Professor John Riddle re-evaluated Dioscorides’ understanding of the effects of the herbs. Though Dioscorides didn’t have the benefit of modern biochemistry, Riddle found his grouping together of herbs with “drug affinities” revealed accurate knowledge of their effects in and on the human body, as confirmed by modern chemical analysis of their properties (4).

Galen of Pergamon (c129-216 AD) was a Greek physician living several hundred years after Hippocrates during the early Roman Empire. He became physician to the emperor Marcus Aurelius. Galen built on the learning of previous generations. He revered ‘Hippocrates’ and based his approach to medicine on the texts which had been gathered together under his name.

However, though ‘following’ Hippocrates in all things, as he saw it, he in fact applied himself to discovering more about the human body, developed innovative methods of treatment and took advantage of the expanded repertoire of medicinal herbs available from the empire.

He emphasised using the importance of understanding the patient in his or her full complexity, based on judging the ‘mixture’ or temperaments of the elements in the individual. These influence not only the condition but the person’s response to treatments.

Like the Hippocratic physician, his therapy was to be tailored to the patient. This constitutional approach was not always possible, of course. Galen was for a time a physician to gladiators where he practised what today would be emergency medicine, and he paid close attention to the effects of their wounds, and the internal workings of the body which they revealed. He applied his skills as a surgeon, using the medicines of the day in wound healing.

In his prolific writings he called for the use of the best quality of medicines, he emphasised that the physician must carry out investigations of his own into the body and the herbal medicines, not relying on received convention, in order to understand from his own experience. His results were constrained by the context of the times; some things he got wrong. He made significant advances in knowledge himself, discovering the difference between venous and arterial circulation, and theorising that the blood received oxygen from the lungs.

There are many other ancient writers whose texts survive, for example Pliny, Celsus, Soranus, Rufus of Ephesus, Alexander of Tralles. The knowledge of these earliest practitioners was essentially still the basis of medicine and domestic medicine until the discoveries of pharmaceutical sciences in the 19th and especially 20th century, for example, the anti-inflammatory effects of aspirin and quinine, and the role of antibiotics.

Yet aspirin was derived from the age-old use of willow bark for fevers, quinine from the South American use of cinchona bark, and digoxin from the folk use of the foxglove.

Since the last quarter of the 20^th century traditional medicines – previously dismissed as of little use and “merely old wives tales” have not only been sought after again by the public but become the subject of research and development as a source for new orthodox medicines. For example, Dr. Cassandra Quave’s work at Emory University (6).  

With the acceleration of science and its discoveries from the mid-19^th century and continuing today herbalists have responded with innovations in training and practice, mindful to incorporate what is useful and appropriate for the best interests of their patients.

They also learn and adopt from their own experience improved therapeutic approaches, selecting the herbal prescription for a patient both in the light of ongoing research and holistically according to the patient’s individual nature and circumstances. They also continue to use many of the herbs in the ancient pharmacy, such as St John’s wort, agnus castus, yarrow, walnut, vervain. By doing my own research, I realised how the influence of the roots of Greek medicine continues to flow like a living sap into the many branches of modern herbalism (5).

1. Hamilton, Walter. Translator. Plato The Symposium. Harmmondsworth, England: Penguin Classics, 1971.
2. Jones, W.H.S. Translator. Hippocrates, Volume IV. London: William Heinemann, 1979.
3. Several blogs on the Herbal Research Network website address topics in the history of Western herbal medicine and include many more resources and references.
4. Riddle, John. Dioscorides on Pharmacy and Medicine. Austin: University of Texas Press, 1985.
5. Pitman Vicki. The Nature of the Whole, Holism in Ancient Greek and Indian Medicine. New Delhi: Motilal Barnasidass, 2006.
6. Quave C. Quave Research Group. Etnobotanica.us. https://etnobotanica.us/. Published 2022. Accessed August 30, 2022.

The Chelsea Physic Garden is the perfect representation of a Healing Garden. Smack bang in the middle of London, it’s the city’s oldest botanic garden. It was established by The Worshipful Society of Apothecaries of London in 1673, as an educational garden to train the apprentices in identification, cultivation, harvesting and making medicine.

Its favourable climate by the Thames river and wind-dissipating walls keep the environment perfect for growing over 4000 edible and medicinal species from ashwagandha to zanthozylum.

There are different themed areas within the garden, offering a ‘Historical walk’, ‘Edible plants’, ‘Medicinal plant s’ areas – including beds dedicated to Dioscorides (the Greek herbalist), an Officinalis bed of recognised medicinal species, traditional medicinal species of the British Isles. A must visit.

This is a gem of a garden tucked into the side of the Northumbrian shire. Established in 2007, inspired and run by two neuroscientists focusing research on how plants can improve memory, focus and attention.

Brimming with over 700 species of well-signed herbs, attractively laid out and filled with quirky corners. They also serve a delicious cup of herbal tea. Well worth the detour.

The inspiration of the Register of Chinese Medicine Chinese and the University of Bristol Botanic Garden, this is one of the best places in the world to immerse yourself in the diversity of Chinese herbs. Tucked into a corner of this fascinating garden you are transported to the healing potential of one of the longest medical traditions in the world.

With over 180 species used in Chinese Herbal medicine it is the largest collection in Europe where you can meet such favourites as the medicinal paeonias, polygonums and panax.

The Botanical gardens themselves are a delight of phlyogenic classification beds, a western herb garden – and even an Evolutionary garden. The tropical glass houses host a range of Ayurvedic herbs including ginger and turmeric too amongst the remarkable lotus house. Bristol Botanical Gardens are a veritable herbal feast.

Recently celebrating its 400^th Birthday, Oxford University established its own medicinal garden in 1621, making it the oldest Botanical Garden in the UK. Laid out in a formal design its brimming with taxonomic beds, a medicinal collection and glasshouses with various temperate zones. A long-standing centre of medicinal knowledge, botanical insight and art. A place to soak up some serious knowledge.

English Heritage has recreated the herb garden at Mount Grace priory established in 1397. Worth a visit to see what a monk’s life would have been like and their connection with growing medicinal herbs such as wood betony, clary sage and hyssop.

Nestled between the Scottish Highlands and the sea in the Black isle, sits this picture perfect herb nursery. Lovingly created since the late 1970s the nursery has a huge range of native, naturalised and international medicinal herbs.

A true classic of Botanical gardens. Established in 1759 it is entwined with early plant-hunting and the evolving science of Botany. With over 50,000 plants and 3 million herbarium samples, Kew is a definitive destination for all plant-lovers. A leading global centre of plant expertise, scientific enquiry and artistic inspiration – you need a whole day to explore the varied arboretums, beds and glass houses.

Just a few miles south of Edinburgh at the Secret Herb Garden, this serene garden holds a bounty of treats. With over 600 different species, including over 50 types of mint, you will be sure to find many of the most important medicinal herbs.

It’s a place to soak up both the beauty and the practical side of the plant world.

The word energetic may conjure images of New Age crystals, and the term is sometimes misapplied to any and all new healing modalities. In truth, though, energetic herbalism is as old as the Earth herself. This mode of healing is based on the truth that the vital force of nature and the vital force of an individual human are one and the same. Indigenous cultures the world over call this force spirit in their native language. Ancient Greeks called this force vitality, the Chinese call it Qi (chi), Iroquois nation calls it Orenda, Ayurveda calls it Prana, West Africans call it Ashe.

The goal of energetic herbalism is to enhance our terrain, which is our inner landscape—our tissues, organs, vessels, and all the forces that are engaged to maintain our health. The aim is to create an environment where we optimize nutrition from food, breath from air, and joy from our surroundings so our vitality flows with the least hindrance. To be in the flow is the goal of these traditions.

In the late 1960s, chemist James Lovelock and microbiologist Lynn Margulis proposed the theory that the Earth is endowed with an ability to communicate across species in effort to provide homeostasis. The well-known Gaia hypothesis or Gaia theory states that the biota communicates with organic as well as inorganic material to ensure evolution as well as feedback systems for an elegant self-regulating balance to occur.

This theory is named after the Mother Earth goddess from Greek mythology. Margulis and Lovelock described planet Earth as a self-regulating being who automatically adjusts the temperature, salinity of the ocean, and atmospheric content in response to changes in the ecosystem. In this respect, the living system of Earth is identical to the workings of our bodies. We are constantly regulating temperature, fluids, and the tone of organs and tissues. Vitalism is a teaching that states there is an invisible force governing our health, lives, and planet that is unseen and unmeasurable. This force has the intelligence to be not only self-directing but brilliantly self-correcting.

Of course, this is what Indigenous teachings have been saying for millennia in describing the sacred connections of all forms of Nature. Amazonian tribes still work with plants according to the stories and dreams that have been sung through ancestral wisdom keepers, as do many First Nation peoples. Creation stories can seem incomprehensible to Westerners, yet they provide meaningful direction and patterns for peoples who experience Nature and time in a sacred and nonlinear fashion.

Vitalist traditions, Ayurveda, Traditional Chinese Medicine, Unani Tibb, and North American Eclectic medicine represent the organization of elements of Nature. These systems describe the patterns of energy present in humans as well as in the plants themselves. Throughout history, there have been translations and modifications of energetic models, whether from within a culture or from outside it, in attempts to appeal to the politics of the day or to be more accessible to other cultures.

For example, folkloric, Taoist, shamanic traditions in China were being practised for centuries before the beginning of the beautiful cosmology of Classical Chinese Medicine. The Classical model then was adapted after the Cultural Revolution of the 1960s, which attempted to modernize and standardize this system, thus birthing Traditional Chinese Medicine, or TCM. This is the nature of systems; there is adaptation and conformity, but still, bodies of knowledge are preserved that can be shared through the ages.

Energetic herbalism is a framework that matches the pattern or spirit (warming, cooling, moving, sedating) of an herb to that of the imbalance (tension, stagnation, dryness) in the body in an effort to gently nudge the body back into balance via the path of least resistance. This is accomplished by removing impediments to the body’s natural state of relaxation. A relaxed person is a highly functioning one because all systems are able to communicate and support each other with optimum efficiency and spirit. As mechanical as that may sound, the less resistance there is in our beings, whether mentally, physically, or spiritually, the brighter our life force and spirit will shine.

My training as a practitioner in allopathic medicine gave me an awe of the articulation of our bodies through the language of biomedicine. In practice, though, I was allotted only fifteen minutes per patient, and I realized that such a rigid system could not allow for the grandeur of medicine/ healing to play out.

It would be impossible to treat a person in a truly holistic sense in such a brief encounter. I also found myself wondering why preventable diseases such as diabetes and hypertension were on the rise at exponential rates. These diseases have become the dreaded comorbidity factors in this time of pandemics. In my training as a physician’s assistant, I seemed to spend all my time chasing numbers and trying to control symptoms rather than restoring a person’s healthy terrain or ecology so that the numbers would take care of themselves.

Wide-angle vision is a technique I use to teach the art of pattern recognition. It involves allowing the gaze to transition from a hard focus to a softer, more expansive contemplation of a scene with the full range of peripheral vision. As you make this shift, your consciousness drops from sympathetic mode (fight or flight) and enters the parasympathetic world of sensing environs from a more holistic vantage point.

The body relaxes and awareness is heightened because the analytical mind is put aside. Patterns emerge and sounds that were inaudible can be heard as you release the mental gyrations that were drowning out the present moment. Trackers, gardeners, hunters, wildcrafters, and those gifted with a natural acumen for high awareness live in this state of being in which many levels of the world can be perceived simultaneously.

This level of perceptiveness is critical in energetic medicine, where the goal is to treat the whole person and not just superficial symptoms. The mantra is to treat what you see, but this “seeing” must include all the senses, not just the eyes. We listen to the client’s history, feel their pulse, smell their scent, and observe (with the heart as well as the eyes) their movements and spirit.

To skillfully observe patterns of disease, we first need to spend time observing patterns in Nature, to learn to grasp patterns of harmony and disharmony. Blowing winds that dry the land, flooding waters that swell rivers, excess heat that rises, and cold that depresses are all vital expressions of Nature that play out in our organs, joints, muscles, thoughts, and spirit. This is the practice of traditional folk herbalism: Through observation of Nature’s patterns, the inherent self-regulating systems of the body are acknowledged and supported.

This practice is the heart of preventative medicine. According to Ayurvedic teachings, if you know the pattern of imbalance, you can successfully treat 80 percent of illnesses with foods and herbs to support self-healing mechanisms, especially when disruptions in patterns are observed early on. The challenge is to trust the inherent wisdom of the body and resist the inclination to take over for the vital force.

An exception is when an illness is left without remedy for too long, and an example of that is mononucleosis (mono). In my clinical practice, I frequently consult with clients who had mono during their young adult years. Although Western medicine considers mono a benign illness, it can seriously drain a person’s vitality. The client recovers from acute symptoms, but modern medicine has nothing to offer in terms of the lost art of convalescence or re-vitalization. Thus, even after the patient “feels better,” they may still experience fatigue. At an energetic level, their body is running colder due to loss of vital energy. They experience a need to add a layer of clothes more often or drink warming beverages.

This shift is so subtle that many people don’t register this change. But over time, even ordinary stress can exacerbate this energetic condition of cold or deficiency, leading to lowered immune function. Eventually, stress can push this condition into chronic fatigue syndrome, which results when the Epstein Barr virus (the same virus that causes mono) takes over the body due to low vitality. As stress continues to drain vitality, this person may progress to metabolic syndrome or hypothyroidism, the latter being a condition that is epidemic in women over age fifty.

In energetic medicine, the approach to helping someone fully recover from mono is to warm the person through use of appropriate tonics and herbs to support the immune system. It is vital to understand the energetics of the herbs you work with, however. For example, echinacea (Echinacea spp.) is specific for mono, but its energy is cold (which is why it excels at clearing toxic heat from snakebites). With mono, echinacea can be helpful, but it should be offered in combination with warming herbs to address deficient vitality. With this kind of simple, knowledgeable herbal support, the patient recovering from mono can potentially avoid years of suffering and loss.

I have found that naming patterns of imbalance for clients empowers them with a greater understanding of their nature and their health. Instead of overwhelming a client by telling them they might have four or five diseases, we can address one, or perhaps two, underlying conditions. That said, herbalists make use of many tools to help clients on their journey toward health, including blood work, bodywork, allopathic testing, and scans when appropriate. Yet time and again I have seen cases that involved a multitude of issues, and by working energetically, as I did with my client Maria, the path to healing unfolds with greater simplicity than might have been imagined.

In addition to their wonderful energetics, plants bring a unique level of compassion to our lives. Plants have an uncanny ability to get in between the spaces to remind our bodies that their self-healing mechanisms are still intact. They are the perfect teachers indeed.

Chaga (Inonotus obliquus) is a black, parasitic mushroom, which looks on the outside like a lump of burnt, craggy charcoal; it belongs to the Hymenochaetacea family of fungi. The genus Inonotus is widespread is widespread in North America, Asia and Europe and comprises around 100 species, represented in Europe by four species, one of which is Inonotus obliquus.

The term ‘chaga’ most probably derives from Russian; chaga is also known as birch conk (a woody growth), clinker polypore, cinder conk and black mass, and may usually be found on the boles of birch trees, (1) though occasionally on other trees: on alder, ash, beech, chestnut, hornbeam, plane-tree, poplar, maple, rowan, oak, walnut, and willow. However, reports on the growth of chaga on trees besides beech are often unreliable as the fungus growing on the other kinds of tree are similar and often confused with chaga. (2)

Chaga grows externally on the bark of the host tree, be it living, dead, standing or fallen. Under the black surface, the chaga mycelium is an orange/brown colour. It causes the decomposition of live boles and usually grows to around between 25-40 centimetres; it dries to a consistency similar to that of hard cork. Chaga usually infects trees that are 30-40 years old through wounds in the bark and can continue to grow on the bole for another 30-80 years. On old trees the growth of chaga can exceed 50 cm in diameter. (3)

Low in calories, high in fibre, and rich in minerals and vitamins, chaga has been used as a traditional medicine in various cultures since time immemorial, particularly in Russia, China, Poland (4) and the Baltic countries. It is also used for food in China. (5) Chaga is used to treat diabetes, parasites, tuberculosis, inflammation, gastro-intestinal problems, heart disease and several kinds of cancer. (6)

Perhaps the oldest reference to the use of chaga as a medicine is by Hippocrates (c. 460–370 BCE) in his Corpus Hippocraticum, in which is described the use of infusions of chaga to wash wounds. (7)

For medicinal treatments chaga is usually ground to a fine powder and made into a tea, which tastes like mushrooms. It is also available in capsule form as a supplement, sometimes in combination with other mushrooms, such as cordyceps.

However, many commercial products are simply unprocessed powdered chaga without having been extracted. This means the active compounds are not bioavailable and so one must be careful when buying a product that the quality is good and that the preparation process is clearly explained if it is simply a powder and not an extract.

The chaga mushroom has been the subject of many scientific investigations to explore its medicinal properties, particularly by researchers in South Korea. (8) Chaga has been shown to be effective in reducing cancerous tumours, thereby suppressing the progression of cancer, through promoting energy metabolism. (9)

In the semi-autobiographical novel Cancer Ward by Aleksandr Solzhenitsyn, set in Russia and first published in 1968, cancer patients are prescribed chaga tea.

Several studies on mice and on human cells in vitro have demonstrated the effectiveness of chaga as an anti-tumour agent, effective in the treatment of several kinds of cancers, including cancer in the colon, (10) liver, (11) prostate, breast, (12) lung, stomach, and cervix. (13)

Compounds known as triterpenes/triterpenoids have been extracted from chaga and found to be effective in killing breast cancer cells. (14)

The chaga fungus contains inotodiol (a lanostane triterpenoid), which has anti-tumour properties. (15) Inotodiol and betulin (another triterpenoid with a lupane structure) are found almost exclusively in the fungus growing on birch trees. (16)

Betulin forms up to 30% of the dry weight of silver birch bark; it is found in large amounts in chaga and has anti-cancer properties. (17) It is currently believed that the anti-cancer potential of the mushroom is primarily due to the high content of polysaccharides (18) in the mushroom. (19)

Chaga has the full spectrum of immune-stimulating phytochemicals found in other mushrooms, such as in maitake and shitake, (21) which are widely consumedin Japan. It has been found that the compounds in mushrooms in general that inhibit tumour growth do so mostly by stimulating the immune system. (22)

Chaga may be useful as an immune enhancer in people with either suppressed or compromised immune systems, who may develop auto-immune diseases such as psoriasis, rheumatoid arthritis or type 1 (auto-immune) diabetes. Chaga is a potent immune modulator and could also be used to treat people whose bone marrow has been damaged by chemotherapy. (23)

Many studies have confirmed chaga’s anti-inflammatory properties. (23) One study (24) concluded that chaga could be useful to treat inflammation, notably in bowel disease. It has now evident that inflammation is implicated in numerous health issues, including anxiety, unipolar and bipolar depression, schizophrenia, post-traumatic stress disorder, asthma, rheumatoid arthritis, cardiovascular disease, obesity, diabetes, osteoporosis, Alzheimer’s disease, certain cancers and stroke.

Eight out of ten of the leading causes of death in the USA involve inflammation. (25) More research is needed for specific inflammatory processes and conditions, however it would be a viable investigation route to see how chaga can effect illnesses where inflammation is involved.

Besides being anti-inflammatory, chaga is also rich in anti-oxidants, (26) the main anti-oxidants being polyphenols and triterpenoids. As noted above, triterpenoids are effective against some forms of cancer. Antioxidants can prevent or reverse damage to cells caused by aging, the environment or lifestyle.

Polyphenols can help manage both blood pressure and blood sugar levels, and reduce chronic inflammation. There are around 8,000 kinds of polyphenols, which are in many kinds of foods in greater or lesser quantities. Some of the commonly consumed polyphenols include flavonoids, such as quercetin and catechins, which are in fruits; capsaicinoids, in chili peppers; lignans and stilbenes, in vegetables and whole grains; resveratrol in red wine; and ellagic acid in berries.

High levels of anti-oxidants are in chokeberries, elderberries and blueberries. (27) However, several surveys indicate that the highest levels, by far, of anti-oxidants in plant sources are in chaga. (28)

Chaga is particularly rich in the antioxidant known as superoxide dismutase (SOD), which has been shown to reduce free radical damage, preventing wrinkles and having an anti-cancer effect. (29) Several extracts from chaga, including polysaccharides, have also been shown to have neuroprotective effects in degenerative diseases such as Alzheimer’s and Parkinson’s. (30)

Studies on the effect of particular compounds in chaga have indicated that after four weeks they can significantly reduce the body weight, blood glucose levels, and plasma insulin levels of mice with diabetes. (31) It has been shown that the polysaccharides in chaga have hypoglycaemic activity, reducing blood sugar levels. (32)

Other studies, (33) also on rats and mice, confirm that chaga is antioxidant, can reduce blood sugar, and provided further indications that chaga would most probably be effective against diabetes in humans.

Two studies suggest the anti-bacterial and probiotic effect of chaga; another study indicates the anti-parasitic properties of polysaccharides in extracts from chaga. (34) The betulin in chaga can easily be converted to betulinic acid, which has been shown to have antiviral activity against HIV and malaria. (35)

Polysaccharides extracted from chaga have been shown to be effective against other viral infections, including herpes, feline influenza (and other feline viral infections), and hepatitis C. (36)

It has been found that chaga modulates immune responses through secretion of cytokines in immune cells, and regulates antigen-specific antibody production. Chaga can increase serum levels of chemoprotective cytokines, (37) which are proteins that regulate the immune system and stimulate white blood cells, which protect against harmful bacteria and viruses.

Cytokines are also implicated in SARS-Covid infection, which causes illness through a cytokine ‘storm’. The triterpenoid inotodiol found in chaga, mentioned above, has been found to induce the proliferation of T-cells, which act against viral infection. (38) So, it may be that chaga can protect against the SARS-Covid virus.

Besides its other effects, chaga has also been shown to be able to reduce levels of total cholesterol in rats, (39) high levels of some forms of cholesterol being a factor in heart disease. It seems that it is the antioxidant effect of chaga that reduces cholesterol.

It has also been found that the polysaccharides in chaga increase in mice the production of sperm and testosterone, and ameliorate impaired reproductive function. (40)

Birch trees are native to northern latitudes of the world: to Russia, Siberia, northern Europe, Canada, Alaska, northern China and Korea. There are far more birch trees in Scotland than in England. The ancient Balts, Slavs and Finns regarded the birch as a sacred tree.

In pre-Christian Ireland, birch was considered as one of seven sacred trees. (41) The name ‘birch’ derives from the Proto-Indo-European (PIE) root *bher∂g, which means ‘shine’/’brilliance’/’white’, reflected in names such as Albert, Herbert and Robert. (42)

The Celts saw in the birch the deity Brigit/Brigid, whose name derives from the same root, *bher∂g. Brigit was the muse of healers and bards in pre-Christian Ireland, where smitten boys would place fresh, green birch twigs in front of the house of the one they were courting. (43)

Birch twigs used to be used in Europe for the beating of bounds and the flogging of delinquents – and formerly lunatics – to expel evil spirits. In Scandinavia the first leaves of birch mark the beginning of the agricultural year. The witches’ broom used to be made from birch and ash. (44)

In India, the birch tree is called bhūrja in Sanskrit. In north India, texts used to be inscribed on birch bark, which is used by North American Ojibwa Indians for many other purposes, such as for tools, mats, canoes and baskets. (45) The sap of birch trees is used to make a sugar substitute, known as xylitol. Birch sap has less sugar than maple and is used as a syrup by Lithuanians. (46)

In herbal medicine the sap of birch is believed to stimulate urine and bile, purify the blood, and strengthen the urinary tract. (47) Tea made from the leaves of white birch is used for dissolving kidney stones and as a laxative. Twigs and leaves are added to bath water as a treatment for itchy skin and hair loss, while the inner bark is simmered for fever. (48)

In the last couple of decades, numerous scientific studies have indicated the potential for chaga to treat several common diseases, including cancer and diabetes, as an immune-system booster, as an antioxidant, and against harmful viruses.

Although the scientific tests so far have been almost exclusively conducted on rats and mice, and many of these studies lack in-depth experiments, (49) it seems highly likely that such effects would be replicated at least to some degree in humans. It should, however, be cautioned that chaga can prevent blood clotting, (50) so it should not be used by anyone using blood-thinning medication.

As mentioned above, the birch tree is revered in several cultures, notably by the Balts, Slavs and Finns. It has been suggested by some commentators (51) that this reverence for the birch tree may derive from the fact that one of the main places where the red, spotted, fly-agaric mushroom (Amanita muscaria) may be found is beneath birch trees.

Fly-agaric has psychedelic effects and is used for shamanic purposes in some cultures in Siberia and North America. (52) It was famously, though incorrectly, (53) identified in the late 1960s by R. Gordon Wasson – one of the great mycologists of the 20^th century – as the ‘nectar of immortality’, the ritual drink known as soma, (54) which is revered by the Brahmins of India. However, leaving this suggestion aside, perhaps, as a speculation, reverence for the birch tree has, instead, practical roots in the ancient use of chaga as a wondrous medicine.

1. Betula fontinalis, Betula lenta, Betula lutea, Betula papyrifera, Betula pendula (silver birch), Betula pubescens/alba (white birch).
2. Szychowski et al. (2021:293).
3. Szychowski et al. (2021:293).
4. Inonotus obliquus is a partially protected species in Poland (Szychowski 2021:293).
5. Ma et al. (2013.
6. Kim (2005).
7. Szychowski et al. (2021:294).
8. For a recent, comprehensive review of the scientific literature on research into the medical potential of chaga, see Szychowski (2021).
9. Arata et al. (2016).
10. Lee et al. (2015).
11. Youn et al. (2008).
12. Ma et al. (2013).
13. Chung et al. (2010).
14. Zhao et al. (2016).
15. Chung et al. (2010).
16. Phillips (2006:310). Betulin is also found in red alder (Alakurtti et al. 2006) and a few other plants (Moghaddam (2012).
17. Alakurtti et al. (2006).
18. Three important polysaccharides – starch, glycogen and cellulose – are composed of glucose.
19. Szychowski et al. (2021:299).
20. Kim (2005).
21. Borchers et al. (2008:259).
22. Kim (2005).
23. Ma et al. (2013).
24. Mishra et al. (2012).
25. Slavich (2015).
26. Cui et al. (2005); Liang et al. (2009).
27. In one survey (WebMD 2020) it is reported that the foods with the highest levels of antioxidants are (per half-cup serving) chokeberries (1,123 mgs), elderberries (870 mgs), blueberries (535 mgs) and blackcurrants (485 mgs). Blackberries, raspberries and strawberries have around 160 mgs. Per ounce, cloves contain 542 mgs, and peppermint 427 mgs. Dark chocolate has 249 mgs per tablespoon (milk chocolate has just 35 mgs). Of all nuts, the most polyphenols are in chestnuts, with 347 mgs per ounce. Other sources of polyphenols include flax seeds (229 mgs per tablespoon); a small artichoke has around 260 mgs; a small red onion has around 170 mgs; an olive has around 20–25 mgs; and a cup of coffee has about 35 mgs of polyphenols.
28. Acai berries reportedly contain 165 oxygen radical absorbent capacity (ORAC) units, pomegranates 105, and blueberries 24; chaga contains 1,104 (Chichaga 2015; Wild Kingdom 2022).
29. Younus (2018).
30. Szychowski et al. (2021: 295).
31. Wang et al. (2017).
32. Szychowski et al. (2021:299).
33. Cha et al. (2006); Diao et al. (2014); Sun et al. (2015); Wang et al. (2017).
34. Szychowski et al. (2021:296).
35. Alakurtti et al. (2006); Moghaddam et al. (2012).
36. Szychowski et al. (2021:294, 296).
37. Kim (2005); Ko et al. (2011).
38. Maza et al. (2021).
39. Sun et al. (2015).
40. Ding et al. (2020).
41. Graves (1977:253).
42. Online Etymological Dictionary (2022).
43. Müller-Ebeling et al. (2003:8).
44. Graves (1977:166, 173).
45. Nyholm (2022).
46. Chepaitis (2016).
47. Müller-Ebeling et al. (2003:7).
48. Hopman (1995:187).
49. Szychowski et al. (2021:298).
50. Hyun et al. (2006).
51. For example: Müller-Ebeling et al. (2003:10).
52. Morgan (1995:106–110).
53. See Clark (2020).
54. See Wasson (1969).

Most animals are born with an innate skill to forage and hunt. Many of us will have observed the incredible wisdom of a domesticated pet self-medicating with wild plants, most of whom were unlikely to have been taught this skill directly by their mother.

Think of dogs chewing on grass for digestion, or cows eating blackberry and raspberry leaves when pregnant- herbal medicine is an instinct. In fact animals self-medicating with plants is a branch of science known as zoopharmacognosy.

It is understood that learning about food begins in early life as flavours of the foods eaten by the mother are then transferred to her offspring both in utero or in her milk.

This would suggest that neural connections between the sensory systems and our subconscious brain are made during gestation. Which may explain, in part, how animals who were separated from their parents during infancy would still retain a degree of this transferred sensory knowledge (4).

Wild animals who stay in parental care throughout early infancy will however learn through parental guidance about the environment, the location of water and shelter, safety and protection from predators and which edibles are nutritious and which are toxic as well as where to find them.

Animal instinct when it comes to learning the foods that are beneficial also in part comes from a level of trial and error, through biofeedback. Palatability is influenced by the nutrient or toxin content of food. Where nutritional needs are met by a certain food, this is thought to increase palatability. Where as if a food is low in nutrients or contains high levels of toxins, this will decrease palatability. This information is then held in the sensory memory which informs the intuition (4).

The intuition is defined by the scientific community as an innate sense used in decision making which involves little or no ‘conscious’ deliberation. The subconscious brain attempts to recognize, process, and use patterns of thinking based in part, on previous experiences (3).

The hidden neurological processes involved in intuition, effect decision making and creativity, allowing one to respond instantly with confidence prior to a more cognitive analysis (3).

In most Western cultures we are now at our furthest point of disconnection from the natural world. For most, hunting and foraging is no longer an essential part of daily life. We are less connected to our food sources than we have ever been.

When we look at the wild foods and plants that grow wild around us, against the limited range of conventional vegetables and fruits that constitute the majority of our Western diet, it is not hard to believe that we are eating only a fraction of the food types once available to us (or that were once a part of our daily routines).

Wild plants contain an incredibly diverse range of phytonutrients and micro-bacterias compared to the farmed and comparatively sterile produce found on the shelves of the supermarket.

A diversity that we would have once benefited from, least not for providing a far superior source of ‘living’ nutrition but for the vital energy that foraged edibles offer (higher vitality- meaning closer to ‘life’, due to being consumed or prepared soon after gathering).

With more foraging and use of wild food and medicines we gain both an enhanced nutritional diversity and a better sense of wellbeing purely through time spent in nature. This makes a strong case for re-engaging with the practice of foraging as a means of enhanced personal and environmental wellbeing.

With this, we can see a clear link between the missing connection that is caused by a lack of interaction with the natural world and lower level of overall wellbeing, in both mind and body.

When humans engage with the world more primitively through foraging, spending time in wild spaces or working with natural resources, the value of the human – nature relationship also becomes more immediate, or more important. With restored connection comes a true value for the natural world.

The Palaeolithic diet understands that our more primitive diet would have been predominantly based on seasonal leafy green vegetables, lean meats, fish, fruits, nuts and seeds – foods that in the past could be obtained by hunting and gathering (1).

The paleo diet limits foods that became common when farming emerged at about 10,000 years ago. These foods include dairy products, grains and legumes (1).

Foraging for medicine would have also been included in the primitive diet. We have evolved alongside the plants in our environment, therefore there is an affinity between our bodies and some of these plants.

It is only relatively recently that we are less in touch with our food and medicine, to the point that we are less likely to have forged this sensory understanding in comparison to our ancestors or other wild species.

We are also predominantly consuming imported and non-native foods, or foods grown out of season. The native, seasonal varieties that we evolved with are probably only a small fraction of the food types that make up our modern diet (2).

This seasonal variety would have once provided the exact nutritional/ medicinal benefits needed to support us throughout their respective season of availability i.e. berries in autumn – increased carbohydrates – energy, antioxidants, immunity whilst faced with the colder months; bitter leafy greens in spring – increased mineral content, blood detoxification – building back up nutrient stores and increasing vitality for the more active months of the year etc (2).

The five senses are key in our understanding and relationship with plants as food and medicine. In view of the above, we may see that our relationship to food in the Western world is limited to a fraction of what would have once been a diverse range of gathered and grown wild foods.

Medicinal plants contain a significantly more diverse range of medicinal and nutritional compounds than that of which is found in the typical foods of a Western diet. The 7 tastes found both in plants and foods are listed as follows; sweet, sour, bitter, salty, pungent, aromatic and umami.

These can all be understood in terms of their chemistry i.e. each taste will indicate the presence of certain groups of nutrients or compounds. The following graph demonstrates how these tastes translate chemically with examples of foods and plant medicines in which these tastes can be experienced;

Taste	Chemical / Nutritional	Actions	Botanical Examples
Sweet	Carbohydrates polysaccharides Energy-rich substances	Energising, immune stimulating	Licorice, fennel, marshmallow, slippery elm
Sour	Detects acidity vitamin C Antioxidants	Cell repair/ regeneration immunity, metabolism, liver stimulant	Rosehips, elderberries lemons, citrus fruit
Bitter	Bitter principles	Liver stimulant, detoxifying, blood purifying	Dandelion, burdock, raw cacao, chicory
Salty	Minerals	Adrenal regeneration, improve blood quality, kidney tonification	Kelp, seaweeds, nettle
Pungent	Volatile oils	Circulatory stimulant, Anti-infective, diaphoretic, vermicide, expectorant	Horseradish, pepper, chillies, garlic, mustard
Aromatic	Volatile oils	Antimicrobial, nervine, anti-infective	Lavender, rose, geranium
Umami	Nutritive substances, B vitamins Amino acids	Tissue regeneration, building blocks	Mushrooms, roots, nuts, grains

Whilst we may now be a degree separated from the primitive sense found in wild animals to identify wild foods and medicines, a relationship to plants created through the intuitive and sensory mind is still well within our reach.With some more understanding about the chemical indications of the seven tastes, hypothetically, it is possible that we can learn about the actions of herbs purely through experience. We know about the pharmacology of these herbs through rigorous scientific research into their actions, which is why we can reference each chemical group to having the actions shown in the graph above.

However, as we have already seen, from the more primitive animal connection to the chemistry of plants, through biofeedback, there is a valuable relationship to be forged. Within us all will be an engrained ability to learn in this way, beyond the world of science and information.

Of course, with the advances of information and science we can understand these processes more deeply. However one thing is lost- the primitive sense that is our relationship to the plant world, the instinct, the intuition, that heritage of knowledge passed down from our descendants. You may wonder why is this still so important? And if it is, what should we do differently?

There is everything to support the value in gaining this quantifiable scientific understanding of the actions of medicines, because it allows us to be accountable, it measures efficacy and safety and creates a solid knowledge base on which to teach.

However, as individuals in our own lives, if we were to reawaken this primitive sense as a means to connect with plant medicine; we enable ourselves to create authentic knowledge through experience, we create a personal connection with the information, we gain a deeper understanding of the nutritional value of our food and above all we can hope to bridge the gap, restoring our value in nature and our connection to the environment.

Many people feel disconnected, and this article highlights in part how we are disconnected from our food and the nature around us. Nurturing our natural instincts allows us to revive a part of ourselves that means we can live in more harmony with our environment, and with more curiosity and reverence. This is invaluable for our wellbeing, and giving more meaning to our large and complex world.

1. Challa, H., Bandlamudi, M. and Uppaluri, K., (2022). Paleolithic Diet. [online] Ncbi.nlm.nih.gov.
2. S. Walsh PhD (2003) Plant Based Nutrition and Health. The Vegan Society. England.
3. M. Gladwell (2005). Blink: The Power of Thinking Without Thinking. Penguin Books. England.
4. Marten G. C. (1978). The Animal-Plant Complex in Forage Palatability Phenomena. Journal of Animal Science, Volume 46. Issue 5.

The term adaptogen was first used by scientist Nikolay Lazarev in 1947 to describe substances that can improve an organisms ‘non-specific’ resistance to stress (1). In 1968 the definition was elaborated by fellow Soviet pharmacologists Brekhman and Dardymov to mean a substance that (2)

• is non-toxic, and causes minimal disturbance to the organism
• is non-specific in pharmacological action, improving the organisms resistance to a broad range of stressors
• tend to have a ‘normalising’ effect on body systems – reducing excess, and raising deficiency

This reflected an attempt to provide scientific support for a common theme in holistic herbal medicine – restoring balance and supporting the body’s natural adaptive resilience.

Not surprisingly herbs with these reported adaptogenic properties remain an attractive prospect for herbalists and patients. As would be expected from such a broad action adaptogens are employed for a whole host of conditions. However, the main therapeutic focus is reducing the extent of the body’s stress response, and improving recovery. Relatedly they will be used to improve stamina and support people with chronic conditions, and improve concentration.

While the word adaptogen is a very recent term, it is not without precedent in the long history of herbal medicine – the preservation and adaptation of herbal uses on which much pharmacological investigation is based. Exploring the histories of the most well known adaptogens shows the connections between their classifications in a variety of herbal traditions and their reinterpretation as adaptogens in the twentieth century.

• Eleutherococcus senticosus (Rupr. & Maxim.) Maxim.
• Family: Araliaceae
• Synonym: Acanthopanax senticosus (Rupr. & Maxim.) Harms)

While commonly known as Siberian ginseng, it has a wider distribution, growing wild across Northeastern and Central China, North Korea, South Korea, Far Eastern Russia and Japan (3).

It grows as a shrub, reaching heights of around 5 to 8 feet, and its light brown stems are covered in prickly spines. Each palmate leaf consists of five leaflets of varying size. It favours the cool semi-shade of mixed mountainous forests.

It produces tiny white flowers in mid-summer, borne on umbels, that produce clusters of black fruits. It is mainly the rhizome with the roots that is used in herbal medicine.

Eleutherococcus senticosus was the main herb of interest to the early researchers on adaptogens in the Soviet Union, and apparently found favour as a replacement for another member of the Araliaceae plant family, Panax ginseng, when supplies were low. Dr. Brekham researched and promoted the herb for convalescents, aiding immunity after surgery and protecting well-being. The herb found favour amongst Soviet athletes as an endurance aid, who then shared its use at international events (4).

It has a long history of use in Traditional Chinese Medicine, first recorded in the Shennong Ben Cao Jing c.220 A.D., and is mainly employed today in a range of combination prescriptions for various conditions.

It is recommended for general invigoration of Qi, with a particular affinity for the kidneys and liver, supporting their effective functioning, which leads to improvements in the health of the musculoskeletal system (5). It was traditionally used by people living in the subarctic forest regions of Siberia to improve quality of life and protect against infections (6).

• Panax ginseng C.A. Mey.
• Family: Araliaceae

Commonly known as Korean ginseng, it is historically associated with the country due to the reputation of the quality of the rhizome that grows there, that is still widely exported and remains an important souvenir for Chinese tourists visiting South Korea. Though like the so-called Siberian ginseng it has a wider distribution than its name suggests – spreading wild across North-Eastern China, North Korea, South Korea, and some regions of Far Eastern Russia (7).

It has a similar appearance to its close relative, though without the very spiney stem and having yellowish to pink flowers on its umbels that produce red rather than black fruits. It shares a similar habitat.

Again, it is the rhizome which is used medicinally, which makes it more at risk of overharvesting and it is now mostly cultivated due to the loss of wild plants, though semi cultivated ‘wild’ ginseng fetches a premium on the market while allowing stocks to be replenished.

The genus name shares the same etymology as panacea, coming from the Ancient Greek pân meaning “all” and ákos meaning “cure”, named for its supposed reputation in Chinese and Korean medicine. Chinese botanist Shiu Ying Hu argued in her 1976 paper that this reputation was based on a misrepresentation of its use in Chinese medicine which was “very specific and restricted”.

This was because it was only prescribed for patients “who have the jo (“weak”) symptoms and who need the pu (“tonic”) remedies”, out of ten possible symptom groups with matching remedy types (8). And in Chinese materia medica texts it is generally recommended for the following conditions – lassitude and anorexia, shortness of breath and low voice, diabetes, insomnia and impotence, and for each condition there is a specific combination of other herbs used alongside ginseng (9).

Despite these specific understandings of prescribing in a clinical tradition, Panax ginseng has gained a reputation across the world, including in China and South Korea, as a general tonic and health supplement on its own, to support peak performance at work, in sport and in the bedroom. It is sold as powder, pills, dried root, infused in wine, cooked in soup and in teabags.

• Rhodiola rosea L.
• Family: Crassulaceae (10)

Both fresh and dried, the root has a rich earthy rose like aroma, hence the species name ‘rosea’ and the common names roseroot and rosewort. It is also known as arctic root due to its affinity for icy habitats, and goldenroot on account of its yellow flowers. It grows upright to around 70cm high, with a fleshy stem and leaves.

Swedish botanist Carl Linnaeus recommended it for “headaches, “hysteria”, hernias, discharges, and as an astringent”(11). Tracing the longer history of the use of roseroot is harder because little detailed work has been published in English as far as I’m aware.

For example, there is debate over whether or not Vikings used it for endurance during their long journeys, which seems likely considering the uses we know of today, but there are very little textual records from this period and only a few studies on the archaeobotanical record. However, the root is used today for a range of conditions across its wide distribution – Arctic and mountainous regions of Europe, Asia and North America, covering around 30 countries (12).

According to a review of traditional uses the Sámi people chew on root pieces during long journeys and use it for urinary infections, Inuit people use the root for infections, colds, fatigue, and toothache, and for mental and physical rejuvenation. Evenki people in North-Eastern Russia use it as a ‘universal’ medicine. Elsewhere it is commonly used for fatigue, strengthening the body, mental stamina, stress relief and as a tonic (13).

It has become popular in recent years in commercial preparations for its advertised adaptogenic properties. The plant is of conservation concern due to climate change and overharvesting for the herbal medicine trade in certain areas (14).

Other herbs most commonly referred to as adaptogens are:

• Astragalus (Astragalus mongholicus Bunge (syn. Astragalus membranaceus Fisch. ex Bunge))
• Ashwagandha (Withania somnifera (L.)
• Schisandra (Schisandra chinensis (Turcz.) Baill.)
• American ginseng (Panax quinquefolius L.).

Mills and Bone, in their widely referenced book Principles and Practice of Phytotherapy extend the definition of adaptogen to:

• Goji berry (Lycium spp.)
• Codonopsis (Codonopsis pilosula (Franch.) Nannf.)
• Echinacea (Echinacea spp.)
• Gingko (Gingko biloba L.)
• Gotu kola (Centella asiatica (L.) Urb.)
• Tribulus (Tribulus terrestris L.) (15)

In addition to these herbalist David Hoffman lists many more as adaptogens. Many of these are in the same family as the ginsengs discussed above:

• Wu jia pi (Eleutherococcus sessiliflorus (Rupr. & Maxim.) S.Y.Hu)
• Japanese angelica tree (Aralia elata (Miq.) Seem.)
• Manchurian aralia (Aralia elata var. glabrescens (Franch. & Sav.) Pojark)
• Sakhalin spikenard (Aralia cordata Thunb.)
• Asian devil’s club (Oplopanax elatus (Nakai) Nakai)

And in diverse plant families:

• Silk tree (Albizzia julibrissin Durazz)
• Chickpea (Cicer arietinum L.)
• Indian hoppea (Hoppae dichotoma  Willd.)
• Guduchi (Tinospora cordifolia (Willd.) Hook.f. & Thomson)
• Arogyappacha (Trichopus zeylanicus Gaertn.)
• Holy basil (Ocimum tenuiflorum L.)
• Hardy rubber tree (Eucommia ulmoides L.)
• Maral root (Leuzea carthamoides (Willd.) DC.)
• And one species of mushroom, also popular for supporting immunity: lingzhi or reishi (Ganoderma lingzhi (Sheng H. Wu, Y. Cao & Y.C. Dai))(16)

As would be expected all these herbs have a long tradition of use both in the regions they grow and through international trade, combine this with the general nature of their actions and you can see how they have been employed for more conditions than it is possible to account for here.

There are however common themes that emerge when connecting these traditions to their more recent classification as adaptogens – the use for fatigue, general debility, endurance, resilience, as a tonic a ‘universal’, for support of the body as a whole or for optimal function of specific organs or systems.

One of the scientists who defined the term adaptogen distinguished it from a herbal tonic in 1968, describing a tonic action as increasing work capacity and correcting weakness and lack of tone, and from a stimulant which provides a temporary increase in work capacity, followed by a decrease (17).

It should also be noted that when studying traditional medical systems the word ‘tonic’ is often simply a translation into English of words that could be understood quite differently within those cultures, that may be closer to or further from the definition of adaptogen.

Some biochemists have argued that the term adaptogen should not be used as it cannot be linked to a few clear ‘mechanisms of action’ based on isolated compounds, and that scientists should ignore “the fact that the word ‘adaptogen’ was ever invented. While others argue the effect is the same as that of a placebo (18).

The original definition of adaptogen was very clear on the non-specific action, and it is seen as a useful way to bridge different approaches to philosophies of healing.

Despite some scepticism, many researchers are still looking to test the adaptogenic theory, and have focused on many different specific actions to understand the possible effects of these herbs on the body. Some areas that the action is understood in biochemistry are as follows – more efficient use of glycogen, regulating metabolism, inhibiting stress hormones binding to receptors, relaxation of blood vessels, antioxidant activity, steroidal activity, immunostimulant, immunomodulatory, hepaprotective, and antifatigue activities (19).

In some cases, as with Panax ginseng, a herb can contain chemicals that have opposing actions that may explain the adaptogenic effect, for example both hypotensive and hypertensive effects (20).

And for randomised controlled trials the focus is normally on work capacity and endurance for exercise, oxygen consumption, heart rate, respiratory exchange rate, blood pressure, blood glucose, tests of cognitive performance, as well as more subjective measures of wellbeing.

The search for a or cure all is not new, the phrase panacea was used for many different species of plants across ancient Greek and Roman texts, that have been linked to the contemporary names lovage (Levisticum sp.), yarrow (Achillea sp.), centaury (Centaurium sp.), tarhan herb (Echinophora), and species of the genus Opopanax, known in English as ‘all heal’.

While the term ‘adaptogen’ is a very recent development in the history of herbal medicine it is not without precedent. It seems there has always been a desire for a general tonic that can provide support to the body’s own resilience, and it is based on real benefits that people have experienced from taking these herbs. While it is not surprising that the idea of a ‘cure all’ plant raises scepticism, when the use of a herb is understood within its specific context it generally becomes clear that different adaptogens will be used for different patients and different manifestations of conditions in clinical practice.

It has become popular among herbalists, probably because it covers the complexity of using plants as medicines while connecting to a pharmacological approach. The ‘non-specific’ action that is so frustrating to biochemical models that rely on isolation and reduction, holds within it an awareness of complexity and the unknown, and of the workings of the body as a whole that may be more than the sum of its parts. More research is still being done to understand how the specific pharmacological actions connect to the more general outcomes in patients, and there are many more herbs that may demonstrate adaptogenic properties that have had very little research on them.

1. Marina Davydov and A. D. Krikorian, ‘Eleutherococcus Senticosus (Rupr. & Maxim.) Maxim. (Araliaceae) as an Adaptogen: A Closer Look’, Journal of Ethnopharmacology 72, no. 3 (1 October 2000): 345–93, https://doi.org/10.1016/S0378-8741(00)00181-1.
2. I I Brekhman and I V Dardymov, ‘New Substances of Plant Origin Which Increase Nonspecific Resistance’, Annual Review of Pharmacology 9, no. 1 (April 1969): 419–30, https://doi.org/10.1146/annurev.pa.09.040169.002223.
3. POWO, ‘POWO’, Database, Plants of the World Online. Facilitated by the Royal Botanic Gardens, Kew., 2022, https://powo.science.kew.org/taxon/urn:lsid:ipni.org:names:90431-1. Accessed 15/02/2022.
4. Tracy Lee Bleakney, ‘Deconstructing an Adaptogen: Eleutherococcus Senticosus’, Holistic Nursing Practice 22, no. 4 (August 2008): 220–24, https://doi.org/10.1097/01.HNP.0000326005.65310.7c.
5. Erich Stöger, Chinese Herbal Medicine: Materia Medica (Eastland Press, 2004).
6. Linzhang Huang et al., ‘ChemInform Abstract: Acanthopanax Senticosus: Review of Botany, Chemistry and Pharmacology’, Die Pharmazie 66 (1 February 2011): 83–97, https://doi.org/10.1691/ph.2011.0744.
7. POWO, ‘POWO’. https://powo.science.kew.org/taxon/urn:lsid:ipni.org:names:91472-1. Accessed 15/02/2022.
8. Shiu Ying Hu, ‘The Genus Panax (Ginseng) in Chinese Medicine’, Economic Botany 30, no. 1 (1976): 11–28.
9. Yao-Zu Xiang et al., ‘A Comparison of the Ancient Use of Ginseng in Traditional Chinese Medicine with Modern Pharmacological Experiments and Clinical Trials: USE OF GINSENG IN TCM AND CLINICAL TRIALS’, Phytotherapy Research 22, no. 7 (July 2008): 851–58, https://doi.org/10.1002/ptr.2384.
10. A. Panossian, G. Wikman, and J. Sarris, ‘Rosenroot (Rhodiola Rosea): Traditional Use, Chemical Composition, Pharmacology and Clinical Efficacy’, Phytomedicine 17, no. 7 (1 June 2010): 481–93, https://doi.org/10.1016/j.phymed.2010.02.002.
11. Carl von Linné, Materia Medica (Holmiae: Typis ac sumptibus Laurentii Salvii, 1749), https://www.biodiversitylibrary.org/bibliography/72911. Quoted in Panossian, Wikman, and Sarris, ‘Rosenroot (Rhodiola Rosea)’.
12. POWO, ‘POWO’, Database, Plants of the World Online. Facilitated by the Royal Botanic Gardens, Kew., 2022, https://powo.science.kew.org/taxon/urn:lsid:ipni.org:names:315148-2. Accessed 15/02/2022.
13. J.A. Brinckmann, A.B. Cunningham, and David E.V. Harter, ‘Running out of Time to Smell the Roseroots: Reviewing Threats and Trade in Wild Rhodiola Rosea L’, Journal of Ethnopharmacology 269 (April 2021): 113710, https://doi.org/10.1016/j.jep.2020.113710.
14. Brinckmann, Cunningham, and Harter.
15. S. Mills and K. Bone, ‘Principles and Practice of Phytotherapy. Modern Herbal Medicine.’, 2000, xx + 643 pp.
16. David Hoffmann, Medical Herbalism: The Science and Practice of Herbal Medicine (Inner Traditions / Bear & Co, 2003).
17. Committee on Herbal Medicinal Products (HMPC), ‘Reflection Paper on the Adaptogenic Concept’ (European Medicines Agency, May 2008), https://www.ema.europa.eu/en/documents/scientific-guideline/reflection-paper-adaptogenic-concept_en.pdf.
18. Davydov and Krikorian, ‘Eleutherococcus Senticosus (Rupr. & Maxim.) Maxim. (Araliaceae) as an Adaptogen’.
19. David Winston and Steven Maimes, Adaptogens: Herbs for Strength, Stamina, and Stress Relief (Inner Traditions / Bear & Co, 2007); Mills and Bone, ‘Principles and Practice of Phytotherapy. Modern Herbal Medicine.’; Joanne Barnes, Linda A. Anderson, and J. D. Phillipson, Herbal Medicines, 3rd ed (London ; Grayslake, IL: Pharmaceutical Press, 2007).
20.  Barnes, Anderson, and Phillipson, Herbal Medicines. 333.

Critics of herbal medicine sometimes lead the public to believe that they should avoid herbal remedies because there is a lack of evidence about the safety or efficacy of medicinal herbs. They often resort to the somewhat exhausted mantra that “just because something is natural does not mean it is safe” (2,3,14,28).

This is on the face of it an accurate assessment, but it may also be a half-truth. It could equally be suggested that because something is natural it is more likely to be safe (due to its longevity of use without incident for example) rather than something which is unnatural, such as a synthetic drug made in a laboratory with all its inherent risks and unwanted side effects.

Indeed, it is because of the latter that the general public often seek a ‘natural alternative’ in the first place.

The general longevity of use in traditional practice over many centuries suggests the vast majority of herbal medicines when used appropriately by practicing herbalists are as safe as fruit and vegetables (indeed many of them are fruits and vegetables), with only a few stronger herbs employed in limited dosages.

Part of the problem is that some researchers chose to ignore the existence of the professional herbalist who is trained to flag any potential contraindications which might assuage at least some of the perennial concerns they raise. Instead, some prefer to put across their conflated concerns of an unsuspecting public stepping into the mire, and rather than suggest that the public consults with a professional herbalist; they play on fears and generate uncertainty (13,16). The objective of this type of criticism is to create a sense of doubt in the public eye, but is it all just smoke and mirrors?

While it’s true to say that some herbs such as Atropa belladonna are dangerous in the wrong hands, access to such plants is legally controlled and these herbs are unavailable to the general public. And while unsuspecting amateurs harvesting from incorrectly-identified species in the wild may cause problems for themselves, such misadventure is not in any way connected to professional herbal medicine.

By and large, the majority of herbs used by herbal practitioners are tried and true over long periods of time. A small selection of herbal medicines may be considered more medicinally “potent”, but the discerning herbal practitioner uses restricted doses and fixed durations of use for such herbal preparations and is trained to be aware of any potential toxicity.

The deconstruction of semantics aside, we are still left with the question – is there a lack of evidence for herbal medicine? In order to put this question into context, we might begin by examining the term “evidence” itself. Critics of herbal medicine believe that herbal medicine can only be understood through certain types of evidence.

In a court of law the defendant or prosecution presents corroborating evidence for particular statements to establish the foundations of their arguments. This corroborating evidence may come from diverse sources. The origins of evidence are less important than the strength of such evidence to convince a judge and jury. But what if the judge demanded that only evidence gathered from the City of London could be considered, even if the events around the case occurred outside the City of London? You would be correct to think that such a hypothetical situation would be ludicrous.

The term evidence-based medicine (EBM) became popular in the 1990s (31). It presents the case that all medical interventions should be “evidence-based”, with the double-blinded randomised controlled trial (RCT) considered the gold standard in clinical research. Systematic reviews and meta-analyses of RCTs (peer review) became the pinnacle of the new evidence hierarchy.

The clinician could then use this information to best inform their clinical judgement. However, evidenced-based medicine in this particular reading has a number of confounders and inconsistencies. Firstly, it implies that there was no evidence before EBM or if there was it was circumstantial (coming from outside the City of London in our earlier hypothetical scenario).

Secondly, it implies that evidence can only be assessed in a certain way and that this evidence is better than other types of evidence such as expert opinion. The imposing hierarchy of EBM is summarised in Figure 1 below:

On first glance it seems odd to put expert opinion at the bottom of the pyramid and place systematic reviews at the top. The concept of defining evidence in this way may well be a noble attempt to eliminate bias from influencing clinical decision making, but this itself is predicated upon the erroneous belief that bias can be completely eliminated. It seems more likely that bias may only be limited through these processes but only in carefully controlled laboratory conditions (creating internal validity) which unfortunately have little connection to what happens in the real world (lacking external validity).

The RCT is a methodology which is used in testing the efficacy of new drugs, treatments and health care services. The use of RCT research is considered highly effective by its supporters because it is thought to minimise allocation bias (Nunan, Heneghan and Spencer, 2018).

The significant characteristic of RCTs is that trials usually include a control experiment alongside the main treatment. These are known as placebo-controlled studies. They are used in comparing changes recorded in the active treatment group in order to ascertain that the placebo group that was not included in the treatment does not react in a similar manner. This serves the purpose of proving whether the active treatment actually had an impact on the active study group.  In this way it can be established whether or not a new drug is superior to placebo. But how do you establish a placebo?

Comparing a drug to a placebo in an RCT sometimes implies that the placebo effect has a fixed value, say 30%, so the new drug must be equal to or greater than placebo in terms of safety and effectiveness and yet placebo effects may be greater or lesser than 30% depending on many factors. For example, there may be more than one placebo effect depending on the circumstances, so placebo controls may actually potentially increase bias in some cases (9).

But let’s assume in a double blind randomised controlled trial that a new drug is found to be greater than placebo and no major adverse reactions are recorded. The trial and methodology should then be independently replicated and a statistically similar result would be expected. Replication trials should mimic the methodology of the original trial, and statistically similar results would either validate the original study or bring it into question. When we speak of gold standards, this extra layer of scrutiny would help to strengthen the clinical trial process. In turn systematic reviews and meta-analyses might include replication trials as specific inclusion criteria.

What if the RCTs are not independently replicated? The results may be unreliable, and the primary research data would be flawed? What if researchers later conducting a meta-analysis only include certain RCTs (some of which may be flawed) and not others (which may not be flawed) in a peer review? In that case secondary and tertiary research could also be flawed, casting shadows over the whole process.

What of researcher conflicts of interest; study cohorts which are not representative of the general public; unrealistic sample size; lack of preclinical screening for participants; use of unrealistic dosages or durations of use; and statistical bias? There are many problems with such a rigid methodology, if full checks and balances are not put in place.

Professor John Ioannidis put this into stark perspective with his highly influential paper Why Most Published Research Findings are False, which has become the most cited research paper of all time (19). Ioannidis argues that due to a lack of replication trials, statistical incongruence and the initial “truth” of a research question, most research may be false. If Ioannidis is correct, could this culture of false or erroneous data account for increasing iatrogenic events which now sees modern medicine as a leading cause of death in annual all-cause mortality statistics? (22) This would imply that there is a crisis in the current EBM paradigm.

On the other hand, expert opinion at the bottom of the EBM pyramid (Figure 1) might be in need of a paradigmatic reappraisal. Imagine a physician who has seen thousands of patients and developed successful healing strategies over many years in real world situations. Would it be advisable to value their expert opinion above the results of a potentially flawed clinical trial?

David Sackett, nominated by his peers as the “Father of EBM” for his pioneering work, describes EBM as an amalgam of the best systematic research, expert opinion and the patient’s rights and choices (29). If we follow Sackett’s description, we see a tripartite approach, not a single approach that favours filtered over unfiltered information but a multifaceted approach which values systematic research alongside expert opinion, and importantly brings in the vital component of patient experience and opinion.

Patient-centred care has become a popular term in modern medical parlance, and yet many patients do not feel satisfied by the care they receive under the current medical model. Patient satisfaction is an important and commonly used indicator for measuring quality of care. Disempowerment of the patient may occur because of long waiting times; the all too brief consultation process where empathy does not occur and where key information can be missed; but also because of side-effects and/or a lack of efficacy of prescribed medications and procedures (17).

Taking these comments into consideration, there are problems and obstacles within the current paradigm of EBM. We must also consider how useful this methodology is to herbal medicine in particular?

The RCT process is designed for pharmaceutical drugs within a reductionist paradigm, where a candidate drug with a single therapeutic target is examined. Clearly, the multi-constituent nature of herbs (with multiple therapeutic targets) does not fit easily into this model. Some researchers have tried, occasionally successfully, to put herbs through such scrutiny, but the cost and time involved may hardly be worth the effort, especially when it is often not reflective of or does not contribute to an understanding of the practice of herbal medicine.

Could the RCT process be reconfigured in such a way so as to examine the protocol a herbalist uses in clinical practice for a particular condition, and compared with an orthodox treatment, rather than testing a single herb or constituent against an imagined placebo? Might this provide evidence of the efficacy and safety of herbal medicine if it is designed to reflect actual practice?

Systematic research can be useful provided it is relevant to herbal practice. Where it is not relevant to practice it may be considered as “background information”. The danger of an obsessive approach to EBM and a paradigm enthralled to scientism is that it may also eclipse other important strands of evidence.

What if the playing field is levelled and we consider other strands of evidence equally and without imposing an EBM-like hierarchy? I propose an “evidence house” model for herbal medicine research on egalitarian lines, where each room yields key information which can establish a foundation of evidence upon which to build. In contemplating this approach I decided that I would examine those stems of evidence upon which I have drawn for practical information and which have since informed my practice and led to successful outcomes for my patients.

While some information offers very basic clues, my approach here is not be overly concerned with the initial ‘strength’ of the data, but rather whether or not these clues may in time provide practical, safe and effective outcomes in clinical practice through comparison and consolidation of other multiple strands of data.

I am alert to the potential weaknesses in such a model in a reductionist sense but I stress that a perceived deficiency in one room may be supported by strengths in another and that it is a combined or holistic approach that might provide the best evidence for herbal medicine. For example, a traditional practice may provide the original clue on how to use a particular herb or treat a certain condition.

On its own, this reference to a traditional use may be unsatisfactory but what if the clue is supported by evidence from one or more of the other rooms in the evidence house? And what if the original clue is not supported?

The six “rooms” for building the proposed evidence house are as follows.

1. Tradition
2. Folklore
3. Organoleptics
4. Phytochemistry
5. Systematic Research
6. Empiricism

Imagine an architect’s blueprint of a ground floor in which all 6 rooms share a “hallway”, meaning that they connect or integrate with each other holistically in the evidence “house”. Each has, or could be considered as having, various strengths and weaknesses and there may be ways of evaluating each of these for “structural integrity” and creating better insulation in time as the model is developed through further research.

All of these rooms alone have yielded clues which in time have led to practical results in my clinical practice, and this is the main criteria upon which I will draw in presenting this model. Some rooms have helped more than others but I reiterate that the room itself is not hierarchically more important as a singular evidence base.

What is important is how one room connects to the other rooms and how the collective gathering of information from multiple rooms leads to an evidence base for safe and effective health outcomes. This approach combines quantitative and qualitative data and both objective and subjective viewpoints. Let us consider each room as if we are viewing the house.

From the beginning of my dedication to herbal medicine, I learned from a tradition. By tradition I mean historical texts which were not lay commentaries but rather, practical guides written by professional practitioners intended as the furtherance of knowledge. These herbals were textbooks in schools of medicine across the world until relatively recent times, written by learned physicians and based on their own experiences and observations.

This differentiates tradition from folklore (the “room next door”) because it is based on the experiences of practitioners whose vocation in life was dedicated to the healing profession. These early physicians, in the cases of Dioscorides or Avicenna for example, were also well-travelled and drew upon other traditions outside of their locality, comparing and contrasting, amalgamating or rejecting different aspects of information and practice over long periods of time.

Their written wisdom is then passed down the generations to new students and apprentices who continue the tradition. In the case of the aforementioned authors, this process may occur over several centuries. Such authors, then, are not only important to herbalists but to the history of medicine itself.

Over the passage of time, we find new herbals appearing; sometimes blindly or lazily following the classic authors without scrutiny; sometimes challenging concepts or contributing new wisdom. The corpus of herbals is actually immense but it is possible to look at certain authors whose significance and contributions were such that they become historical beacons. It is possible to trace the use of a single herb over the centuries by giving precedence to such classical texts in the Western Herbal Tradition to show continuity of medicinal uses along with fresh approaches and scholarly commentary. Such a process has been neatly established by herbalists already (32).

One of the confounders in this approach discussed by these authors is the identification of a plant. Different common names, incomplete descriptions or poorly drawn figures may be misrepresentative of a plant when comparing one author with another in historical texts and cause dilemmas of identification and for tracing continuity, at least until the times of Linnaeus and the development of the standard Latin binomial classification of genus and species.

Such a pitfall has also been negotiated by a number of scholars such as Beck (6)in the case of Dioscorides, or (1) in the case of Avicenna, and is no longer as big of a problem problem in modern times with international acceptance of Latin binomial classification. In fact there is a research project at Kew Gardens being conducted to solve this very issue. A researcher can now chart the history of a plant’s medicinal uses over thousands of years.

Importantly, the use of what herbalists refer to as “energetics” is also a crucial and fundamental aspect of herbal medicine tradition because its application, irrespective of the herb or herbs used, is still pertinent today. This is all the more relevant because it is precisely this heuristic tool of energetics that allows for individualised protocols within a holistic paradigm. Compare a bespoke strategy such as this with the apparent one size fits all approach of allopathic medicine.

Energetic differentiation establishes principle qualities of disease using basic concepts such as hot, cold, dry or damp and variations thereof. Similarly, a herb or herbal formula can also be categorised as hot, cold, dry or damp or variations thereof. Part of the practitioner’s traditional role is to access the patient and decide which of these categories best relates to the patient’s symptoms in terms of having an excess or a deficiency of these basic qualities.

A patient could be too cold or too hot, but they could also be cold and dry, hot and dry, or hot and damp (but not cold and hot, or dry and damp. which are mutually incompatible). These conditions can progress and change so that someone who starts off too hot can become too cold in time. The practitioner must use pattern recognition to deduce the initial imbalance as well as the progress of that imbalance.

Once recognised through good case taking and diagnostic examination the physician uses herbs in a treatment of opposites, according to the appropriate action of the herbs. In rudimentary terms, the “strength” of the herbal protocol would also be surmised from the stage of disease progression as well as the patient’s individual predicament by using a system of degrees.

A person with the common cold may feel cold and shivery or hot and sweaty. This would require a different approach in each case. Compare this to allopathic medicine where there is no differentiation and both patients may receive the same antibiotic treatment. The traditional holistic approach does not end here.

The patient is also given adjunct advice whose remit is to challenge the potential causes of their condition, thereby treating both causes and symptoms in a holistic root and branch approach. In the Hippocratic school of thought, for example, we find reference to the 6 non-naturals – six areas of life over which the patient has some influence and which ultimately affects their health.

The non-naturals include fresh air; motion and rest; sleeping and waking; food and drink; excretion and detoxification and the passions/ emotions. Incorrect diet and lifestyle choices may lead to contra-naturals, or symptoms, in the Hippocratic model. In a sense then, traditional herbal medicine is not so much a system of healthcare as the practice of ‘life-care’.

This basic view of herbal tradition describes fundamental principles which are as valid today as they were in centuries past. By researching a herb in classic texts at various junctures in time, the researcher discovers uses, preparations, specific indications, energetics, dosages (though not always), contraindications, synergies with other herbs and other practical information developed over immense periods of time. This tried and true information can be applied practically, and it is a route by which many first find themselves intrigued by the possibilities of medicinal plants.

Although folklore is certainly a part of Tradition in its wider sense, it can also be treated separately. While the herbal Tradition can be discussed in terms of herbal medicine as a vocation and a profession, there are also myths and legends particularly in rural areas where local people (folk) carry on ancient oral traditions about the local use of plants (lore).

Such lore is often dismissed as archaic, superstitious or at best anecdotal but such accusations belie a partiality. Common people often filter their understanding of the world through the lens of local customs, beliefs and religions which create cultural meaning and identity. In dismissing folklore, one may also be dismissing the entire culture that goes with it!

A modern reader wanting to understand such a culture from an ethnobotanical perspective might embrace local customs, beliefs and religions as a means to set the scene for a wider cultural understanding within which such customs evolve.

For example, a piece of lore might call for the use of a herb for a particular condition but this may be accompanied by prayers, songs or magic rituals which the modern reader may feel is out of time or incongruent  within the current scientific paradigm. Therefore because of this “superstitious” misunderstanding of folk tradition in general, any suggestion of a folk cure being effective is often dismissed.

The American linguist Kenneth Pike saw a similar discrepancy in the anthropological sciences. He coined the terms Emic and Etic in his seminal 1967 text Language in Relation to a Unified Theory of the Structure of Human Behaviour to describe the difference between looking at the worldview of another through your own cultural lens to “establish an objective, scientific approach to the study of culture” (Etic) and looking at it within the context of “grasping the world according to one’s interlocutors’ particular points of view” (Emic). Emic assumes the role of “native perspective”; Etic the role of an “arm’s length” approach (27).

However, some scholars have begun to compare ancient descriptions with modern interpretations. This is an instance of taking a clue from one room and supporting it with clues from another. For example, researchers compared Ginger (Zingiber officinale) in Persian folk medicine with indications from contemporary research, concluding that modern uses of Ginger confirmed the traditional folk uses of Ginger. The research also revealed that there were other properties from traditional folk use which have yet to be elucidated in a modern context thereby offering more new clues for medicine (21).

In order to consider folklore as an evidence base I refer to my original criteria – does it yield practical information which can lead to safe and successful clinical outcomes? Ethnobotany is the study of human relationships to plants. A study of this subject may yield useful information when assuming an Emic approach, using Pike’s descriptors. This does not mean such a study is without its own inherent problems.

There may be discrepancies with the correct botanical identification of the plant in question if it is known by a local name which cannot easily be equated to its modern binomial taxonomy. There may be an absence of cultural context in regards to the customs and rituals which may accompany it. There may also be a dilution of the original practice over the generations. These confounders do not prevent the discovery of practical information.

For example, researchers considered a number of plants from 10^th century Anglo-Saxon texts for their potential use as antimicrobials. In the study, several preparations of Agrimonia eupatoria, Arctium minus and Potentilla reptans were screened for antimicrobial activity against gram-positive and gram negative bacteria (Watkins, Pendry, Sanchew-Madina and Corcoran, 2012).

The texts examined had previously been considered as having “little or no value to medical understanding” (8). The authors cross-referenced from several translations of the Anglo-Saxon texts to negotiate potential confounders and keep close to the original clinical indications. All plants demonstrated antibacterial efficacy and the authors concluded Anglo-Saxon texts may be a good source for rediscovering plants lost to current herbal practice (34).

An ethnobotanical study of Allen & Hatfield’s Medicinal Plants in Folk Tradition: An Ethnobotany of Britain and Ireland (2004) which has been gathered from multiple sources including the work of the Irish Folk Commission based on oral tradition, concluded that many of the plants studied may be potential sources for new therapies (10).

Ethnobotany is unfortunately an area of concern where indigenous information is stolen to discover interesting compounds for novel drug discovery. The term ‘biopiracy’ is sometimes used to describe this theft of cultural intellectual property from native cultures (4) If used respectfully, it offers data which can be cross-referenced with other ethnobotanical uses in other parts of the world, much like historical research of traditional use in established herbals, and provides clues which can be filtered through other rooms.

The term organoleptics refers to the use of the senses to acquire information. The skills of the wine taster or the perfumer who can detect and describe multiple flavours or scents are well known to modern culture. In the history of herbal medicine we also find reference to a concept known as the Doctrine of Signatures which infers that the shape of a plant or plant part may resemble a part of the body and so it must be intended for healing that part, by the signature of God. However, this may be an oversimplification.

The shape may be important, but so too is the taste of the herb, the scent of the herb, its colour, its texture, its location and so on. Rather than fixating on shape alone, information may be gathered and consolidated from multiple sensory experiences. For example, a sweet-tasting plant may reveal the presence of polysaccharides or a salty taste might reveal the presence of mineral salts such as magnesium and potassium. A bitter taste may reveal the presence of alkaloids. An aromatic scent might reveal the presence of terpenes. A yellow colour may indicate a connection to the liver; a red colour may indicate a connection to the heart and so on.

Philippus Theopastrus Bombastus Von Hohenheim (1493-1541) also known as Paracelsus wrote his famous comments on signatures in the text Supreme Mysteries of Nature (1656).

Jacob Boehme (1575-1624) wrote Signatua Re-rum (The Signatures of All Things) which was a contemporary work. TheGiambattista Della Porta (1535-1615) text Phytognomonica (1588) is even earlier, and mention must also be made of William Cole (1626-1662) and his book The Art of Simpling (1656) which serve as early works in regards to organoleptics, however these concepts and methods are much older than the 16^th century!

They developed independently across centuries in multiple cultural centres – Europe, China, America, India and Africa (12)). Many ancient tribes discovered the medical properties of plants in manners such as this, gaining empirical data from sensory information. The concept of entrainment with plants does not literally mean “talking to plants” but implies the tacit gathering of information between two living beings through sensory engagement.

Spending time in the company of plants is what Aristotle would call “learning by doing”. Developing the senses in this way may take years to learn but in time allows one to elucidate constituents and also to intuit from other information to create tacit patterns of association that can only come from direct encounters.

Modern research also confirms organoleptics.  De Medeiros et al., 2015 found significant associations between both taste and therapeutic indications (p<0.001); and smell and therapeutic indications (p<0.0001). (23) provide evidence for a highly significant association between the organoleptic properties of plants and the use of these species as medicine. Geck et al., 2017 show that organoleptics guide the choices of the therapeutic actions of medicinal plants.

Organoleptics is something of an art form but with careful practice, the novice can gain useful information of a practical nature, but for some this may take decades. However, initial clues from inspecting a plant, no matter how strange they may seem at first, can be compared with clues from other rooms.

It may seem tangential to consider phytochemistry as a singular source of evidence; however the effects of a plant’s primary and secondary constituents are now largely established in terms of their effects on the body. Taking an unfamiliar plant and researching its chemical composition allows a fundamental understanding of what a plant might do medicinally, once its phytochemistry can be elucidated.

This information can be found in research databases and with practice via organoleptic techniques. In the absence of historical record or clinical trials, knowing a plant’s phytochemistry can provide an understanding of both therapeutic qualities and potential cautions if toxic constituents are present.

Phytochemical analysis such as high performance liquid chromatography (HPLC) involves both qualitative and quantitative analysis of plant chemistry. While qualitative analysis is concerned with the presence or absence of a compound, quantitative analysis accounts for the quantity or the concentration of the compound present in the plant sample (15).

Several phytochemical databases already exist such as Phytochem and Duke’s, documenting qualitative and quantitative levels of primary and secondary compounds in plants. Considerable research has been done into singular constituents.

For example, alkaloids are now known to have a notable physiological effect on the body in general because they have a structural relationship with neurotransmitters such as dopamine or acetylcholine (33). Another family of phytochemicals, flavonoids, are similarly well documented and some constituents such as the polyphenolic compound quercetin have demonstrated antioxidant, antifungal, anti-carcinogenic, hepatoprotective, and cytotoxic activity (5).

When working with an unfamiliar plant, perhaps one which has little historical information or research, information as to its potential medical uses can be gained by knowing the range of secondary metabolites present and whether they are water soluble (hydrophilic) or fat soluble (lipophyllic) which would inform of the most appropriate solvent to use for crude extraction, depending on the intended actions.

One confounder, and perhaps the bane of this approach, is to see one constituent as having more importance than other constituents (much like the question if one type of evidence is superior to another). This is reductionism at work where value is placed on a single compound and medicines are standardised to meet very specific levels of this compound because it has been previously found to have a certain effect in cell lines for example.

The original medicine is thus modified, and may be considered a phytopharmaceutical. A case in point here may be Ginkgo biloba leaf, which does not have a long history in herbal medicine but systematic research has tended to use standardised extracts in past research and so some promote the standardised extracts accordingly. But, is there more to Ginkgo than gingkoflavones?

Plants generate compounds in the wild to deter pests and diseases or in reaction to its overall environment. The traditional use of a herbal medicine has been the use of the whole herb, plant part or crude extract where there will be seasonal and locational variability in constituents.

A plant’s medicinal actions occur when a combination of phytochemicals interacts with the epithelium on ingestion. It is the combination of actions, not one action in particular, that creates the healing effect. Indeed, when singular compounds are extracted side effects may ensue because a compound may be toxic or non-toxic depending on the presence of other constituents.

Phytochemistry can help to corroborate ancient uses in the absence of systematic research. Organoleptics can help to identify constituents and effects in a similar way. This is a good example of how the interrelationship between each room helps to improve the overall structure of the evidence house.

Modern forms of research such as double blind randomized controlled trials are not wholly applicable to herbal medicine because of their reductionist philosophical underpinning. A standard trial tends to investigate the effects of one compound on one molecular target. This is unsuitable because herbal preparations contain multiple constituents with multiple molecular targets. I have already discussed some other inherent problems earlier.

However, clinical trials can be designed in such a way so as to evaluate the herbalist “package” (the in depth consultation, the bespoke formula and tailored advice) and its effects on a particular health condition.

For example, a pilot study (n=45) was conducted by herbal practitioners to assess the effectiveness of professional herbal practice in the treatment of menopausal symptoms. All participants completed the study.

The treatment group (n=15) demonstrated a statistically and clinically significant reduction in menopausal symptoms compared to controls (n=30). Reduction in symptoms for the treated group was 9.05 points greater than that for the control group, CI 5.08-13.03, as were changes in vasomotor scores (mean 1.81, CI 1.00-2.62). Libido increased (mean 0.69, CI 0.38-0.99) in the group receiving herbal treatment (18).

Another study (n=120) into the alleviation of menopausal symptoms used a herbal formula containing Chamomilla recutita, Foeniculum vulgare and Crocus sativa (25). The formula was tested against placebo in different dosages in a randomized triple blind study.

After 12 weeks of daily treatment there were significant improvements in physical, psychological and urogenital domains in group B who had taken a dose of 1000 mg, 120 mg, 60 mg of the aforementioned herbs in drop form, whereas improvements in symptoms were less significant in the other dosage groups (Madhavian, Najmabadi, Hosseinzadeh, Mirziaean, Aval and Esmaeeli, 2019).

Such a trial is informative about dosage as well as the particular herbs that could be used to treat menopause. Bringing a greater emphasis to qualitative approaches helps to unpack other aspects of the herbal package, such as patient centred care through empathy and the length of time herbalist consultations typically afford (11).

Studies such as these are appropriate because they inform about herbal practice. Other studies which, for example, utilise a single isolated compound on a susceptible inbred animal at unrealistic doses are being geared towards the development of pharmaceutical drugs and have no bearing on actual practice. Unfortunately, background information such as this is sometimes used to justify or refute usage.

Qualitative studies, for example using questionnaires to access patient perceptions may also be valuable. Mixed-method research which utilises both quantitative and qualitative disciplines may also yield useful information, but the main criterion for any systematic research applies here – does it ultimately inform about herbal practice?

If we consider the EBM pyramid in its current form as a hierarchy of evidence, we may ask who decides which type of evidence is superior and which type of evidence is inferior, and what criteria are used to make these distinctions? On first glance it appears that these distinctions are made through an epistemological bias which favours one type of knowledge above another. It seems ironic that what we consider to be “expert opinion” is ranked at the very bottom of the EBM pyramid.

The term “expert” can also be misleading because it suggests complete knowledge of a subject which is not possible, but what is implied by EBM is that knowledge gained through empiricism is somehow inferior to knowledge gained from rationalism and quantitative data. The relegation of empirical knowledge in this way reveals an epistemological bias which may undervalue traditional herbal medicine (20).

Empiricism is the theory of knowledge which claims that most or all our knowledge is obtained through sensory experience over time, rather than through rational deduction (24). Therefore knowledge gained a priori is considered by empiricists to be inferior to knowledge gained a posteri in philosophical terms. Practitioners of traditional herbal medicine gained knowledge over the ages largely through empiricism. It is only with the development of reductionist philosophy, such as the mechanisation of the body as promoted by Descartes and the scientific method as espoused by Bacon that rationalism became prominent and increasingly dominant as a philosophical paradigm.

However, in herbal medicine empiricism always tends to the individualisation of treatment. Conversely, in reductionist medicine the individual patient is labelled with a disease (machine with broken part) and the emphasis is on more universal treatment protocols. Nonetheless a consequence of this approach may be to confound the concept of patient centred care within the current reading of EBM.

A holistic approach considers that a body is an interconnected whole with multiple influences that can affect any particular part. A “broken part” may therefore not be at fault in and of itself, nor are things always down to genetic “bad luck” (though of course with some conditions this is inevitable).

Rather illness is often caused by an ongoing homeostatic imbalance in one or more systems of the body. To focus solely on the perceived “broken part” misses this wider reality. It can also be argued that most diseases are consequences of poor diet and lifestyle choices (30).

To focus on “broken parts” as being self-responsible confirms rational medicine’s place as a system for a masking of symptoms rather than a removal of causes, and so confutes the perception of patient centred care by neglecting the bigger picture.

Rational philosophy contends that empiricism is subjective and that different observers may have different interpretations of the same object. The rationalists argue that elimination of bias, at least insofar as this is possible, helps to remove the doubt that may be caused by these conflicting views. Yet, by disengaging with causative factors and avoiding a holistic approach, the patient is not wholly treated, leaving room for error.

It is argued that a better approach may therefore be a combination of rationalism and empiricism as practiced by the 2^nd century Roman physician Galen (35). Indeed, central to the argument for an “evidence house” for herbal medicine is that we draw on multiple sources of evidence without preference.

What has become known as ‘practice-based evidence’ places greater emphasis on the experiential approach where the practitioner gains knowledge by working directly with patients rather than theorising about them. The practitioner learns over time what does or doesn’t work in real world conditions. After treating a number of patients with the same condition or similar symptoms, the practitioner learns to understand the triggers and drivers which lead to a particular imbalance.

In time the practitioner also notices that the same herbs or herbal combinations and particular adjunct advice may often be indicated for this condition. This empirical knowledge is therefore an important evidence base that is generated over time. It is the foundation upon which many of our classic herbals were written. The case-series which documents the herbal treatment of a condition in multiple patients is an evidence base that can be developed from such empirical data.

Practice-based evidence also bears some hallmarks of a long term clinical trial. Recently, researchers examined what are referred to as N=1 trials which incorporate much of the rigour of clinical trials, but are designed for individual patients. Individualising treatment interventions and outcomes in research designs is consistent with the movement towards patient-cantered care, according to the authors (7).

A more inclusive approach to evidence also encapsulates qualitative data from patient observations and narratives, creating space for involvement and therefore patient empowerment.

To ascertain evidence for the safety and efficacy of herbal medicines by systematic research alone is in and of itself a limited and limiting process. Such reductionism is inconsistent with the holistic paradigm of herbal medicine.

However, one form of research and evidence can be complimentary to another. A double blind randomised clinical trial may back up a historical use described in a classic herbal for example (26).  An ethnobotanical use may provide hypothesis for clinical research and so on.

Part of the problem with contemporary research into herbal medicine though is the focus on singular constituents perceived as active ingredients rather than the vocational practice of herbal medicine itself and what it has to offer. While the study of phytochemistry provides insight it is best served by focusing on the matrix of compounds rather than a singular compound. It can also help give weight to historical observations or folk practices.

In this more complex assessment of herbal medicine, we may be better served by drawing on a holistic perspective. The evidence house offers multiple rooms of information which connect into each other to form a whole foundation.

Each room may lead the researcher to practical information which can deliver successful outcomes, although each room taken alone has its own pros and cons. Information from one room can go some way to offsetting the limitations of another room in a complimentary manner. This prevents epistemological tensions and allows for a greater appreciation of traditional herbal medicine.

Further research could be done into each room and a potential weighting, the strength or weakness of evidence, could be quantified for each room but this may be a slip towards reductionism. Rather, a researcher might consider that where there is an obvious weakness in one room, there may be strengths in other rooms.

Drawing on all of these areas, and perhaps others not mentioned here, answers the question on how to access the safety and efficacy of a herbal medicine while attempting to avoid the clash of incongruent paradigms.

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26.  Mazengenya, P., & Bhikha, R. (2020). The genitourinary and reproductive systems: Interpretation of Avicenna’s (980-1037 AD) treatise in the Canon of Medicine. Morphologie : bulletin de l’Association des anatomistes, 104(346), 196–201.
27. Mostowlansky, T., & Rota, A. (2020). Emic and etic. Cambridge Encyclopedia of Anthropology.
28. Novack, G. D. (2016). Natural Does Not Mean Safe. The ocular surface, 14(4), 515-519.
29.  Nunan D, Heneghan C, Spencer EA (2018). Catalogue of bias: allocation bias. BMJ Evidence-Based Medicine 2018;23:20-21.
30.  Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t.
31.  Schulze, M. B., Martínez-González, M. A., Fung, T. T., Lichtenstein, A. H., & Forouhi, N. G. (2018). Food based dietary patterns and chronic disease prevention. bmj, 361.
32. Sur, R. L., & Dahm, P. (2011). History of evidence-based medicine. Indian journal of urology : IJU : journal of the Urological Society of India, 27(4), 487–489. https://doi.org/10.4103/0970-1591.91438
33.  Tobyn, G., Denham, A., & Whitelegg, M. (2016). The Western herbal tradition: 2000 years of medicinal plant knowledge. Singing Dragon.
34. Verpoorte, R., Choi, Y. H., & Kim, H. K. (2005). Ethnopharmacology and systems biology: a perfect holistic match. Journal of ethnopharmacology, 100(1-2), 53-56.
35. Watkins, F., Pendry, B., Sanchez-Medina, A., & Corcoran, O. (2012). Antimicrobial assays of three native British plants used in Anglo-Saxon medicine for wound healing formulations in 10th century England. Journal of ethnopharmacology, 144(2), 408-415.
36.  Webb W. M. (2018). Rationalism, Empiricism, and Evidence-Based Medicine: A Call for a New Galenic Synthesis. Medicines (Basel, Switzerland), 5(2), 40. https://doi.org/10.3390/medicines5020040

Ephedra species have been found in the fossil record going back 125 million years, when dinosaurs still walked the earth (1).There are around 71 species of ephedra recognised by current taxonomy, with a wide distribution through most of Asia and Europe, North Africa and the Horn of Africa, and the Western sides of South and North America (2). It is the only genus in the family Ephedraceae.

The botanical classification of this group of plants has been particularly difficult there are many close similarities in appearance between species. Ephedra species mostly grow as shrubs, consisting of long slender green stems that can photosynthesise. Their leaves appear as small scales on the stem and often turn brown and drop off.

Ephedra spp. have been confused with very ancient group of plants, the horsetails (Equisetum spp.) both historically and more recently in the herbal medicine trade (3).Market surveys today have found several species of Ephedra are sold as Ma Huang, sometimes differentiated as varieties of Ma Huang, but not always (4).

Ephedra sinica is the species most widely used for its medicinal properties. This species is found growing wild in Mongolia, Southern eastern provinces of Russia and in Northeastern China (5). While ephedrine is the most well known constituent, it contains 6 other structurally similar alkaloids in lesser concentrations with similar effects. Not all Ephedra species contain ephedrine type alkaloids (6).

The drug Ma Huanghas always been defined in Chinese Materia Medica texts as the aerial parts of several species of Ephedra. The less commonly used root of Ephedra spp. is known as Ma Huang Gen, which has long been seen as acting in opposition to the aerial parts; for example being prescribed “for checking excessive perspiration of a weak patient” (7). This traditional understanding has been corroborated by studies showing that chemicals that cause blood pressure to lower are only found in the root (8).

Ma Huang has been traded from China to Japan from at least the 16^th century, where it was incorporated into Japanese herbal medicine as a treatment for colds and flu in a combination with four to six other herbs known as Maoto, based on the Chinese formulation Ma Huang Tang (9).

The active chemicals of Ma Huangwere first isolated in 1887 by a professor at Tokyo University, Nagajosi Nagai. Of particular interest was a new chemical that was named after the plant as ephedrine.

However, it was not until 1923 that researchers at Peking Union Medical College, K.K. Chen and Carl Schmidt, began investigating in detail how it could be used as a drug (10). They found that ephedrine acted in a very similar way to adrenaline, though with a milder, but longer lasting, effect (11).

Adrenaline, also known as epinephrine, is a hormone produced in the adrenal glands above the kidneys that acts as an essential messenger in the fight or flight response – this is how the body prepares itself to deal with a potentially dangerous situation.

Adrenaline helps stimulate a range of changes including increased heart and breathing rate, slowing down digestion, releasing energy sources into the blood, dilation of blood vessels to the muscles, constriction of peripheral blood vessels, central nervous stimulation and bronchodilation. This response is coordinated by the sympathetic nervous system, that is why ephedrine is classed as a ‘sympathomimetic’ as it mimics the body’s natural messenger chemicals to activate receptors of this system.

Because of this effect ephedrine has become a popular drug for athletes to improve performance. It has also been used as a weight loss drug because it suppresses appetite and increases the rate that fat tissue uses and releases energy. It is also widely used in combination with caffeine in over the counter cold and flu remedies for opening nasal passages to relieve sinusitis (12).

However, care should be taken in dosage and duration of use, especially if taking any other medications that produce similar effects. It can lead to anxiety, restlessness, insomnia and a tolerance develops, and in extreme cases of improper use has caused heart attack and stroke. (13)

Both Ephedra spp. and ephedrine should not be taken by people with hypertension, diabetes, hyperthyroidism orglaucoma (14). Because of these concerns there have been bans imposed on the use of ephedrine in sports and weight loss supplements by various regulatory bodies around the world.

Of particular interest for respiratory health is the bronchodilatory effect of ephedrine (15).When you breathe in air enters through the mouth and down the trachea, which divides into the left and right bronchi to enter the lungs, the bronchi further divide into many bronchioles, which then divide to join the many alveoli where gas exchange takes place.

People suffering from asthma experience a tightening of the bronchioles causing coughing, wheezing and shortness of breath. The bronchi and bronchioles are lined with smooth muscle, which relaxes and opens up in response to adrenaline and ephedrine, this bronchodilatory effect relieves the symptoms of asthma.

While adrenaline had been used for treating asthma it had significant issues: it had to be injected, its effects were short lived, and it was chemically unstable.

Ephedrine solved all these problems, leading to excitement amongst physicians in Europe and the USA, where it was widely adopted for treating asthma from 1926 the 1950s (16). Work on adrenaline led to the synthesis in the laboratory of several similar chemicals, one of which was salbutamol which became the next main treatment for asthma.

When used as an asthma treatment, and for Chronic Obstructive Pulmonary Disorder (COPD), ephedrine was commonly combined with two weaker bronchodilators: caffeine and theopylline, chemicals which were also isolated from a Chinese herbal medicine: tea (Camellia sinensis) (17).

According to legend, the mythological Chinese ruler Shennong (神农) discovered the medicinal effects of tea when tea leaves from the twigs in his fire were carried up the hot air into his pot of boiling water.  This was just one of the hundreds of herbs he tested on himself to identify their properties and taught people their uses, along with the practice of agriculture.

He is credited with writing The Shen Nong Ben Cao Jing (神农本草经), the oldest surviving written record of Chinese materia medica, thought to have been compiled in the 1^st or 2^nd Century CE. It is variously translated to English as The Divine Farmer’s Materia Medica, The Herbal Classic of the Divine Farmer, or Divine Husbandman’s Classic of the Materia Medica (18,19,20).

This text has been continously referred to in texts on Chinese materia medica ever since, and many of the uses of herbs it describes are still employed today(22). It covers 365 herbs in total, corresponding to the natural cycle of days in a year, that are divided into three scrolls:

“120 ‘upper’ (shang) herbs, which can be taken daily to lengthen the lifespan; 120 ‘middle’ (zhong) herbs, which can be taken to prevent and hold back illness; and 125 ‘lower’ (xia) herbs which treat illness, are mostly toxic and should not be taken for a long time(23)”.

Ma Huang appears on the ‘middle grade’ scroll, which would match with the use of Ephedra spp. today – the use of ephedrine for acute infections only, and not longer term use for general health such as athletic training and weight loss.

The text describes Ma Huang as:

“bitter and warm. It is nontoxic, treating mainly wind stroke cold damage, headache, and warm malaria. It effuses the exterior [through] sweating, eliminates evil heat qi, suppresses cough and counterflow qi ascent, eliminates cold and heat, and breaks concretions and hardness, accumulations and gatherings. Its other name is Long Sha (Dragon Sand). It grows in rivers and valleys.”

The translator notes that a renowned scholar, known as ‘Chancellor in the Mountains’, Tao Hong-jing (452-536 CE) later wrote, “Ephedra is the first choice in treating cold damage and resolving the muscles” and that, combined with “Sinnamon Twig, Armeniaca, and Licorice” it “may effect the cure of a tai yang pattern of wind cold in the exterior with pain and stiffness in the head and back of the neck, fever, generalized joint pain, a floating, tight pulse, absence of sweating, chest fullness, and panting”(24).

This is perhaps the first description of the Ma Huang Tangformulation that became so poular for respiratory infections, consisting of: Ma Huang (aerial parts of Ephedra spp.), Gui Zhi (twig of Cinnamomum spp.), Xing Ren (kernel of fruit of Prunus armeniaca) Can Gao (root of Glycyrrhiza spp.).

Writing 1,000 years after Tao Hong-jing, Li Shizhen (25) compiled a Compendium of Materia Medica, the Pents’ao Kang Mu, including 1,900 substances and referencing 900 previous works, critiquing them where necessary. Like his father and grandfather before him he travelled the countryside as a physician, both treating people and learning remedies from them.

Ephedra is described and recommended for stimulating circulation, as a diaphoretic (to induce sweating) and antipyretic (to prevent or reduce fever). According to contemporary TCM herbalists Chen and Chen in the text “It was also believed to be useful in the treatment of cough and as a result the stem became an important ingredient of many antitussive preparations.” (26).

Which they do themselves in their indications for Ma Huang: “Relieves Wheezing and Dyspnea, Stops Cough Wind-cold constriction of the Lung leading to Lung qi reversal: Ma Huang ventilates Lung qi and is useful in treatment of wheezing, dyspnea and cough characterized by wind-cold attacking the exterior that leads to abnornormal rising of Lung qi.” (27).

As is so often the case, exploring the history of this herbal medicine indicates it has been used for a range of conditions on its own and in combination with other herbs, and that fully understanding these uses requires detailed knowledge of philosophies of healing of the time.

Seen through a contemporary biomedical lens, some connections can be made between these texts and the studied effects of ephedrine. The focus on sweating and treating cold and resolving the muscles can be linked to the increased blood flow to the muscles caused by ephedrine.

From the mention of ‘suppressing cough’ and curing ‘chest fullness and panting’ in the The Herbal Classic of the Divine Farmer (Ben Cao Jing) we can assume it was used for treating conditions that we today would classify as asthma. This indication can be found throughout the history of writing on the materia medica of TCM, though it is important to note that it is normally accompanied by a detailed discussion of the cause of the disease and the particular manifestation in specific patients.

A full understanding of these aspects requires a detailed knowledge of the healing principles of TCM, from the concept of the flow Qi, generally translated as ‘life force’, the elements and their relation to the organs, and the importance of the tastes of herbs, and how these combine. Asthma, cough and shortness of breath have many manifestations that will be caused by the interplay of environmental, internal, physical and emotional causes.

Based on research on ephedrine, a standard European reference on herbal medicines understands Ma Huang in biomedical terms as vasoconstricting, bronchodilating, and central [nervous system] stimulating properties (28).

However, like many herbal medicines the chemical constituents of the whole herb are not fully characterised or understood, and these may also aid in managing asthma, coughs and colds. For example research on Ephedra sinica shows it contains chemicals that have anti-inflammatory, anti-bacterial, anti-fungal, antioxidant and anti influenza effects that could explain other ways the herb extracts can work in treating respiratory infections (29,30).

Ephedra is just one example of a medicinal plant with rich history, that’s traditional uses can now partially be explained by modern science. This plant can only be prepared and prescribed by licensed herbalists, due to its potential side effects. We really recommend seeing a herbalist for a personalised treatment plan for all sorts from respiratory health to other ailments. You can find one on our resources page here.

1. Ickert-Bond, S.M., Rydin, C. and Renner, S.S., 2009. A fossil‐calibrated relaxed clock for Ephedra indicates an Oligocene age for the divergence of Asian and New World clades and Miocene dispersal into South America. Journal of Systematics and Evolution, 47(5), pp.444-456.
2.  Plants of the World Online. Facilitated by the Royal Botanic Gardens, Kew. Published on the Internet; https://powo.science.kew.org/taxon/urn:lsid:ipni.org:names:328160-2 Retrieved 02 Jan 2022.
3. Yoshizawa, C., Kitade, M. and Mikage, M., 2005. Herbological studies on Chinese crude drug Ma-huang. Part 1-On the botanical origin of Ma-huang in ancient China and the origin of Japanese Ma-huang. Yakushigaku zasshi, 40(2), pp.107-116.
4. Hu, S.Y., 1969. Ephedra (Ma-huang) in the new Chinese materia medica. Economic Botany, pp.346-351.
5. Plants of the World Online. Facilitated by the Royal Botanic Gardens, Kew. Published on the Internet; https://powo.science.kew.org/taxon/urn:lsid:ipni.org:names:383460-1 Retrieved 02 Jan 2022
6. Abourashed, E.A., El‐Alfy, A.T., Khan, I.A. and Walker, L., 2003. Ephedra in perspective–a current review. Phytotherapy research, 17(7), pp.703-712.
7. Hu, S.Y., 1969. Ephedra (Ma-huang) in the new Chinese materia medica. Economic Botany, pp.346-351
8. Tamada M, Endo K, Hikino H, Kabuto C. 1979. Structure of Ephedradine A, a hypotensive principle of Ephedra roots. Tetrahedron Lett 10: 873–876.
9. Yoshino, T., Arita, R., Horiba, Y. and Watanabe, K., 2019. The use of maoto (Ma-Huang-Tang), a traditional Japanese Kampo medicine, to alleviate flu symptoms: a systematic review and meta-analysis. BMC complementary and alternative medicine, 19(1), pp.1-11.
10. Lee, M.R., 2011. The history of Ephedra (ma-huang). JR Coll Physicians Edinb, 41(1), pp.78-84.
11. Chen, K.K. and Schmidt, C.F., 1926. The action and clinical use of ephedrine: an alkaloid isolated from the Chinese drug Ma Huang. Journal of the American Medical Association, 87(11), pp.836-842.
12. Abourashed, E.A., El‐Alfy, A.T., Khan, I.A. and Walker, L., 2003. Ephedra in perspective–a current review. Phytotherapy research, 17(7), pp.703-712.
13. Lee, M.R., 2011. The history of Ephedra (ma-huang). JR Coll Physicians Edinb, 41(1), pp.78-84.
14. Abourashed, E.A., El‐Alfy, A.T., Khan, I.A. and Walker, L., 2003. Ephedra in perspective–a current review. Phytotherapy research, 17(7), pp.703-712; Chen, J.K., Chen, T.T. and Crampton, L., 2004. Chinese medical herbology and pharmacology (Vol. 1267). City of Industry, CA: Art of Medicine Press.
15. Barnes, J., Anderson, L.A. and Phillipson, J.D., 2003. Herbal medicines: a guide for healthcare professionals (No. Ed. 2). pharmaceutical press. p.244
16. Lee, M.R., 2011. The history of Ephedra (ma-huang). JR Coll Physicians Edinb, 41(1), pp.78-84.
17. Schultze‐Werninghaus, G. and Meier‐Sydow, J., 1982. The clinical and pharmacological history of theophylline: first report on the bronchospasmolytic action in man by SR Hirsch in Frankfurt (Main) 1922. Clinical & Experimental Allergy, 12(2), pp.211-215
18. Daniel, Gillian, 2015. The Legend of the Divine Farmer. Public Domain Review. Published 03 Nov 2015. Retrieved 02 Jan 2022 https://publicdomainreview.org/essay/the-legend-of-the-divine-farmer
19. Nugent-Head, J., 2014. The First Materia Medica: The Shen Nong Ben Cao Jing. Journal of Chinese Medicine, (104).
20. Evans, L., 2017. Reading of the Divine Farmer’s Classic of Materia Medica: Shen Nong Ben Cao Jing Du. The Journal of Chinese Medicine, (114), pp.64-65.
21. Shen Nung seated on a rock, wearing simple garments fashioned from leaves, holding a small plant; a selection of roots and plants are also shown on a ledge by his side. Watercolour, China, 1920?. Wellcome Collection. https://wellcomecollection.org/works/z5w9zzbf/images?id=z9szdx4b . Published 1920. Accessed January 6, 2022.
22. Chen, J.K., Chen, T.T. and Crampton, L., 2004. Chinese medical herbology and pharmacology (Vol. 1267). City of Industry, CA: Art of Medicine Press.
23. Nugent-Head, J., 2014. The First Materia Medica: The Shen Nong Ben Cao Jing. Journal of Chinese Medicine, (104). p.24
24. Yang, S., 1998. The divine farmer’s materia medica: a translation of the Shen Nong Ben Cao Jing. Blue Poppy Enterprises, Inc.. pp.51-52.
25. Li, M. and Liang, Y., 2015. Li Shizhen and The Grand Compendium of Materia Medica. Journal of traditional Chinese Medical Sciences, 2, pp.215-216.
26. Chen, J.K., Chen, T.T. and Crampton, L., 2004. Chinese medical herbology and pharmacology (Vol. 1267). City of Industry, CA: Art of Medicine Press. p.14
27. Chen, J.K., Chen, T.T. and Crampton, L., 2004. Chinese medical herbology and pharmacology (Vol. 1267). City of Industry, CA: Art of Medicine Press. p.36
28. Barnes, J., Anderson, L.A. and Phillipson, J.D., 2003. Herbal medicines: a guide for healthcare professionals (No. Ed. 2). pharmaceutical press.
29. Theory of diseases treated with ephedra decoction, Chinese. Wellcome Collection. https://wellcomecollection.org/works/pxhq48mb . Published 1833. Accessed January 6, 2022.

On a daily basis, we are eating more than we did fifty years ago, with calories in the US and Western Europe topping 3,500 kcal per day (2). One underlying factor is greater consumption of high calorie ultra-processed foods. In the UK these are estimated to account for 57% of our total energy intake and provide two thirds of the total free sugars in our diets (3).  

These foods are processed and can be characteristically sugary or salty to make them more palatable. We all enjoy tucking into burgers or chocolate, and population-based studies have found that consumption of ultra-processed food is associated with almost every chronic disease (4).

The ‘omic’ studies are showing us that these foods alter the balance of our gut microbiota from helpful Bacteroides species that metabolise non-digestible polysaccharides, leading to a loss of healthy bi-products like butyrate.

By unbalancing the system this allows less helpful bacteria to occupy niches in the intestine (5). In almost every other instance of our modern lifestyles, we see a similar pattern of dysregulation of our microbiota. Exposing it to environmental pollutants initiates a protective response by the gut that releases inflammatory compounds that damages the gut wall – the delicate single layer of epithelial cells on the inner most surface (6).

A commonly used insecticide diazinon disrupted the microbiome in animals for up to 13 weeks following a single dose (7). Multiply that up by the thousands of pesticides used globally (8), even if our agricultural and food systems can adhere to safe levels, the impact on our planetary microbiota – be it the bugs within our soils or our life-giving human and animal microbiomes – is not fully known.

Another area of our modern living that may have a detrimental impact on our microbiomes is our choice of healthcare. In one study, a quarter of commonly used pharmaceuticals were found to prevent the growth of our microbes, potentially adversely affecting our health and also contributing to the risk of antibiotic resistance (9).

Antibiotics are known to create competition within microbial communities and upset the balance of mutually beneficial co-habitation (10). Whilst it might be the case that in adults they can recover from a course of antibiotic treatment, in infants there may be lasting changes along with the risk of building the pool of antibiotic-resistance genes in our residing communities (11).

At this half-way point, there is a picture emerging from the research that how we treat our gut through our foods and medicines causes disturbances that can have lasting ill-effects. However, I believe the gut is not called the “little brain” for nothing (from Michael Gershon MD) and it is well poised to offer us help using herbs and spices.

What we do know is that positive lifestyle changes such as eating more nutritiously can improve health at any stage of life (12). Research is putting the benefits of herbs and spices into the spotlight, with turmeric increasing beneficial butyrate-producing gut bacteria and other herbs also modifying our microbiota (13).

The wide-ranging effects of herbs and spices may reflect the array of polyphenols and plant compounds that we ingest and are consequently metabolised by our bugs.

There is also much more intrigue beyond the gut microbiota. Why is it that our gut walls contain a myriad of receptors for plant-based compounds? I can’t help but think why are they there, and what is their importance? We evolved to eat a diverse plant species that were seasonally available, and this has dwindled in our modern diets. So, can we use herbs and spices to kick-start our physiology again?

Firstly, it is recognised that bitter receptors are located throughout the mouth, throat and gastrointestinal system and enhance digestive processes (increasing secretions and supporting the cardiovascular system in diverting blood flow to the gut). Bitter herbs – ‘bitters’ – like gentian and wormwood have longstanding use as aperitifs as digestive aids (14). Within the gut are also an abundance of cannabinoid receptors which regulate gut function and barrier integrity, located throughout the epithelial cell lining and extensive enteric nervous system (15).

Capsaicin which is a plant compound from chilli peppers binds to vanilloid receptors and also stimulates gut function (16). It is suggested that our body’s processes are now at odds with our unhealthy lifestyles. Just as we need vitamins and minerals in our diets, the presence of these receptors suggests that consumption of herbs, spices and green leafy vegetables, might be just as essential to reset our systems.

The notion of diversity increasingly seems to hold the key to the future, whether we are talking about diversity in our diets, diversity of gut microorganisms, or the diversity of receptors in our gut.

Concepts like the dietary phytochemical index may help us understand the importance of diverse plant compounds like polyphenols and phytoestrogens in our foods and how these relate to our gut processes and body’s health (17).

The latest research is helping us understand the significance of our bug’s bugs – the viruses known as bacteriophages that interact with our bacteria. In this intriguing area of science, the phages become more diverse shortly after birth, and they manipulate our gut bacteria to have both good and bad effects on our health (18).

We know that our modern lifestyles do not allow the orchestral capabilities of our microbiomes or gut receptors to be fully played. The science points towards plant compounds within our herbs and spices as being important elements within these systems. More research is needed to see how we can encourage lifestyle changes to off-set some of our poor habits, and how we can spice up our lives so that our digestive systems can flourish and bring our bodies into better health.

1. Agrawal A, Yadav C, Meena M. Physiological aspects of Agni. AYU (An International Quarterly Journal of Research in Ayurveda). 2010;31(3):395. doi:10.4103/0974-8520.77159
2. Daily supply of calories. Our World in Data. https://ourworldindata.org/grapher/food-supply-kcal?tab=chart&time=1961..2013&country=OWID_WRL~Europe%2C+Western~Eastern+Europe~Africa~Asia~South+America~Northern+America. Published 2021. Accessed October 29, 2021.
3. Rauber F, Louzada M, Martinez Steele E et al. Ultra-processed foods and excessive free sugar intake in the UK: a nationally representative cross-sectional study. BMJ Open. 2019;9(10):e027546. doi:10.1136/bmjopen-2018-027546
4. Consumption of ultra-processed foods and health outcomes: a systematic review of epidemiological studies – Nutrition Journal. Nutrition Journal. https://nutritionj.biomedcentral.com/articles/10.1186/s12937-020-00604-1. Published 2020. Accessed October 29, 2021.
5. Martínez Leo E, Segura Campos M. Effect of ultra-processed diet on gut microbiota and thus its role in neurodegenerative diseases. Nutrition. 2020;71:110609. doi:10.1016/j.nut.2019.110609
6. Defois C, Ratel J, Garrait G et al. Food Chemicals Disrupt Human Gut Microbiota Activity And Impact Intestinal Homeostasis As Revealed By In Vitro Systems. Sci Rep. 2018;8(1). doi:10.1038/s41598-018-29376-9
7. Gao B, Bian X, Mahbub R, Lu K. Sex-Specific Effects of Organophosphate Diazinon on the Gut Microbiome and Its Metabolic Functions. Environ Health Perspect. 2017;125(2):198-206. doi:10.1289/ehp202
8. Pesticide Residues in Food. Report of the 1974 Joint Meeting of the FAO Working Party of Experts on Pesticide Residues and the WHO Expert Committee on Pesticide Residues. Food Cosmet Toxicol. 1976;14(5):491. doi:10.1016/s0015-6264(76)80206-4
9. Maier L, Pruteanu M, Kuhn M et al. Extensive impact of non-antibiotic drugs on human gut bacteria. Nature. 2018;555(7698):623-628. doi:10.1038/nature25979
10. Seelbinder B, Chen J, Brunke S et al. Antibiotics create a shift from mutualism to competition in human gut communities with a longer-lasting impact on fungi than bacteria. Microbiome. 2020;8(1). doi:10.1186/s40168-020-00899-6
11. Gibson M, Crofts T, Dantas G. Antibiotics and the developing infant gut microbiota and resistome. Curr Opin Microbiol. 2015;27:51-56. doi:10.1016/j.mib.2015.07.007
12. Calder P, Carding S, Christopher G, Kuh D, Langley-Evans S, McNulty H. A holistic approach to healthy ageing: how can people live longer, healthier lives?. Journal of Human Nutrition and Dietetics. 2018;31(4):439-450. doi:10.1111/jhn.12566
13. Peterson C, Rodionov D, Iablokov S et al. Prebiotic Potential of Culinary Spices Used to Support Digestion and Bioabsorption. Evidence-Based Complementary and Alternative Medicine. 2019;2019:1-11. doi:10.1155/2019/8973704
14. McMullen M, Whitehouse J, Towell A. Bitters: Time for a New Paradigm. Evidence-Based Complementary and Alternative Medicine. 2015;2015:1-8. doi:10.1155/2015/670504
15. Hasenoehrl C, Taschler U, Storr M, Schicho R. The gastrointestinal tract – a central organ of cannabinoid signaling in health and disease. Neurogastroenterology & Motility. 2016;28(12):1765-1780. doi:10.1111/nmo.12931
16. Du Q, Liao Q, Chen C, Yang X, Xie R, Xu J. The Role of Transient Receptor Potential Vanilloid 1 in Common Diseases of the Digestive Tract and the Cardiovascular and Respiratory System. Front Physiol. 2019;10. doi:10.3389/fphys.2019.01064
17. Sotoudeh G, Abshirini M, Mahaki B, Bagheri F, Siassi F, Koohdani F. Higher intake of phytochemical-rich foods is inversely related to prediabetes: A case-control study. Int J Prev Med. 2018;9(1):64. doi:10.4103/ijpvm.ijpvm_145_18
18. Townsend E, Kelly L, Muscatt G et al. The Human Gut Phageome: Origins and Roles in the Human Gut Microbiome. Front Cell Infect Microbiol. 2021;11. doi:10.3389/fcimb.2021.643214

The extracts used in liquid bitters are often in a base of alcohol, though one can find them made with vinegar, or as powders meant to be mixed in a little water. This liquid form allows for the full experience of the bitter flavour on the tongue – an essential part of how bitters work, and why they seem less effective when taken in capsule form (2).

But alcohol also makes for an excellent solvent and preservative, drawing out bitter and aromatic components from the herbal ingredients and stabilizing the final solution. Alcohol-based bitters are also a very traditional part of mealtimes. But the bitter liqueurs we see today (like Cynar, Fernet, Underberg, Unicum, and so many more) may not have been the first documented medicinal bitters in the European tradition.

That honour may belong to a blend from a now-lost herbal written and illustrated over 2,000 years ago in northern Turkey by a physician known as Crateuas. He helped to develop the formula as an antidote to poison, and it included over 40 different botanicals (3).

The remedy proved popular, and countless variants were passed on through the generations. These became known as “theriac” (the physician Galen coined this name, which roughly means “remedy for the bite of wild beasts”).

Though their ingredients evolved over time, they followed a similar template: strong bitter herbs like centaury (Centaurium erythraea Raf.), costus (Saussurea costus (Falc.) Lipsch), and the wild poppy (Papaver rhoeas L.) were blended with pungent, aromatic herbs like ginger, pepper, and asafoetida (Ferula assafoetida L.). Herbal resins and gums came next – both as flavour, and to soften and harmonise the formula. Finally, the herbs were ground into powder and mixed with a little honey as a binder and sweetener (4).

This same template is still followed today: strong bitter herbs, a custom cocktail of aromatic and pungent spices, and finally gummy, starchy, or sugary ingredients to bind the formula together and offer a (relatively) sweet counterpoint. The indications for these formulas are similar to what they were 2,000 years ago: bitters assist and modulate the process of digestion and assimilation and encourage gentle daily detoxification. These are crucial physiologic functions – no wonder the theriac of antiquity was so revered. At the heart of its power is the bitter taste itself. What might be happening when it hits our tongue?

Our taste buds contain a few types of specialized receptors, each tuned to a broad flavour category. Receptors for sweetness, saltiness, and delicious “umami” (a savoury quality linked to amino acids found in protein, especially glutamate) give us a sense of pleasure and encourage us to eat more of the simple sugars, important electrolytes, and nourishing protein that elicit these flavour experiences (5). There may be a receptor for fats as well (6), another important source of nutrition.

Sour taste receptors have a more neutral role: if coupled with sweetness (think fruit), sourness can be pleasant. In other cases (think spoiled meat, or rancid fat), acidity feels wrong, and leads us to stop eating (7). But bitterness always acts as a deterrent: folks report that they just don’t like the flavour and tend to avoid bitter-tasting foods (8).

This is obvious in children, who may have a higher concentration of bitter taste receptors compared to adults (9): even the small amounts of bitter compounds in vegetables like broccoli send them running. But if you look at the modern Western diet, you will find that we’ve systematically removed bitter ingredients from our food supply (10), and even altered our vegetables to contain fewer bitter constituents (compare the wild versions of carrots and lettuce to their domesticated, supermarket varieties) (11). Indeed Western culture seems to have a child-like palate.

The reason we turn away from the bitter flavour is the same reason children are more sensitive to bitterness: toxic, poisonous substances are often very bitter, and the receptors that detect their presence (known as T2R, or “taste type 2 receptors”) are there to protect us (12). This is important at any age, but even more so for the sensitive metabolisms of children.

T2Rs on the tongue, like other taste receptors, are linked to the brain’s flavour perception centres via nerve fibres (13). There are more than 25 different types, sensitive to hundreds of different bitter compounds from the natural world (14).

This broad spectrum includes simple polyphenols, such as the flavonoids in goldenrod herb (Solidago species); strongly bitter lactones found in roots from dandelion to gentian (Gentiana lutea L.); and alkaloids, from caffeine to atropine, which are rare, intensely bitter, and often deadly. While the protective effect of T2R stimulation makes sense for a poison like atropine (from Atropa belladonna L., the deadly nightshade), you might wonder why we need protection from the non-toxic dandelion root (or broccoli for that matter).

In fact, we don’t – but whether goldenrod or dandelion, plants that are not toxic to humans may still be toxic to many insects, and a deterrent to browsing (15). Insects have primitive taste receptors that are thought to be the evolutionary precursors of T2Rs: similar in structure, they activate a primal, aversive response (16). The insect gets the message, and eats less.

This message alters behaviour in mammals, too. An interesting area of clinical research on the bitter taste involves appetite modulation. In an apparent paradox, bitters have been used to stimulate appetite in conditions like anorexia, or when appetite is suppressed during illness or convalescence (17).

This gentle effect can help folks maintain or recover a healthy weight and may be related to the increase in digestive juice production and stomach muscle tone that accompanies a dose. But for those whose appetites are normal (or excessive), recent clinical research suggests that experiencing a bitter taste before or during a meal reduces overall consumption of food between 20% and 30% (18).

The effect lasts throughout the day and can be valuable for those attempting to control their weight or reduce their intake of carbohydrate-rich foods (19). Bitters may affect our appetite much the same way bitter compounds affect insect browsing.

The protective effect that comes from stimulating T2Rs with bitter compounds starts by slowing down our overall intake of food. But it does not stop there: many of the classic effects we associate with bitters, from improved digestion to enhanced liver function and bile production, are part of an overall protective effect, too.

Bitters inspire the production of digestive juices across the entire GI tract (20): as a result, food is bathed in secretions that neutralise bacteria and break down potential toxins with digestive enzymes. Furthermore, bitters may increase the activity of molecular “pumps” in the intestine that keep harmful substances from entering the bloodstream, favouring their expulsion via the colon (21).

And finally, by supporting the metabolic function of the liver, bitters help ensure that our bodies break down, neutralise, and eliminate unwanted substances (22). When you put it all together and take a step back, the role of T2Rs becomes apparent: these receptors engage multiple physiologic processes that act in concert to protect us from toxicity, enhance digestion, and keep detoxification and elimination working smoothly (23). They are triggered by the bitter taste.

When you taste something bitter, the T2Rs on your tongue send a signal to your brain, and you perceive the flavour. Perhaps there is a brief shudder, but soon you can feel an increase in saliva – a harbinger of things to come, as digestive juice production increases and your body gets ready for a meal.

These are reflex effects: the sensation of bitterness triggers a cascade throughout the gut, mediated by a signal sent via the vagus nerve (a key nerve “superhighway” that regulates the function of our internal organs) (24). But this nerve reflex is just one way bitters activate our digestive and detoxification processes: over the last twenty years, researchers have discovered T2Rs all over the body, not just on the tongue.

Stimulating intestinal T2Rs, for example, triggers the release of hormones that make us feel full (this may help explain the clinical research showing we eat less when tasting bitterness before a meal) (25). T2Rs are also found in the airways, both lungs and sinuses, where they open the passages and stimulate the secretion of antibacterial compounds (bacterial waste, it turns out, tastes bitter) (26). Some immune cells may have T2Rs on their surfaces (27). T

he thyroid gland carries T2Rs (28). Even the heart can “taste” bitterness: cardiac T2Rs may help modulate blood vessel diameter and blood pressure (29). This line of research hints at applications for everything from asthma and sinusitis to high blood pressure. While these effects are not evident when we take liquid bitters by mouth, they still reinforce the understanding that the bitter taste elicits a suite of protective activity from the body.

In the herbal clinic, we turn to bitters to manage and prevent digestive complaints, particularly for simple issues like gas, bloating, and indigestion. Liquid bitters can be taken in moderate doses to address these concerns and, over time, will help them appear less frequently. They do this by encouraging our own bodies to rise to the occasion: as such, they are a more tonic strategy when compared to digestive enzyme pills, antacids, or laxatives.

A few millilitres (about 60-90 drops) is a fine place to start. To address concerns in the lower belly, such as bloating, cramping, or occasional constipation, take bitters before a meal. For indigestion and overfullness, try them after eating.

We also recommend a week or two of thrice-daily bitters during the change of seasons, particularly in early spring and fall, when our diets shift and when many folks experience digestive upset. It is important to remember that, however they are used, bitters are not a “herbal detox”: yes, we feel better after taking bitters. But this is because of their protective, enlivening effects and not because they are “cleaning” us: our liver does a great job of that every day.

Bitters just help support that work. Finally, folks who have active peptic ulcers, or liver disease (including gallstones), should use bitters with caution and only after consulting a competent herbalist. The stimulating effect bitters have on digestive juice production and bile secretion from the liver could complicate those conditions. And because some of the herbs used in bitters can have strong effects, pregnant people should use extra care and try gentle preparations, like dandelion root tea, first.

In conclusion, bitters are supreme allies for digestion and metabolism. Because these functions are foundational, bitters often improve overall health. They help reduce overconsumption of food: the antidote to “super-size” meals. In fact, digestive complaints, metabolic dysregulation, and difficulty with maintaining healthy weight (all of which are so common in the Western world) may be partly due to the child-like diet so many follow: our digestion is drowned in sweet treacle, missing the crucial signal for effective function that the bitter flavour provides. The promise of bitters is the restoration of the theriac in our lives: the antidote to poison, the flavour of the wild, the crisp, clear signal that allows us to maintain moderation, to nourish ourselves with grace.

1. Hoffmann, David. Medical Herbalism: The Science and Practice of Herbal Medicine. United States: Inner Traditions/Bear&Co., 2003:498-500
2. McMullen MK, Whitehouse JM, Towell A. Bitters: time for a new paradigm. Evidence-Based Complementary and Alternative Medicine. 2015;670504.
3. Norton S. The Pharmacology of Mithridatum: a 2000-year-old Remedy. Molecular interventions. 2006;6(2):60.
4. Karaberopoulos D, Karamanou M, Androutsos G. The theriac in antiquity. The Lancet. 2012;379(9830):1942-3.
5. Breslin PA, Huang L. Human taste: peripheral anatomy, taste transduction, and coding. Advances in oto-rhino-laryngology. 2006;63:152-90.
6. Liu D, Costanzo A, Evans MD, Archer NS, Nowson C, Duesing K, Keast R. Expression of the candidate fat taste receptors in human fungiform papillae and the association with fat taste function. British journal of nutrition. 2018;120(1):64-73.
7. Breslin PA, Huang L. Human taste: peripheral anatomy, taste transduction, and coding. Advances in oto-rhino-laryngology. 2006;63:152-90.
8. Drewnowski A. Taste preferences and food intake. Annual review of nutrition. 1997 Jul;17(1):237-53.
9. Correa M, Hutchinson I, Laing DG, Jinks AL. Changes in fungiform papillae density during development in humans. Chem Senses. 2013;38:519–27.
10. Roy GM. The applications and future implications of bitterness reduction and inhibition in food products. Critical Reviews in Food Science & Nutrition. 1990;29(2):59-71.
11. Fenwick GR, Curl CL, Griffiths NM, Heaney RK, Price KR. Bitter principles in food plants. In: Rouseff RL,ed. Bitterness in foods and beverages; developments in food science. 1990;25:205-50.
12. Glendinning JI. Is the bitter rejection response always adaptive?. Physiology & behavior. 1994;56(6):1217-27.
13. Schoenfeld MA, Neuer G, Tempelmann C, Schüssler K, Noesselt T, Hopf JM, Heinze HJ. Functional magnetic resonance tomography correlates of taste perception in the human primary taste cortex. Neuroscience. 2004;127(2):347-53.
14. Meyerhof W, Batram C, Kuhn C, Brockhoff A, Chudoba E, Bufe B, Appendino G, Behrens M. The molecular receptive ranges of human TAS2R bitter taste receptors. Chemical senses. 2010;35(2):157-70.
15. Napal GN, Palacios SM. Bioinsecticidal effect of the flavonoids pinocembrin and quercetin against Spodoptera frugiperda. Journal of pest science. 2015;88(3):629-35.
16. Weiss LA, Dahanukar A, Kwon JY, Banerjee D, Carlson JR. The molecular and cellular basis of bitter taste in Drosophila. Neuron. 2011;69(2):258-72.
17. See, for example, the monograph on gentian root in: Blumenthal M, Goldberg A, Brinckmann J. Herbal medicine. Expanded commission E monographs. Integrative Medicine Communications; 2000.
18. Andreozzi P, Sarnelli G, Pesce M, Zito FP, D’Alessandro A, Verlezza V, Palumbo I, Turco F, Esposito K, Cuomo R. The bitter taste receptor agonist quinine reduces calorie intake and increases the postprandial release of cholecystokinin in healthy subjects. Journal of neurogastroenterology and motility. 2015;21(4):511.
    Kim HM. Modulation of the Bitter Taste to Reduce Calorie Intake. Journal of neurogastroenterology and motility. 2015;21(4):457-8.
19. Mennella I, Fogliano V, Ferracane R, Arlorio M, Pattarino F, Vitaglione P. Microencapsulated bitter compounds (from Gentiana lutea) reduce daily energy intakes in humans. British Journal of Nutrition. 2016;116(10):1841-50.
20. Bone K, Simon Mills MC, Fnimh MA. Principles and practice of phytotherapy: modern herbal medicine. Elsevier Health Sciences; 2012:40
21. Jeon TI, Seo YK, Osborne TF. Gut bitter taste receptor signalling induces ABCB1 through a mechanism involving CCK. Biochemical Journal. 2011;438(1):33-7.
22. Raka F, Farr S, Kelly J, Stoianov A, Adeli K. Metabolic control via nutrient-sensing mechanisms: role of taste receptors and the gut-brain neuroendocrine axis. American Journal of Physiology-Endocrinology and Metabolism. 2019 Oct 1;317(4):E559-72.
23. Harmon CP, Deng D, Breslin PA. Bitter taste receptors (T2Rs) are sentinels that coordinate metabolic and immunological defense responses. Current Opinion in Physiology. 2021; 20:70-6.
24. Darby SA. Neuroanatomy of the autonomic nervous system. Clinical Anatomy of the Spine. Spinal Cord, and ANS. 2017:466-469.
25. Sternini C, Anselmi L, Rozengurt E. Enteroendocrine cells: a site of ‘taste’ in gastrointestinal chemosensing. Current opinion in endocrinology, diabetes, and obesity. 2008;15(1):73.
26. Maina IW, Workman AD, Cohen NA. The role of bitter and sweet taste receptors in upper airway innate immunity: recent advances and future directions. World journal of otorhinolaryngology-head and neck surgery. 2018;4(3):200-8.
    Deshpande DA, Liggett SB. Regulation of Intracellular Calcium by Bitter Taste Receptors on Airway Smooth Muscle. Calcium Signaling In Airway Smooth Muscle Cells 2014;409-421.
    Devillier P, Naline E, Grassin-Delyle S. The pharmacology of bitter taste receptors and their role in human airways. Pharmacology & therapeutics. 2015 Nov 1;155:11-21.
27. Gopallawa I, Freund JR, Lee RJ. Bitter taste receptors stimulate phagocytosis in human macrophages through calcium, nitric oxide, and cyclic-GMP signaling. Cellular and Molecular Life Sciences. 2021;78(1):271-86.
28. Clark AA, Dotson CD, Elson AE, Voigt A, Boehm U, Meyerhof W, Steinle NI, Munger SD. TAS2R bitter taste receptors regulate thyroid function. The FASEB Journal. 2015;29(1):164-72.
29. Bloxham CJ, Foster SR, Thomas WG. A bitter taste in your heart. Frontiers in Physiology. 2020;11:431.

The first to highlight the problem of herbal adulteration was Dioscorides in 50 CE, who authored the first systematic pharmacopoeia De Materia Medica (Περὶ ὕλης ἰατρικῆς). He described over 40 tests to examine the quality of herbal products bought from traders in ancient Rome (1).

Most of these were organoleptic but some used simple chemico-physical tests, such as flame tests, solubility, measurements of weight and displacement and other unique properties of authentic herbs such the ability of balsam (probably Commiphora gileadensis (L.) C.Chr., Burseraceae) to be washed clean from a woolen cloth while its adulterants stain (2).

Later Roman authors such as Pliny the Elder (23 – 79 CE) also documented widespread adulteration in food and drugs in his Natural History with methods to detect them (3,4).

The physician Galen (131 – 201 CE) was also aware of adulteration in his supplies, often complaining of fraudulent merchants and asserting the need for a physician to know his materials (5), even suggesting animal testing for the formulated antitoxin theriac (θηριακή) to determine its authenticity (6).

A similar trend emerged in China. In the 5th century, as medicine developed into increasingly specialised roles of harvesters, market-traders and physicians, scholar-hermit Tao Hongjing (陶弘景) wrote his Collected Annotations to the Materia Medica (Ben Cao Jing Ji Zhu, 本草經集注) where he lamented the poor quality of herbs in his day, accusing the market traders of deliberately selling low quality products for profit, and the physicians of being only concerned with looks and unable to recognise genuine potency (7).

To remedy this state of affairs, he hoped his detailed additions to each entry of the earlier 1st century classic, the Divine Farmer’s Materia Medica (Shen Nong Ben Cao Jing, 神農本草經), would help physicians to recognise true potency and value it over cosmetic appearance.

In particular he highlighted the issue of correct species from poor growing regions, lacking the potency of the genuine article, being sold as the real thing. This problem of functional adulteration is very difficult to detect and still pertinent today.

In 659, during the Tang dynasty the world’s first national pharmacopoeia, the Newly Revised Materia Medica (Xin Xiu Ben Cao, 新修本草) was published (8).

The whole country was surveyed for specimens and detailed colour drawings were included to complement textual descriptions. Improvements to authenticating herbal medicines continued with the Extension to the Materia Medica (Ben Cao Yan Yi, 本草衍義) by Kou Zongshi (寇宗奭), an expert in authentication, compiled in 1116 being one of the first printed texts that focused on differentiating authentic from inauthentic herbal medicine (9).

However, it was not until the Origins of the Materia Medica (Ben Cao Yuan Shi, 本草原始) in 1788 that pictures of the prepared herbal materials were included rather than just the live plants.

The medieval period saw little development in the technology for detecting adulteration but instead relied on the development of ethical and legal frameworks to ensure the purity of medicinal herbs.

As the Islamic Golden Age dawned under the Abbasid Caliphate in 9th century Baghdad, a new class of professional pharmacists started writing new pharmacopoeias, beginning with Yuhanna Ibn Masawayh (يوحنا بن ماسويه‎, Romanised: Johannes Mesue), who focused one work on aromatics, including methods of detecting their adulteration (10).

A code of ethics was established for this emerging class who were held to higher standards than regular spice traders and enforced by a government appointed official, al-Muhtasib (محتسب), who inspected pharmacies for potential adulteration, degradation, fraud and excessive profiteering (11).

Saffron (Crocus sativus L., Iridaceae) adulteration was a particular concern due to its culinary and medicinal use in many healing traditions. Often ascribed with magical properties, with its labour intensive harvesting procedure, made it worth its weight in gold (12).

From the 5th to the 15th centuries, an armed guard was charged with inspecting saffron supplies coming into port in Venice and in 1358 the first known food law was enacted in Nuremberg, punishing the adulteration of saffron with death, sometimes by being burnt alive with your own adulterated products.

The scientific revolution ushered an age of using technology to enhance the senses. Magnifying lenses had been known to the ancient Greeks and Romans (13) but the invention of the compound microscope allowed Nehemiah Grew to provide the first vivid descriptions of plant anatomy in 1682 (14,15). Over time new technologies such as fluorescence, confocal microscopy and imaging techniques have added new dimensions to what we can see in order to differentiate plant materials (16).

In 1735 Linnaeus applied scientific methodology to taxonomic classification in his Systema Naturae (17), developing the binomial nomenclature still used today (18). This initiated a systematic method of classifying species and therefore determining which species should be considered authentic or adulterants, and clarifying which species referred to by traditional or local names have the medicinal benefits required of them (19).

The industrial revolution saw a new wave of advances in botanical sciences. The age of chemometric testing began when Mikhail Tsvet demonstrated the first chromatographic technique to separate plant pigments in 1903 (20).

Spectroscopic analysis, observing the unique interactions of the separated compounds with energy from ultraviolet or infrared radiation, or from magnetic or ionising charges, could be used to speculate on their structures with far greater accuracy than smell or taste alone, even detecting deliberate adulteration with drugs, dyes or similar herbal materials designed to be undetectable by routine methods of examination (21).

With increased sensitivity, it became possible to detect new potential contaminants that would have escaped detection or even consideration in the past.

This includes both naturally occurring toxic compounds in plants which can arrive in the supply chain by being inherently present in a species, or by contamination with plants that contain them, heavy metals drawn from the environment, or contamination with artificial substances such as pesticides. Pyrrolizidine alkaloids caused particular concern in herbal medicine, being discovered in several plants considered safe for centuries, such as borage (Borago officinalis L., Boraginaceae), comfrey (Symphytum officinale L., Boraginaceae) and coltsfoot (Tussilago farfara L., Asteraceae). 

These have no obvious toxic effects in moderate doses but long term use can cause irreparable liver and lung damage, even leading to cancer (22). The use of these herbs has since been voluntarily suspended by most professional herbalist associations (23) but potential contamination of other herbs and foods with plants that contain PAs is harder to control. These toxins are too widely distributed in nature to ever make total eradication feasible and as little as one ragwort (Senecio sp. L., Asteraceae) per hectare of St. John’s Wort (Hypericum perforatum L., Hypericaceae) is enough to exceed the suggested threshold of 1.0 μg PAs daily (24).

However, through implementation of Good Agricultural and Collecting Practices combined with batch testing using a combination of chromatography and spectroscopy, it is hoped that exposure can be kept within safe limits. Tropane alkaloids have caused a similar concern, often ending up in the supply chains through accidental contamination with Datura sp. or Convolvulus sp. and these too are managed with chemometric and spectroscopic analysis to ensure levels are below the regulatory limits (25).

Likewise, pesticides are monitored with published reports containing chromatographic-spectroscopic analysis (26,27) with similar monitoring of heavy metals (28).

This field continues to advance with more refined techniques and computing power to analyse the data providing even more sophisticated models (29). Initiatives like the High Performance Thin Layer Chromatography Atlas of plants (30) aim to publish the chemical fingerprint of every species, against which unknown samples can be compared to determine the species or the presence of adulterant chemicals.

Within a few years of the first Nature papers on human DNA fingerprinting being published by Alec Jeffries in 1985, the technique had revolutionised botanical sciences (31). DNA analysis enabled faster and more precise taxonomic classification, based on snippets of genetic code, than the traditional system and could even determine distinctions between apparently identical species or from fragments that had been cut and no longer had distinguishing characteristics visible.

For example, the Chinese names of some medicinal herbs, such as Mu Tong and Fang Ji, may both refer to several separate species, one of which is a toxic Aristolochia species (A. manshuriensis and A. fangchi respectively) containing aristolochic acids that cause kidney damage, while the other is not (Clematis armandii Franch., Ranunculaceae or Akebia trifoliata (Thun.) Koidzumi seu quinata (Houtt.) Decne., Ranunculaceae and Stephania tetrandra S. Moore, Menispermaceae respectively) and can be used safely (32).

It can be almost impossible to tell dried, cut specimens, powders or extracts apart and while some countries have responded with outright bans on all species where confusion could happen (33), others have implemented testing and analysis to regulate imports (34). An integrated approach of chemometric testing for the presence of aristolochic acids combined with DNA barcoding to ensure correct species (35) seems to be the best option to enable herbal medicine to continue to be practiced effectively and safely without unnecessary restrictions.

Similar to, and complementing, the chromatographic atlases of plants, databases of genetic information such as the Barcode of Life Data (BOLD) (36), the NCBI Genome Database (37) and the Medicinal Materials DNA Barcode Database of Traditional Chinese Medicines (38) have been developed enabling samples to be compared against verified specimens.

Modern chemometric and genetic analysis of plants have undoubtedly enhanced the quality assessment of herbs, but they are not without their drawbacks. Chemometric analysis often relies on identifying active ingredients or known adulterants and searching for these markers to determine the quality of the medicine but the effects of many herbal medicines cannot be traced to single compounds and in many cases their mechanisms remain unknown, requiring new strategies to be considered (39). DNA fingerprinting can also be problematic when applied to extracts where the DNA is often degraded after processing (40).

The ultimate purpose of herbal medicines is to have a biological effect which is difficult to determine without functional testing on a biological system. Some forms of adulteration, like that highlighted by Tao Hongjing, may pass chemometric and genetic analysis, especially where a specific drug compound is not the key to the herb’s activity, or in formulae where there may be too many markers to effectively search for them all.

Until recently the only methods of functional testing were either animal experiments, which are ethically problematic (40) and only provide limited information (42), human trials, which are very expensive to run in an area that is chronically underfunded, or by observation of the effects of each batch in the clinic, which is less than ideal.

Mitochondrial testing presents a new and exciting opportunity for the functional analysis of the quality of herbal medicines. Mitochondria stand at the centre of biological activity, not only providing the energy required for most biological functions but being integral to almost every aspect of multicellular life (43). Their broad range of functions has even led to suggestions that they may be behind similarly broad traditional concepts fundamental to life such as Qi (44).

Changes in mitochondrial function have been implicated in many states of health and non-inheritable disease including metabolism, stress responses, inflammation, ageing, cancer, cardiovascular and neurological function (45), and immune responses to viral infections including SARS-CoV2 (46).

Many of these have been traditionally attributed to Reactive Oxygen Species (“free radicals”) generated as by-products from the mitochondrial respiration process and treated with antioxidants.

However, current research shows that the picture is far more complex, with antioxidants failing to show an improvement in living subjects (47), maybe even eliminating the beneficial effects of exercise triggered by a moderate rise in free radicals (48) and having contradictory results in cancer, where free radicals induce both the proliferation and the self-destruction of cancer cells (49).

Through the use of dyes that react with specific mitochondrial processes, fluorescent microscopy and highly sensitive probes that can measure the oxygen consumption rate or temperature changes in a culture of cells, it is possible to generate a mitochondrial profile of the effects of herbal substances on specific tissues (50).

Besides gathering invaluable information on the potential mechanisms of many herbs, this approach also provides a novel method of functional evaluation, closer to the clinical effects than chemical or genetic profiles can provide on their own.

Moreover, it could be used routinely on herbal batches for the purposes of quality, safety and efficacy assessment, while being less ethically problematic than testing on animals and less costly than running conventional human trials.

The Research Centre for Optimal Health is at the forefront of this research methodology with several PhD and postdoctoral projects currently being undertaken and papers already published (50,51,52,53,54). We have also developed a high-throughput testing pipeline that is able to rapidly determine the biological potency of individual herbs and herbal formulas as well as being able to analyse how herbal medicine may improve mitochondrial health in humans.

For further information about mitochondrial testing contact Prof. Jimmy Bell at: J.Bell@westminster.ac.uk.

Acknowledgements: Thanks to Pukka Herbs for providing the PhD scholarship funding for Steve Woodley.

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(As told to the author by Frank and Julia King-Ni-Vanuatu; Mélé Village, Efate Island, Vanuatu-July 2017)

Our story begins with two brothers Ben a farmer and Cassie a fisherman.  Each day Ben would rise early and work his crops in the forest, while his brother would fish when the tides allowed, and he would come and go with the water and bait and was often around the village during the day due to bad fishing or weather. One day Ben came home to find Cassie in bed with his wife and in a fit of rage killed his wife and his brother. He buried them in the earth behind his hut and went into a long state of depression so dark that he could not expose himself to the light nor could he sleep.

He had a dream that came during one of his long nights of restless sleep that a plant with heart shaped leaves spoke to him, and told him to get up and look for it in the forest behind his house where he buried his wife.

The next morning Ben got up and went looking for the plant and sure enough there it was sprouting branches that looked like the brown knuckles of his wife’s hands coming from the ground with green heart shaped veined leaves. It was the first time Ben had come out of his hut since the event and he began to have more dreams about the plant and seemed to sleep better and be more at ease just being around it.

The next night he dreamt that the plant told him that it was the spirit of his slain wife and that she forgave him for his rage and could help him with his heavy guilt, shame and lift the darkness that he was living with.

The plant told of how Ben should carve a board out of black wood to resemble her womb, and then of the plant with the heart shaped leaves, “pull up my feet and legs (roots) and grind them into the womb you will make out of dark wood and with a long, rounded piece of dead coral and some fresh rainwater until it forms a milky liquid that you should squeeze through coconut fibers and drink the liquid.

While you are drinking you will not think of me or think about sex and your wife, your sore muscles will be warmed by the drink and the pain will ease and I promise to keep you peaceful if you only remember to cut up my arms and hands at each joint and stick them into the earth to grow more and tell other men in the village how I make you feel and how to prepare me and how to grow more of me.”

And so, Ben did this…

He began to sleep well and went back to farming and told the men in the village about his dreams. They tried the drink together at night in the village hut and found that not only did it help them sleep, but it eased their sore muscles from working the forest gardens and waters all day. From then on Kava has been consumed and loved within the communities. That is the story of how Kava came to this Island and spread to the other islands.

The Medicinal plant Piper methysticum G. Forst is commonly referred to as Kava, ‘Awa, or Yaqona in Vanuatu, Hawaii, Fiji respectively. Kava relies on asexual propagation since it cannot produce a viable seed. After I heard and read about the various Kava origin stories, I wondered if the buried corpse of a woman was representative of the indigenous tribe’s explanation for how a plant could reproduce without a seed and why it made them feel at ease in body and mind.

The answer as with most things in the botanical world is not so simple and requires more research. It is a conversation better had in person for the ethnobotanical inquiry, preferably while in the Nakamal after a shell or two of Kava and certainly not via WhatsApp or Zoom.

The phytochemical research also continues, and volumes are dedicated to characterization and isolation still without complete agreement amongst analytical chemists. The plant that is thought to be the “Mother” of Piper methysticum G. Forst; Piper methysticum var. wichmannii is also an asexual or vegetative reproducer though it is physically much larger than the drinking varieties, grows more rapidly and is substituted intentionally and unintentionally for Noble or commonly consumed Varieties.

This plant is considered a spiritual and ceremonial plant in Vanuatu and typically has not been consumed for nakamal drinking but only used in ceremonies. On my last visit in 2017 I heard from several Ni Vanuatu that they were drinking “wild kava” P. methysticum var. wichmannii (‘wael kava’ in Bislama language). That they would drink from a plant normally reserved for spiritual and ceremonial practice is indicative of the strain on this plant in trade.

During my times visiting the islands with Frank and Julia King they began facilitating the transplanting of some Noble varieties on Efate from Pentecost and other island’s. This was because of various tropical storms, volcanic eruptions and cyclones damaging Kava crops specific to those islands (Efate, Pentecost and Ambrym in this case).

This left the islanders unable to work the crop with many other life preserving activities taking precedent, such as replanting food gardens, clearing debris and building water storage. The fresh kava trade between islands for drinking has extended into selling young shoots for cultivation.

For much of the known history of Kava dating back to the works recorded by early Botanist J.G. Forester who travelled on Captain Cook’s expeditions around the pacific Islands in 1777 each Island cultivated, harvested and traded varieties that were endemic to that Island with varieties such as Borogu and Borogu Temit predominant on Pentecost and varieties such as Pia being more predominant on Tanna.

There are 16 known folk cultivars of Kava that have been identified on Pentecost and about the same on Tanna but the reader must also consider the linguistic diversity of Vanuatu and the fact that there are over 20 different Islands that have cultivated Kava for centuries in a concentrated geographic area. There are 105 languages spoken in the archipelago of Vanuatu (the most of any Country by population) and cultivars are recorded in as many languages. The gathering and recording of this information have been long and laborious and a debt of gratitude is due to Dr. Vincent Lebot for his work (1,3).

As efforts to increase diversity and inclusion increase, they extend to the plants in addition to the people. Of interesting note here; the trip in 2017 was the first time I had seen Women in Nakamals and drinking Kava in public. Custom or “Kastom” a Bislama/Pigin word for culture, including religion, economics, art and magic, has not allowed native Vanuatu women to harvest, process or drink Kava with the exception of masticating rootstock on some occasions for ceremony.

Despite this strict adherence to Custom in conversations with locals on different islands, it is clear that some women do drink Kava regularly, they are just doing so in hiding. Now, attitudes are changing and the women I spoke with said for the better.

The Kava Origin story above is just one of many stories on the origin of Kava and I encourage the reader to find more information freely available online concerning this subject, or better yet, travel to any Kava bearing island in the South Pacific and ask for yourself. They will be happy to share their information with you and it’s a great thing to chat about after a shell or two.

Kava grows in some of the most beautiful tropical paradise locations known, Fiji, New Guinea, Tonga, Samoa, Hawaii, New Caledonia, Papua New Guinea, The Cook and Solomon Islands and Vanuatu among the jewels in this pacific treasure chest. This plant perhaps more than any other I’ve encountered represents the human, plant coevolutionary process in the most sublime of ways. It is a plant that prepared properly, from the correct species, relieves anxiety and opens certain areas of perception and the plant must be reproduced by humans.

It grows naturally where rainfall is plentiful (average 2,000 mm/yr). Ideal growing conditions are 21–35 °C and 70–100% relative humidity. Too much sunlight is harmful, especially in early growth. The beverage is prepared in commercial nakamals and villages using a mechanical grinder, most often a manual hand crank meat grinder.

The ground roots are then put into a mesh cloth, though one time in Mele village I helped prepare some of that night’s Kava and we used a pair of men’s mesh football shorts as a strainer (they were clean!), proving that necessity is the mother of invention. In the USA Kava is regulated as a dietary supplement and dried lateral root  stock in a powdered form and various extracts are available.

I do take an extract of Kava from time to time and there’s a slight feeling of warmth, an ease in tension without cognitive inhibition, this is more pronounced in the water extracted dried root preparations than from capsules or extracts. To emphasize the difference for this subject; when drinking fresh kava on Vanuatu, I have thought to be able to see the vacuoles opening and closing on the underside of plant leaves, breathing in CO2 and out oxygen molecules, so relaxed and calm amongst natives yet over 8,000 miles from my home on a dot of land in the South Pacific.

The experience of drinking fresh kava on the islands is not easily reproduced through even the best of Dried Kava preparations or extracts. The word Kava is thought to be from Tongan language meaning ‘bitter’ and in Hawaii it is ‘ava’, also meaning bitter as it is so indicated in almost all the languages that refer to this beverage (2). It’s not a flavor that one savors.

Spit troughs are common at the Nakamals in Vanuatu and there’s always some coconut meat, paw-paw (Papaya), or pineapple to cleanse the bitterness from the palate after knocking back a shell of fresh Kava. It is also a type of “prayer offering” to spit and cough after consuming and ask the kava spirits for good fortune. I am grateful to have access to Kava as we do in the US and feel for my fellow herbal enthusiasts in the UK that cannot so freely enjoy this plant.

In 2001 concerns about Kava’s safety were raised by European media reports of liver toxicity involving the use of Kava.

Then in 2002 the Office of Dietary Supplements issued this statement: “On March 25, 2002, the Food and Drug Administration (FDA) issued an advisory notifying consumers that kava-containing dietary supplements may be associated with severe liver injury.

The FDA reported that kava-containing products have been associated with liver-related injuries, including hepatitis, cirrhosis, and liver failure, in over 25 reports of adverse events in other countries. In the U.S., FDA received a report of a previously healthy young female who required liver transplantation, as well as several reports of liver-related injuries.” (8).

Though not “banned” in the US many companies subsequently stopped selling Kava and products and those that remained in the market were mandated to contain a detailed label warning relating to potential liver toxicity. Some researchers believe that extraction using solvents other than water create chemistries not found in traditional water extracts and these non-traditional extraction processes remove glutathione. This is a powerful antioxidant that the liver and plants produce to protect from peroxide and other free radical induced damage (7).

More research is needed in this area though The World Health Organization in it’s 2007 report on the safety and efficacy of Kava noted: “2.1.3. Products from water-based suspensions and further synthetic preparations should be developed and tested in clinical trials and consideration given to using these in preference to acetonic and ethanolic extracts.” (9).

Of interesting note are the lack of studies using water extracts of the peeled roots and rhizomes, to evaluate the safety of traditional preparation methods. The dangerous preparations recommended for the removal from the market in the UK and other countries were based on the evaluation of acetone and ethanol extracts, that did not respect or adhere to traditional extraction methods. This is despite WHO recommending studying water based traditional beverages.

One effort in the right direction was initiated in a study conducted in 2009 called The Kava Anxiety Depression Spectrum Study (KADSS). This was a 3-week placebo-controlled, double-blind, cross-over trial involving 60 adult participants (18–65) with elevated stable anxiety and varying levels of depressive symptoms. (4)

It is one of the only studies we are aware of using an aqueous extract of Kava. In the study the researchers from Queensland University in Brisbane, Australia and School of Health, University of New England, Armidale, Australia concluded in their summary:

“The study demonstrated that an aqueous extract of Kava was a safe and efficacious anxiolytic in participants with elevated, stable generalized anxiety and may also have antidepressant effects.

In accordance with our results, aqueous preparations of Kava may tentatively be recommended for intermittent or short-term use in people with generalized anxiety. In cases of regular use, liver function tests and clinical examinations should be periodically conducted, and dosages should not exceed 250 mg of kavalactones per day. Kava should preferably not be consumed with alcohol, benzodiazepines, or anticonvulsants.

This current study—and research that follows—may encourage the reassessment of Kava as a first-line treatment of anxiety. Such a decision would provide a significant expansion of viable treatment options for people with acute anxiety. It is necessary to continue more work in this area with aqueous extracts if we are to uncover the evidence contained in traditional preparations.”

One of the practical limitations of the study is the lack of preparations commonly available for aqueous extracts of Kava. The majority of preparations are Ethanolic Tinctures or straight powder/dried roots of Kava. It is however landmark in its efforts to approximate a traditional beverage, which to date had not previously been accomplished.

A notable 8-week randomized, double-blind multi-center placebo controlled clinical trial in 129 out-patients was conducted in 2003 using a 95% ethanolic extract of 400mg kava standardized to contain 30% kavapyrones at an average dose of 120mg (5). The study concluded that the preparation was well tolerated and as effective as Buspirone and Opipramol in the acute treatment of out-patients suffering from generalized anxiety disorder (GAD).

This study is encouraging for the types of preparations that are available in areas where commerce on extracts is allowed. More research on the solvent and aqueous preparations is needed and would hopefully lead to the development of safe, evidenced based therapeutics which also align with traditional preparations of the plant.

The first time I gave a native Pentecost islander a taste of an Ethanolic extract made from their harvests the reaction was one of amazement, a bit of worry and a bit of disbelief that it was actually Kava as they whooped out a loud “Kava Strongfala hafkrangke!!!” in Bislama, translating to “Crazy Strong Kava!!!”.

On my last trip to Vanuatu, I had the ultimate good grace to travel there with my son Cameron who was 22 at the time and studying Sustainable Tourism and Fisheries Biology at Colorado State University in Fort Collins, CO. One of the goals was to see some Kava “gardens” as they call them on the Island of Ambrym and for Cam to see firsthand the results of a study he had read for a fisheries class investigating the impact of commercial fishing and coral bleaching on Efate island (6).

We waited at the Port Vila International Airport for an 8 seat small engine flight to Ambrym Island with the customary live chicken in tow that I had become accustomed to on island visits with Frank. When we walked out to load the plane, Cam was asked to sit in the Co-Pilot seat up front as the Pilot needed proper weight distribution and he was about the same height and weight as our pilot, a nice young Fijian man about Cam’s age. The islands appeared and disappeared into the clouds amidst a turquoise coral backdrop with nothing but pelagic pacific waters as far as one could see on this thankfully clear day.

We landed safely coming into the Ulei Airport, a small grass landing strip emerging out of the palms with a brick building containing a latrine. I hugged Cam a little extra tightly in gratitude once we were taxing in and also marveled at the thought of the original islanders making that trek across treacherous waters in a hand hewn outrigger canoes.

We met the Chief of the village (Aram) that was farming the Kava who also ran a small shop with essentials that came in with the Kava trade. Aram was carrying a rifle which was something I had never seen on the islands before but was assured it was only to hunt fruit bats or Flying Foxes in the local language.

Such is life in the bush, but I would later learn that the rifle was in fact for our protection since a neighboring tribe had gotten word of this one’s success in trade with Kava to pharmaceutical companies and was making threats. The chief confided to me that his brother was sick with “stomach cancer” and it was putting a strain on harvesting and planting Kava since he was responsible for a small crew and becoming unable to work.

I immediately went to work scouring the landscape for plants I may recognize that may be beneficial and asked what he was doing for food and medicine. Later during that trip while hiking to the active Volcano (Benbow) as we made our way through the forested part of the Lahar, I spotted two species of fungi that surprised and delighted me: a Ganoderma species and Coriolus versicolor.

I made a mental note of their location, took some pictures, wrote a note in my journal but did not take any of them as I only wanted to ask the chief if he knew about them or if there was any use of them known to his tribe. Our Volcano guide from the village; Solomon had not known about them and said they don’t eat any of those since they don’t know if they are poisonous or not.

I showed the chief the photos who also had no experience with them when we returned to the village the next day told him how to prepare the fruiting bodies of those fungi (The Mushroom ‘caps’) if he felt inclined by making a decoction for his brother to drink for his stomach and vitality. He was grateful for my time and sharing and promised strong kava when we returned to the village nakamal that night to drink.

This exchange of knowledge and caring was facilitated through the business of botanicals and the plants themselves and is an unspoken language of unity that compels one to act with ethics and compassion. The plants take you on an amazing journey and the road maps for proper engagement can be found in the language of cultural tradition, the plants themselves, and the soil web connection that is emerging as the center of it all, facilitating a community of interconnectedness and interdependence.

1. Applequist, Wendy L.; Lebot, Vincent (25 April 2006). “Validation of Piper methysticum G. Forst var. wichmannii (Piperaceae)”. Novon: A Journal for Botanical Nomenclature. 16 (1): 3–4. doi:10.3417/1055-3177(2006)16[3:VOPMVW]2.0.CO;2
2. http://wehewehe.org/gsdl2.85/cgi-bin/hdict?a=d&d=D1669
3. Kava: The Pacific Drug, Vincent Lebot, Mark Merlin; Lamont Lindstrom. Copyright Date: 1992. Published by: Yale University Press. https://doi.org/10.2307/j.ctt211qwxb Pages: 256
4. Sarris J, Kavanagh DJ, Adams J, Bone K, Byrne G. Kava Anxiety Depression Spectrum Study (KADSS): a mixed methods RCT using an aqueous extract of Piper methysticum G. Forst. Complement Ther Med. 2009 Jun;17(3):176-8. doi: 10.1016/j.ctim.2009.01.001. Epub 2009 Feb 7. PMID: 19398072.
5. Boerner RJ, Sommer H, Berger W, Kuhn U, Schmidt U, Mannel M. Kava-Kava extract LI 150 is as effective as Opipramol and Buspirone in Generalised Anxiety Disorder–an 8-week randomized, double-blind multi-centre clinical trial in 129 out-patients. Phytomedicine. 2003;10 Suppl 4:38-49. doi: 10.1078/1433-187x-00309. PMID: 12807341.
6. https://www.icriforum.org/wp-content/uploads/2019/12/Pacific-Coral-Reefs-2011.pdf
7. Peter A. Whitton, Andrew Lau, Alicia Salisbury, Julie Whitehouse, Christine S. Evans: Kava lactones and the kava-kava controversy, Phytochemistry, Volume 64, Issue 3, 2003, Pages 673-679, ISSN 0031-9422, https://doi.org/10.1016/S0031-9422(03)00381-9.
8. https://ods.od.nih.gov/HealthInformation/kava.aspx
9. https://apps.who.int/iris/bitstream/handle/10665/43630/9789241595261_eng.pdf

The earliest evidence of what may be the cannabis plant has been found in pollen samples found in Lake Baikal in Southern Russia, dating to around 130,000 years ago; though these traces in pollen may instead be of Humulus (the hop family) (1). 

The cannabis plant probably first disseminated before the last Ice Age (c.13000 BCE) in at least two regions: Central Asia and Eastern Europe.

The earliest evidence of humans using cannabis comes from recent research conducted at the Okinoshima (on the Boso peninsular) site in Japan, which indicates the use of cannabis (adhering to pottery of the Jomon culture) in 8200 BCE. Cultivation of the plant appears to begin in the Copper Age (c.3500–2300 BCE), increasing in the Bronze Age (c.3500–1600 BCE) (2). 

Historically, cannabis has been one the most widely cultivated plant in human history (Schultes et al. 1975:22) (3). Due to travel, cultivation, selective breeding, trade and global seafaring, numerous varieties of the cannabis plant grow on all continents; cannabis finally arrived on the continent of South America in the 15^th century (4).

There is abundant evidence for the use of cannabis in Europe for fibre, rope and textiles that dates back several millennia;(5) there is also archaeological evidence from Eastern Europe (in Bulgaria) and Central Asia dating from the 5^th millennium BCE which has revealed that in antiquity cannabis was smoked for inebriation. Buds would be placed on hot stones or a brazier inside a simple, tent-like structure made of felt, which then became filled with smoke (6).

Amongst other similar discoveries, cannabis material, almost certainly used for inebriation, has been found at sites in Xinjiang Province in western China,(7) dated to the mid-first millennium BCE, and in Israel at the Judahite shrine at Arad, dated to the 8^th century BCE (8).

The earliest, extant report in the West of the effects of cannabis, which is well known, is by the Greek historian Herodotus in his Histories,(9) who around 450 BCE described militant, wild, horse-riding Scythians in a region near the Black Sea inhaling cannabis smoke in felt tents and “howling with laughter.”

Despite the report of the psychoactive properties of cannabis by Herodotus and later accounts from the world of radical Qalandar Sūfīs in the Middle-East and Central and South Asia from the 12^th century onwards,(10) and although known as a medicine in the classical Greco-Roman world, the psychoactive effects of cannabis were hardly known about in Europe until the mid-nineteenth century.

As mentioned above, research suggests that the cannabis plant may have originated in at least two regions, in Eastern Europe and Central Asia, resulting in at least two main varieties, which may have resulted from early human selection and cultivation.

The botanical classification of cannabis plant species began in 1542 with the identification and image of Cannabis sativa (“cultivated” Cannabis) in a work on plants (De historia stirpum commentarii insignes) by the German physician and botanist Leonhart Fuchs (11).

More than 200 years later, Carolus Linnaeus, the Swedish “father” of modern botanical classification, also identified Cannabis sativa from specimens growing in Holland and Sweden (12) in his 1753 compendium Species Plantarum. The variety grown in Europe, and subsequently in North America, which was psychoactively weak, was generally known as “hemp.”

The classification of the cannabis into Cannabis indica (“Indian cannabis”)and Cannabis sativa began with the Frenchman Jean-Baptiste Lamarck in his Encyclopédie méthodique, publishedin 1785 (13). Lamarck was of the opinion that the indica variety was the kind native to India and Persia.

Cannabis ruderalis (“roadside Cannabis”), a small (two feet high), dark green, weedy variety found primarily in parts of Russia, was subsequently added to the classification in 1924(14), making a tripartite classification of the naturally growing cannabis plant. It was, however, only in the 1960s that botanists became fully persuaded that cannabis is not a monotypic plant but is, rather, polytypic (15). 

The current, general consensus is that Cannabis sativa strains have thinner leaves, are taller, spindlier, have less dense branch formations, and are generally reputed to have a proportionally higher component of THCs, while Cannabis indica strains have broader leaves, are shorter, and are reputed to be higher in CBDs, with less THCs. The third variety, Cannabis ruderalis, has a low THC and CBD content. (THCs provide the stimulating “high” of cannabis, while CBDs have a generally non-psychoactive, sedating effect.)

Although still adhered to by consumers, growers and suppliers, with the current awareness of the diversity of plant types, referred to above, this three-type classification of cannabis now seems inadequate (16). Based on extensive research, particularly by Karl Hillig at Indiana University, Clarke and Merlin (17) tentatively classify ten historical strains of cannabis originating in Europe and Asia.

Medicinal uses of the cannabis plant were known to the Greeks and Romans. The works of three medical authorities, Pliny, Discorides and Galen, are cited below, as they were perhaps the most influential on the subsequent development of medicine in Europe.

Pliny The Elder

Pliny (the Elder) (23–79 CE), the Roman naturalist and military commander, knew cannabis. He describes it in his work Natural History (17), but not at all as an inebriant, even though he also discusses the inebriating, sleep-inducing properties of opium in this work (20.76), which was written in 77 CE. In Book 20 (“Drugs Obtained from Garden Plants: Hemp, Nine Remedies”), Pliny made the following observations:

Hemp originally grew in the forests, where it is found with a blacker and rougher leaf than in the other kinds. Hempseed, it is said, renders men impotent: the juice of this seed will extract worms from the ears, or any insect which may have entered them, though at the cost of producing head-ache.

The virtues of hemp, it is said, are so great, that an infusion of it in water will cause it to coagulate: hence it is, that if taken in water, it will arrest looseness in beast of burden. A decoction of the root in water, relaxes contractions of the joints, and cures gout and similar maladies. It is applied raw to burns, but it must be frequently changed, so as not to let it dry.

Dioscorides

Dioscorides (40–90 CE), the Greek physician and pharmacist, also knew cannabis. In his five-volume work on herbal medicine (De Materia Medica), he lists two kinds of cannabis, Kannabis emeros and Kannabis agria (19). He observes that Kannabis agria and Kannabis emeros are useful for making ropes, earache, “quenching conception,” inflammation and aching joints:

3–165. Cannabis Emeros

Cannabis is a plant of considerable use in this life for twisting very strong ropes. It bears leaf with a bad scent, similar to the ash; long hollow stalks, and a round seed. Eaten in quantities these quench conception. The herb (juiced while green) is good for earaches. It is also called cannabium, schoenostrophon, or asterion; the Romans call it cannabis.

3–166. Cannabis Agria

Cannabis sylvestris bears little stems similar to those of althea [3­–163] but darker, sharper and smaller. The leaves are similar to the cultivated but sharper and darker. The reddish flowers are similar to lychnis [3–114, 3–115], with the seed and root similar to althea. The root (boiled and applied) is able to lessen inflammation, dissolve oedema, and disperse hardened matter around the joints. The bark of this is suitable for twining ropes. It is also called hydrastina, the Romans call it terminalis, and some, cannabis.

Galen

Galen (Claudius Galenus) (129–c.199–216 CE), the great, Greek medical author and physician to several Roman emperors, briefly discusses cannabis in his De alimentorum facultatibus (34 [550]) (19) He observes that:

[Cannabis] produces headaches and unhealthy humours. Nevertheless some people roast and eat it with other sweetmeats. (Clearly, I am calling things that are eaten after dinner for pleasure while drinking, sweetmeats.). The seeds are quite warming, and consequently when they are taken in quantity over a short period they affect the head, sending up to it a vapour that is both warm and like a drug.

It has been suggested by some scholars that the classification of the cannabis plant into two kinds by Pliny and Dioscorides supports a thesis that they only used Cannabis sativa, which had little or no psychoactive resin, and that the other kinds he referred to were the more psychoactive variety Cannabis indica. However, neither Pliny, Dioscorides or Galen seem to have fully known about the psychoactive effects of any variety of cannabis. It seems more likely that the varieties of cannabis that they were acquainted with were simply those with a low THC content.

Perhaps the first reports in any European language about the psychoactive effects of cannabis was by François Rabelais (1490–1553), who had translated the Histories of Herodotus before writing the novel Gargantua and Pantagruel,(21) in which he enthuses about the usefulness of the fibre of cannabis (which he refers to as “Pantagruelion”); he also notes the “perfect jollity” induced by cannabis and some of its medical applications

The first substantial notice in a European language of the medical and psychoactive properties of the plant comes from two doctors stationed on the west coast of India.

Cristoval Acosta, from Burgos in Spain, wrote a treatise on medicine and drugs in 1578; Garcia d’Orta, from Portugal, was the first European to compile a materia medica for India, in 1563, entitled Coloquios dos simples e drogas he cousas medicinais da India, which became a major source of information for Linnaeus. d’Orta observes how his servants are reluctant to work, get hungry and laugh after eating cannabis, and how women are particularly prone to its aphrodisiac effects (22). 

Cannabis was subsequently referred to in several important botanical works, including the voluminous, twelve-volume work in Latin, Hortus Marlabaricus, which was published in Amsterdam between 1678 and 1693 by the Dutchman Hendrik Adriaan van Rheede tot Drakenstein (van Rheede), who became the Dutch Governor of Cochin in 1663 (23) In this work, cannabis is referred to as Kalengi Cansjava (24).

Cannabis continued to be known in Europe as a medical remedy throughout the medieval period (25). Robert Burton, an English clergyman, recommended cannabis for depression in his Anatomy of Melancholy, published in 1621.

Nicholas Culpepper writes in his widely-read Complete Herbal that, (26) “[Hemp] is so widely known to every good housewife in the country, that I shall not need to write any description of it.” Similarly to other physicians of the time, he records its usefulness for jaundice, earache, swelling, cough, worms, and other ailments; but he makes no mention of its inebriating properties.

Nicholas Culpepper

“It is sown in the very end of March, or beginning of April, and is ripe in August or September. It is a plant of Saturn and good for something else you see, than to make halters only. The seed of Hemp consumes wind, and by too much use thereof disperses it so much that it dries up the natural seed for procreation; yet, being boiled in milk and taken, helps such as have a hot dry cough.

The Dutch make an emulsion out of the seed, and give it with good success to those that have the jaundice, especially in the beginning of the disease, if there be no ague accompanying it, for it opens obstructions of the gall, and causes digestion of choler. The emulsion or decoction of the seed stays lasks and continual fluxes, eases the cholic, and allays the troublesome humours in the bowels, and stays bleeding at the mouth, nose, or other places, some of the leaves being fried with the blood of them that bleed, and so given them to eat.

It is held very good to kill the worms in men or beasts; and the juice dropped into the ears kills worms in them; and draws forth earwigs, or other living creatures gotten into them. The decoction of the root allays inflammations of the head, or any other parts: the herb itself, or the distilled water thereof doth the like.

The decoction of the root eases the pains of the gout, the hard humours of knots in the joints, the pains and shrinking of the sinews, and the pains of the hips. The fresh juice mixed with a little oil and butter, is good for any place that hath been burnt with fire, being thereto applied.“

The New London Dispensary, published in 1682, also includes hempseed decoctions for various ailments (27). 

The first report in English of the inebriating effects of cannabis was around the same time, by Captain Thomas Bowery, who drank bhāṅg on the west coast of India and published a short (and quite hilarious) account of his and his ten friends’ experience of it around 1680 in a Geographical Account of Countries Round the Bay of Bengal. Interestingly, Bowery notes how bhāṅg, “operates accordinge to the thoughts or fancy of the Partie that drinketh thereof.” (28)

The great scientist, architect and polymath Robert Hooke (1635–1703) obtained some cannabis in a coffee shop in London from Robert Knox, an East India Company merchant who had used bhāṅg successfully in India to cure dysentery, after he had escaped from captivity in Sri Lanka (29).

On December 18^th 1689, Hooke gave a lecture entitled “An Account of the Plant call’d Bangue” (29) to the Royal Society in London, in which he explained that the drug is used by thousands of people and that the person who introduced it to him had experimented with it many times himself. Hooke reported that the dose of powdered leaves to be eaten was about the quantity that would fill a common tobacco pipe.

He observed that: the patient understandeth not, nor remembereth any Thing that he seeeth. heareth or doth, in that Extasie but becomes, as it were, a mere Natural, being unable to speak a Word of Sense; yet he is merry, and laughs, and sings and speaks Words without any Coherence, not knowing what he saith or doth; yet he is not giddy or drunk, but walks and dances and sheweth many odd Tricks.

He did not consider it at all dangerous, giving “no Cause of Fear, ‘tho possibly there may be laughter”. Hooke (27) also observed that cannabis could: “prove as considerable a Medicine in Drugs, as any brought from the Indies; and may possibly be of considerable Use for Lunaticks, or for other Distempers of the Head and Stomach, for that it seemeth to put a Man into a Dream, or make him asleep, whilst yet he seems to be awake, but at last ends in a profound Sleep, which rectifies all…and in all probability would cure them [lunaticks]”.

In these remarks, Hooke is anticipating by around three hundred years the potential of cannabis for treating particular psychiatric disorders.

William O’Shaughnessy

Knowledge in modern Europe of the psychoactive effects of cannabis was primarily due to psychological research by French investigators, principally Moreau de Tours (1845). Two other French medical doctors, Raymond Meunier and Pascal Brotteaux also published detailed accounts of the psychological effects of cannabis inebriation, in 1909 and 1934, respectively.

Besides the investigations by French psychiatrists, the person most influential in drawing attention to both the psychoactive effects and potential medical applications of cannabis was the Irish doctor and pioneer cannabis researcher, William O’Shaughnessy, who first reported his research findings in 1839 (32).  

He observed in Bengal first-hand the well-known effects of cannabis inebriation and wrote detailed reports of its various medical applications. He brought cannabis back to England and had a cannabis tincture manufactured by Peter Squire, a well-known pharmacist of Oxford Street in London who produced “Squire’s Extract.”

From the mid-19th century until global prohibition began in 1924, medical preparations that included “Indian hemp” were widely prescribed by western doctors for a range of ailments. Between 1840 and 1900, around a hundred articles on the therapeutic applications of cannabis were published in medical journals.

We have seen how knowledge of the medicinal and psychoactive properties of cannabis had a long gestation period in Europe, stretching back two millennia to Greco-Roman times. Between 1924 and until December 2020, when cannabis was finally rescheduled by the UN as having potential medical applications, global medical research was hampered in various ways for nearly a century by legal restrictions.

In recent years great progress has been made uncovering the potential uses of cannabis for a host of ailments. The full range of the possible medical applications of “soe admirable a herbe” are finally being brought to light, with attention now being focussed on several of the hundreds of molecular components of the plant.

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Prior to the advent of modern analytical chemistry, microscopic examination of crude herbal drugs, along with gross morphological and organoleptic assessment as described above, were the primary tools used for crude herb assessment.

European and American pharmacognosists put tremendous emphasis on the ability to identify plants to species microscopically, including those that that are closely related, detect adulterations, and, in some cases, even assess relative quality. According to noted American pharmacognosist Henry Kraemer (1908):

“The microscope furnishes the surest means of determining the identity of a powdered drug at our command…the microscope also furnishes the most reliable means for detecting and determining adulterants in powdered drugs… [and] detecting the presence of worm-eaten drugs or powders of certain classes of drugs which have been exhausted in whole or in part…”

Kraemer went so far as to say that even the time of gathering, method of drying, and length of time for which a botanical had been stored could  “be judged in many instances by the use of the microscope”. Additionally, there is great sensitivity in being able to detect adulterating species.

For example, many years ago there were numerous reports of the Chinese herb stephania (Stephania tetrandra) being mixed up with a different species of plant (Aristolochia fangchi), which contains the renal toxin and potential carcinogen aristolochic acid (AA). This adulteration was responsible for from several hundred to a few thousand deaths. With microscopic examination, the addition of as little as 0.3% of Aristolochia fangchi in a stephania sample can be detected by observation of the differing oxalate crystals that occur within the species (Upton 2006).

Discerning crude drug species microscopically reached a very high level of refinement and is reflected in numerous seminal texts on the subject in the middle 19–20^th centuries, most notably Berg (1865) and Meyer (1892) of Germany; Moeller of Austria (1890); Tschirch and Oesterle of Switzerland (1900); and microscopists of the UK and US such as Sayre (1917), Mansfield (1937), Greenish (1904), Kraemer (1920), and Youngken (1930), to name a few.

With advancements and evolution of analytical chemical techniques, first with paper chromatography followed by thin-layer chromatography (TLC) and then more quantitative techniques (liquid chromatography [LC], gas chromatography [GC], and finally molecular technologies (e.g., DNA), microscopy, like morphology and sensory assessment, as a scientifically valid analytical tool was regarded as outdated in the face of these more recent techniques.

However, seldom is one analytical technique inherently superior to another. The superiority or applicability of one analytical method over another is dependent upon the desired analytical endpoint. From this perspective, microscopy is as scientifically valid of an analytical tool as any other technique and is currently enjoying a resurgence in the US where it had fallen into almost complete neglect in previous decades.

The first of the chemical assessment techniques in most pharmacopoeias, Eastern and Western, is thin layer chromatography (TLC), and more recently, high performance TLC (HPTLC), and is primarily used as an identification assay.TLC and HPTLC analysis provide a snapshot of the constituent profile of crude plant drugs and has been a standard entry in pharmacopoeias for decades.

In previous decades, TLC as an analytical technique was very crude, had a limited degree of reproducibility, was cumbersome, and not very GMP-compliant. In more recent decades, the introduction of HPTLC has addressed many of these deficiencies. As a chemical analytical tool, HPTLC is extremely versatile and sensitive for the identification of many crude herbal drugs and is especially useful for the detection of adulterations, often with a very high degree of sensitivity.

However, it must be recognized that any chemical testing is a surrogate for identification as, in contrast to identifying the actual plant material botanically, morphologically, organoleptically, or microscopically; it is the chemical profile that is being identified not the plant. Closely related species of plants may be very similar chemically.

Additionally, the constituent profile of the plant can vary dramatically across the range of commercial materials that may be traded, variations occurring due to growing, harvesting or post-harvesting conditions, age of the plant, or extracting parameters. Identification of plants chemically is therefore limited and is most accurate when coupled with appropriate physical tests. For compliance with pharmacopoeia monographs, TLC/HPTLC or other quantitative assays are conducted in tandem with the physical tests outlined above.

Critical to any chemical testing methodology of medicinal plants is to look at the suite of constituents from the perspective of chromatographic fingerprinting and not only individual markers. The concept of chromatographic fingerprinting was developed primarily by Chinese phytochemists who recognized that the activity of a Chinese herb is in its collection of compounds not just the single active constituent approach typical of modern drugs.

Numerous papers have been published on the subject and provide guidance on appropriate ways to apply modern chemistry to the analysis of traditional herbal drugs (Fan et al. 2006; Liang et al. 2004; Xie et al. 2006, among others).

A critical starting point to chromatographic fingerprinting is to obtain multiple samples of the desired botanical that is grown, harvested, and dried in a manner that is optimal for the plant part. Such criteria are traditionally determined organoleptically by evaluating the color, smell, taste, texture, relative purity, and other physical characteristics of the plant. Optimal picking times can be informed by traditional literature, such as harvesting the flowering tops of St. John’s wort on the eve of St. John’s day (June 24).

While the specificity of a single day may not be required, in most growing areas, St. John’s day reflects a harvest time when the plant is in full bloom, the traditional time to harvest most flowers; roots and barks are typically harvested in the Spring or Fall; leaves, prior to flowering before the energy of the plant goes to flower, seed, and fruit production.

In Chinese herbal medicine, specific herbs must be gathered at a specific age, such as the roots of dang gui (Angelica sinensis) at a minimum of four years of age; or Chinese ginseng (Panax ginseng) at a minimum of five years of age. Optimal harvest times can be greatly informed by chemical analysis. Specifically regarding St. John’s wort, the highest concentration of the suite of St. John’s wort constituents including flavonoids and napthodinathrones are yielded during the budding and flowering stage (during blooming), the concentrations dropping dramatically after flowering and being higher in upper leaves than lower leaves (Tsitsina 1969).

Another critical aspect in developing chromatographic fingerprinting methodologies for medicinal plants is to obtain samples of closely related and potentially adulterating species that may be inadvertently traded for the authentic material.

Having multiple species of the same appropriate quality material, ideally from multiple regions for multiple years, allows the analyst to observe the variation inherent in natural products due to changing environmental conditions. Having closely related or adulterating species helps the analyst know if the chromatographic fingerprint is robust enough to identify the authentic from substitute species.

In recent decades, chromatographic fingerprinting techniques have been coupled with chemometric programs (Mok and Chau 2006, among others). These programs are designed to store and analyze multiple datapoints from multiple samples and provide statistically relevant comparative fingerprints that allow for developing relatively objective criteria for what constitutes an acceptable chromatographic fingerprint. Ideally, such determinations should be made based on the available clinical data that establishes the efficacy of the herbal drug being analyzed; without a clinically relevant correlation, even the chemical fingerprint is only a surrogate marker of quality.

It is important to recognize that much of the basic work in developing appropriate chromatographic fingerprints is best done in academic settings and is a very expensive and time-consuming process that does not allow for the high throughput testing often required by industry. Once done in academia, such testing criteria can then be codified into pharmacopoeia as a way to promote a consistent standard.

In addition to identity tests, most Western pharmacopoeial monographs require quantitative assays, many of which will correlate directly with the pharmacopoeial definition of the botanical drug ingredient and may or may not directly correlate with activity. Quantitative assays are often lacking in Eastern pharmacopoeias (e.g., Ayurvedic Pharmacopoeia; PPRC). In most cases, quantitative assays will quantify a specific compound that is correlated with a known active constituent or class of constituents.

Other compounds assayed are considered surrogate marker compounds for activity, other chosen compounds may reflect a constituent or class of constituents that provide a baseline of “quality” based on harvest or processing practices, which may or may not correlate with activity, and yet others will reflect other measures of “quality”, such as an organoleptic bitterness value for a particular botanical such as gentian root (Gentiana spp.) or a swelling index as discussed previously regarding mucilage content of slippery elm bark or flax seed.

As noted, very seldom is a single constituent correlated with the total activity of a particular botanical. Rather, the total extract or profile of the crude drug is considered the active ingredient or substance.

This is reflected in WHO documents (WHO 1991) and acknowledged by renowned medicinal plant researchers (e.g. see Mukherhee 2011; Wagner et al. 2009; Xie et al. 2013). For example, valerian root (Valeriana officinalis) is a sedative herb used at least since the 1st century (Pickering 1879). The essential oil was long considered to represent the active fraction.

However, early pharmacological work demonstrated that the essential oil fraction was only associated with approximately 1/3 of the total activity of the extract (Gstirmer and Kind 1951). Later, research demonstrated depressant activity of the dichloromethane extract but activity could not be attributed to either the valepotriates, valerenic acid, valeranone, or the essential oil (Krieglstein and Grusla 1988).

To date, the total activity of valerian has not been fully articulated though its efficacy in reducing the time required to fall asleep and to stay asleep is supported. Today, Western pharmacopoeias require quantitation of the essential oil fraction of valerian as the primary marker of quality.

St. John’s wort (Hypericum perforatum) provides another example of a plant whose efficacy as an antidepressant has been documented over a period of more than 2000 years, but for which the pharmacological mechanisms in humans have yet to be determined (Cott 2005). Thus, quantification of a single marker or group of markers should be viewed as representing only a portion of the activity of the whole plant or extract made therefrom.

Regarding quantitative assays, varying pharmacopoeias take different approaches in determining what compound(s) are to be assayed. For example, the pharmacopoeias of Germany and the US tend towards specificity of compounds favoring relatively sophisticated quantitative technologies such as HPLC in contrast to more generic technologies such as spectrophotometry. Whereas HPLC has greater accuracy in quantifying individual compounds, spectrophotometry groups like compounds together, often resulting in higher quantitative values as compared to HPLC.

Both technologies have strengths and weaknesses. HPLC offers greater accuracy in quantitation; this is its primary advantage. If used appropriately, HPLC can also be used for purposes of identification if the total chromatographic fingerprint of the plant is considered and thus has a greater chance of detecting adulterants. Spectrophotometric techniques, in grouping like compounds, may give a more accurate representation of the totality of the plant or extract, but has the distinct disadvantage of being easily fooled by purposeful admixtures of adulterants.

In the US, there are no requirements to follow any monograph standards for herbal supplements. Analysts and botanical dietary supplement manufacturers often attempt to perform a single test for all or most identity and quality testing, often times choosing the most economically feasible assay, but not always the most appropriate.

Such testing may or may not provide scientifically valid results for the desired analytical endpoint. In the EU, where there is a legal requirement to follow all aspects of the European Pharmacopoeia monographs, there appears to be a greater use of spectrophotometric methods, which are only employed after appropriate identity of the botanical ingredient has been confirmed. In the USP, there appears to be greater utilization of specific methods, requiring multiple analytes, greater time, and greater expense.

Another limitation of current pharmacopoeial works include the fact that many perceived independent standards are based on single proprietary products. In such cases, a sponsor submits analytical data, often of a proprietary extract, and the characterization of that proprietary extract becomes the standard for the botanical generically, but may not be widely applicable to generic products creating a false sense of independent verification.

However, also codification of a commercial proprietary product as a generic standard may provide an unfair advantage to the submitting manufacturer as all competitors then must either submit their own data for consideration of revision of the monograph (a lengthy process) or be encouraged to follow the standards of the their competitor, which they may not be able to do due to the proprietary nature of the original extract used. This is more of an issue in countries where the process is driven more by commercialism than science.

Some Chinese researchers propose a tiered approach to traditional Chinese herbal drug quality control development, recommending “elementary, intensive, and advanced” levels of testing. The “elementary” level reflects current standard requirements of pharmacopoeias that focus on basic identity, qualitative tests, and analysis of a single marker compound.

The “intensive” level includes multiple component analysis, including differentiation between “high” and “low” quality materials based on quantitative assays of a particular compound(s).

The “advanced” level proposes that the multiple component herbal medicine be subjected to formal pharmacological study but acknowledges the inherent lack of Western pharmacological models for assessing traditional Chinese actions of herbs such as to “expel wind” and “nourish kidney” (Xie and Li 2007).

Similarly, it has been proposed that the comparison of a crude herbal drug to a properly made well characterized extract is a more appropriate way to assess the quality of a Chinese herbal drug than to simply assay a single constituent (Xie et al. 2013). While these represent more appropriate ways to ensure the integrity of multi-component ingredients and formulas than the typical Western pharmacopoeial approach, they continue to depend on chemical analysis versus traditional herbal assessment skills and therefore, do not take into consideration the full suite of traditional assessment techniques.

Botanical identification

Botanical identification remains the primary technique for the identification of plants worldwide. While chemotaxonomy and DNA analysis have made great strides in altering the classifications of traditional taxonomy, neither technology has supplanted botany as the primary means of identifying medicinal plants. However, in virtually all official pharmacopoeias, botanical identification is not included as a required test with which to conform. The reason for this is that oftentimes the botanically unique characters of a specific plant are not intact in the crude plant drug.

Historically, different species of a specific genus of plant, and sometimes, different genera of plant, were used as a specific botanical drug. Rather than being referred to by its generic and specific name e.g., Salix purpurea, medicinal plants were described according to their Galenic names e.g., Cortex salicis, the Galenic name referring to the bark of varieties of willow that were historically used interchangeably without differentiation of species.

Such a practice is represented in most pharmacopoeias but is increasingly moving towards greater speciation. For example, in the European Pharmacopoeia, the bark of several species of Salix is allowed as long as the barks conform to the identity tests given and possess a minimum quantity of salicin (1.5%), the primary putative active constituent, and precursor to the development of acetyl salicylic acid (aspirin).

Conversely, in the US, where herbs are predominantly traded as ‘dietary supplements’ not ‘medicines’, for purposes of supplement labeling, the names of botanical ingredients must conform to Herbs of Commerce of the American Herbal Products Association (AHPA). The current edition of this text, rather than recommending use of Galenic or more common names (e.g. “willow bark”), mostly requires speciation such as crack willow (Salix fragilis), purple willow (Salix purpurea), white willow (Salix alba), etc.

Unfortunately, while conformity to the identification tests of pharmacopoeias for these barks can be assured, most of these barks cannot be identified to species when in their crude form as they are morphologically, organoleptically, chemically, and medicinally very similar, the very reason why the multiple species are used interchangeably. Thus, greater levels of specificity are often required for either academic or arbitrary regulatory reasons creating unnecessary impediments, to continued use of traditional herbal medicines.

Daodi (region specificity)

Daodi is a philosophy that is exclusively applied to the development of medicinal substances. Dao is an ancient Chinese unit of measure, which became applied to the development of districts. Di means earth or land and is applied to specific geographical regions.

According to Zhao et al. (2012), daodi medicinal materials are generally defined as medicinal materials produced in specific geographic regions under natural ecological and environmental conditions that are optimum for the growing of the plant, with particular attention to cultivation, harvesting, and processing techniques.

Daodi lead to quality and clinical effects that are considered to surpass those of the same botanical produced in a different region. The concept of daodi was used by early Chinese herbalists and codified by Sun Simiao in his Qian Jin Yi Fang (Supplement to the Formulas of a Thousand Gold Worth). According to Sun:

“When ancient doctors used medicinals they depended on the earth, therefore when the treated ten people they achieved results in nine. Although contemporary doctors understand the pulse and prescriptions, they discard the timing for harvesting medicinals. They are not familiar with the originating land or the freshness, aged nature, emptiness or fullness; therefore they only achieve results in five or six cases out of ten.”

Sun’s teachings underscore the importance of daodi, organoleptic assessment, and a quality control system that integrates the proper harvest time and source of the originating plant material. Furthermore, in the Ben Cao Pin Hui Jing Yao (Essentials of Chinese Materia Medica) of China’s Liu Wentai (1488–1505), specific attention was given to medicinal plant development that encompassed the sprouting of the plant, the land on which it was grown, the timing of planting and harvest, and potential substitutes.

Thus, prior to the development of formalized good manufacturing practices and prior to the adherence to mandatory pharmacopoeial standards, Chinese physicians recognized the need for strict adherence to quality control in ways that ensured the quality of the medicinal plant from the field to the medicine long before the advent of chemical analytical techniques. This care is reflected in the many grades of herbs that can be observed in any Chinese herbal pharmacy today.

Such principles reflect common sense in ensuring the quality of herbal drugs. Similar principles are being applied internationally and in a myriad of Good Agriculture and Collection Practices (GACP) developed by varying national and international bodies. The People’s Republic of China (PPRC) is perhaps most active in establishing good agricultural practices (GAP) for medicinal herbs and integrating them in medicinal plant production.

Similar to Sun’s observation in the Tang Dynasty, modern herbal practitioners are often not aware of the quality control needs of herbal medicines, and rather rely on industry to produce quality medicines, when much of the industry lacks the skills necessary to do so.

Daodi is an important concept to include in the development and selection of herbal medicines and there may be wisdom in codifying such principles in modern pharmacopoeias. According to Zhao et al. (2012), among the 500 most commonly used Chinese medicinal materials, approximately 200 are recognized as having daodi medicinal material specifications.

These 200 medicinal materials account for 80% of the total consumption of medicinal materials in China, making daodi a very important concept in modern herbal medicine GMPs. Today, the source and manner in which the botanical was grown and harvested is seldom considered by industry and regulators.

Molecular identification

In animals, a single barcoding region from the mitochondrial cytochrome c oxidase-1 gene can identify most species. In plants, no single barcoding region has been identified with sufficient resolution to identify most species, therefore a combination of at least two regions (barcodes) is required and use of other techniques in tandem provide greater levels of accuracy. Molecular techniques of medicinal plant identification are not currently included in most pharmacopoeia but some attempts have been made to consider their inclusion.

Like all analytical technologies, molecular analysis has strengths and weaknesses in crude plant identification. First and foremost it is solely a identification tool.

Whereas most all other methods provide both identity and quality assessments, molecular techniques is only for species identification. Among the technique’s strengths are its great sensitivity.

If the unique identifying primers for the particular target species has been appropriately developed, and the technique used is robust enough to filter DNA from non-target organisms (e.g., other plants, non-target plant parts, etc.), then it is an exceptionally powerful tool for identifying plant material to species and beyond, including the same species that have different genetic lineage, such as wild American ginseng (Panax quinquefolium) grown in Kentucky, versus the same species from cultivated root stock in Wisconsin, versus that grown in Canada.

A second advantage of molecular techniques is in detecting admixtures with other species with great sensitivity. A logistical advantage of the technique is that it uses very small amounts of material for analysis.

Among its weaknesses is also the technique’s great sensitivity. Molecular techniques have the ability to detect the presence of trace of insignificant amounts of non-target species, such as rice and pollen or a blade of grass, the results of which can be interpreted as ‘contamination’. In other cases, genetic material of a non-target species can be preferentially amplified over the genetic material of the target species, that can be inaccurately interpreted as an ‘adulteration’.

A significant disadvantage is its inability to discern different plant parts, a requirement of all medicinal plant GMPs. As with chemical analysis, DNA analysis will not detect the presence of non-organic contaminants that are readily detected organoleptically or microscopically.

Perhaps the greatest strength of genetic testing is in forensic analyses of plant material that is difficult to identify with standard testing methodologies or to detect the presence of difficult to find adulterations and contaminations.

Perhaps its greatest weakness, unlike virtually all other standard techniques from sensory assessment to chemistry, is its inability to offer any meaningful data regarding quality. It is purely an identification tool that is limited in its ability to discern plant parts, that works best in intact plant material, where most other techniques provide data points for both identification and quality of a crude plant or extract.

However, its utility in routine quality control is limited as was poignantly highlighted by researchers in Australia who applied various methods of genetic barcoding to various stages of the manufacture of medicinal plant products. The researchers attempted to determine if DNA barcoding was a useful routine test for the quality control of botanicals and genetically analyzed the ingredients throughout the manufacturing process from gathering of botanical vouchers to drying, to pulverizing, to extracting, to preparation of the finished product.

Even for vouchered specimens, a high of only 40% of specimens were able to be identified with DNA using one set of markers and a low of about 18% with another set of markers, determining that substantial degradation of DNA occurred in properly dried materials.

Early pharmacopoeias (e.g., Pharmacopoeia Augustana 1601; Pharmacopoeia Londinensis 1618) were predominantly books of recipes for extracts, syrups, and oils and provided guidance for relative standardization of medicinal preparations, many of which were Galenical, relatively crudely extracted, herbal preparations.

Over time, pharmacopoeias (e.g., British Pharmacopoeia 1864) introduced standards of identity and quality for individual herbal medicines. Many of these reflected relative generality, sometimes not specifying plant species (e.g., acacia) but notably included information regarding the identifying morphological characters, origin, collection practices, and drying conditions of the drug material, clearly the primary considerations of early herbalists and plant collectors.

Another early pharmacopoeia, the Dispensatorium Lippiacum (Scherf 1792) introduced organoleptic characterizations and the use of magnifiers as part of the assessment criteria for plant medicines. Interestingly, the Dispensatorium Lippiacum was described as “predominantly addressing handcraft savvy pharmacists in small towns” (Friedrich no year), a description that could readily be applied to numerous traditional herbal extract (tincture) manufacturers in the US today.

In addition to being predominantly recipe books of relatively crude herbal preparations, some of the earliest of formal pharmacopoeias (e.g., Augsberg Pharmacopoea 1613), attempted to resist the ever-growing movement to use Paracelsun “chemical” medicines. According to history of pharmacy scholar George Urdang (1882–1960), in a decree of the Augsburg Senate in 1582, the apothecaries (druggists) were “admonished” not to prepare or offer for sale “substances which are known to be detrimental or poisonous, such as Labdanum minerale, the so-called antimony, also Turpethum minerale and other purging mecurials.”

Many of the precepts of the Paracelsun use of powerfully acting drugs, were in direct opposition to the empirical lineages of Galenists and Hippocratists. However, soon after, in 1589, the London College of Physicians proposed that the chemicals, salts, extracts, and metals of Paracelsus be included in the London Pharmacopoeia. This was eventually realized in 1618 with the inclusion of calomel (mercury chloride) among the medications for internal use.

While the juxtaposition of Paracelsun ideologies and those of the Galenists where in great part an attempt of the Paracelsuns to not blindly follow the empirical philosophies of the ancients, and were very much attempting to apply scientific experimentation in medicine, Galenists were alarmed at what they saw as the introduction of highly poisonous substances that had no basis of safety or efficacy into medical practice. As noted, this trend laid the groundwork for modern drug development that predominates today.

Another development marking the distinction between traditional and modern drugs was the introduction of chemical testing methods into pharmacopoeial monographs. Prior to analytical chemistry, the focus of pharmacopoeias and materia medicas was on morphology as the primary identity test and proper harvesting conditions and organoleptic characters as the primary criteria by which herb quality was assessed.

The Pharmacopoea Wirttembergica (1741) was the first pharmacopoeia to introduce chemical testing of drugs, a trend that continued as analytical chemistry advanced and chemically characterized drugs became dominant. Whereas the earliest pharmacopoeias and materia medicas reflected a relatively herbal-botanical approach to the assessment of herbal medicines, later Western pharmacopoeias, persisting to the current day, deferred to chemistry.

Pharmacopoeias codify the standards of identity, purity, quality, and testing for herbal drugs, traditional and modern. Generally speaking, if a pharmacopoeia does not provide a monograph for a specific drug then the drug cannot be traded commercially.

However, in herb-friendly societies, such restrictions do not apply. Most pharmacopoeias worldwide are relatively consistent in the fields of information they provide. The primary principle of pharmacopoeial monographs is to ensure the proper identity of the herbal ingredient to be used in a drug and develop minimal standards of quality and purity, so that when a pharmacopoeial-grade drug ingredient is used it will deliver the intended activity.

Some of these pharmacopoeial monograph standards are consistent with herbal assessment practices employed by traditional herbalists. Others are a result of the ever modernization of herbal medicines including the requirement for chemical testing that often overshadows traditional assessment techniques as discussed below.

Most pharmacopoeias lack information that is essential to procuring a high quality herbal medicine and rather create a minimum standard of acceptance. This influences many product manufacturers to produce products that meet a minimal quality standard rather than an optimal quality standard.

For example, the North American botanical goldenseal root (Hydrastis canadensis) contains from 2.5% to 6% of berberine alkaloids. Most pharmacopoeial standards (e.g. AHP, USP) formally require for the botanical to contain not less than 2.5% berberine alkaloids, the lowest amount the plant contains. In contrast, a traditional herbalist attempts to determine optimal harvest times in order to prepare an optimal medicine.

In most all cases, the interface between the medical practitioner, the classical botanical pharmacognosist, and the resultant pharmacopoeial standard has been largely lost creating a significant disassociation between the manufacture and practice of medicine, a connection that traditionally was much more integrated.

Approximately 74% of countries do not have their own pharmacopoeias. Of these countries lacking their own pharmacopoeia, approximately 56% utilize the monographs of the European Pharmacopoeia (EP) or United States Pharmacopeia (USP); approximately 30% utilize no pharmacopoeia; and, perhaps most telling, 78% of countries do not include herbal medicines in their national drug lists (WHO 2005).

In both developed and developing nations, unless provisions for access to non-official plant drugs are in place, or at the very least not restricted, availability to traditional herbal drugs can be impeded, a situation currently in place in the US where there is no regulatory allowance of traditional herbal medicines.

The following fields of information are contained in the majority of pharmacopoeial monographs worldwide. Different pharmacopoeias give greater or lesser emphasis to certain fields of information over others. Compliance with all aspects of the monograph in developed countries, most represented by the pharmacopoeias of China, the European Union, Iran, and the United States, is required, a requirement that contains redundancy and, in some cases, unnecessary testing, all of which drives the cost of traditional herbal medicines up.

Pharmacopoeial definition

Most monographs begin by defining the medicinal substance. This definition establishes the identity of the material being used and oftentimes, the minimum quality of the ingredient to be used, usually determined by the presence of a specific quantity of a chemical compound as noted in Table 3.

The pharmacopoeial definition is often the first body of information that establishes that a chemical test is required for acceptance of the herbal drug. Chemical testing is especially relevant when most of the activity of the botanical can be assigned to a specific constituent, when there is a narrow therapeutic to safety window of the drug, or when the medicinal qualities of the plant cannot be discerned through sensory analysis.

Generally speaking, and specifically regarding relatively safe herbal drugs, chemical testing has great value as a complement to organoleptic assessment. Chemical assessment is most critical for the more toxic of herbal medicines that possess a narrow therapeutic window.

However, analytical chemistry does not take the place of ensuring optimal times of harvest and proper drying, processing, and storage conditions. Chemistry can more fully inform these practices, but in itself is not sufficient to render analytical techniques such as botany, microscopy, and sensory evaluation obsolete or inferior to other techniques (see Macroscopic and Sensory [Organoleptic] Evaluation below).

Pharmacopoeia	Definition
European Pharmacopoeia (EP)	Whole or cut, dried flowering tops of Hypericum perforatum L., harvested during flowering time. Content: minimum 0.08 per cent of total hypericins, expressed as hypericin (C30 H16 O8; Mr  504.4) (dried drug).
United States Pharmacopoeia (USP)	St. John’s Wort consists of the dried flowering tops or aerial parts of Hypericum perforatum Linne´ (Fam. Hypericaceae), gathered shortly before or during flowering. It contains not less than 0.04 percent of the combined total of hypericin (C30H16O8) and pseudohypericin (C30H16O9) and not less than 0.6 percent of hyperforin (C35H52O4).

Macroscopic and sensory (organoleptic) evaluation

All pharmacopoeia monographs include a morphological description of the plant drug under various descriptive headings such as: Identification in the European Pharmacopoeia; Botanic characteristics in the USP; and Description in the Ayurvedic Pharmacopoeia of India and Pharmacopoeia of the People’s Republic of China.

These sections primarily give the relative form, size, shape, and physical features of the crude plant drug. These were the primary criteria used by traditional herbalists and early pharmacognosists in discerning the authenticity of the plant drug material. Great emphasis was similarly placed on plant morphology in the numerous pharmacognosy works of the 19^th and early 20^th centuries (e.g., Flückiger and Tschirch in 1887; Mansfield 1926; Sayre 1917; etc.).

Detailed instruction was provided in how an appropriate macroscopic/morphological assessment was to be performed on various plant parts. Today there is a plethora of references (e.g; Applequist 2006; Leon and Lin 2018; Pfaender 1991; Wichtl 2004; Zhao 2009; 2014) on the morphological assessment of crude plant drugs that provide a scientifically valid means for identifying a large number of medicinal plants to determine conformity with pharmacopoeial identification specifications.

Organoleptic assessment was, historically, and among herbalists today, the most important suite of characters for determining the relative quality of a crude plant drug. Organoleptic evaluation of plant material includes an assessment of the flavor, aroma, texture, and sensation experienced by the assessor and requires a specialized skill set akin to those required by food scientists and sommeliers, but to a much lesser degree. From a botanical medicine sense, flavor is broadened to include the sensation of texture and mouth feel.

Flavor arises when chemicals in foods (and herbs) react chemically with receptors on taste buds (gustatory calyculi) on the tongue, mouth, and throat. The tongue is covered with 2000–5000 taste buds, each one containing 50–100 taste receptor cells. In modern food sensory evaluation, five basic flavors are recognized: sweet, sour, salty, bitter, and umami.

This latter umami flavor was defined by the Japanese to describe the “savory” flavor of the commonly used food flavoring monosodium glutamate (MSG). There are relatively few herbs that possess this flavor and so its relevance to organoleptic assessment of botanicals is limited. More relevant are the flavors recognized in traditional herbal medicine systems, namely, sweet, sour, bitter, salty, pungent, and in Ayurveda, astringent, which is more accurately a mouth feel, but never-the-less, regarded as a flavor for purposes of describing herbal actions.

From an evolutionarily perspective, flavors are either aversive or desirable and inform human decisions about what and what not to eat. At a very basic level, the sweet flavor typically identifies high-energy foods; strongly bitter and or strongly acrid flavors are undesirous and may indicate a poison.

Flavors contribute part of the sensation of foods, and are complemented by aroma detected by olfactory epithelium receptors, texture detected mechanically such as through nerves in muscles, temperature through thermoreceptors, and sensations of coolness (peppermint leaves or oil), heat (cayenne, black pepper), and pungency (cloves, ginger root) through chemical sensations detected by skin and mucous membranes (chemesthesis), all of which are referred to by some as the “nature” of the herb.

In some cases, the flavors directly correspond to medicinally active constituents as established in western science, such as menthol from peppermint; capsaicin and piperine from cayenne and black pepper, respectively; and eugenol and gingerol from cloves and ginger root, respectively. Medicinally, menthol is an active constituent in topical analgesics. Menthol triggers cold-sensitive TRPM8 receptors in the skin.

It is through this mechanism that the familiar cooling sensation when inhaled, ingested, or applied topically is experienced (Eccles 1964), while menthol’s analgesic properties are mediated through a selective activation of κ-opioid receptors (Galeottia et al. 2002).

• The yellow color and bitter taste of the Chinese herb huang lian (Coptis spp.) (Zhao and Chen 2014) and the North American goldenseal root (Hydrastis canadensis) is correlated with berberine content, the herbs’ putative primary active constituent
• The mucilaginous content of herbs such as slippery elm (Ulmus fulva), flax seed (Linum usitatissimum), and psyllium seed (Plantago ovata), as determined by the swelling index included in most pharmacopoeias, is correlated with the soothing and moistening nature of the herbs
• The bitter flavor of Ganoderma species is correlated with immuno-modulating triterpenes (Kubota et al. 1982; Nishitoba et al. 1989)
• The numbing effect of Echinacea angustifolia root experienced when chewed is correlated with isobutylamides, which are among the most biologically and pharmacokinetically relevant of echinacea constituents (Woelkart et al. 2005).

These are only a few examples where there is a clear association between herbal flavors, known active constituents, and pharmacological effects.

Prior to the advent of chemistry, traditional herbal systems developed a very sophisticated system of sensory assessment that formed the didactic basis for understanding the pharmacology of the herbs. These systems also linked sensory qualities found in nature with sensory qualities of pathology and health (hot, cold, moist, dry, etc.), and then correlated those with the sensory quality of plant drugs.

On a philosophical level, Chinese medicine assigns the five specific flavors identified in that system to five organ complexes, respectively; bitter to the heart; sweet-spleen/pancreas; pungent-lungs; salty-kidneys; sour-liver.

Each taste is considered to have specific attributes such as bitter substances are draining and drying; salty substances soften and attract moistness; sweet substances nourish; pungent substances disperse; and sour substances astringe.

Chemically, bitter substances often correspond to alkaloids and certain triterpenes; sweet substances to carbohydrates and complex sugars (e.g. polysaccharides); pungency to volatile oils; salty substances to mineral salts; and sour to flavonoids and plant acids. While these basic flavor-chemistry correspondences are simplistic and not specific to disease complexes from a Western medical approach, they form the basis of pharmacology that is completely unified in the diagnostic system of Ayurvedic and Chinese medicine.

While herbalists historically did not specifically know what compounds were correlated with what activity, they recognized that it was the whole herb and the predominant nature of the herb that was considered active and that the quality of the herbal drug was discerned, and often directly correlated, to its sensory characteristics. These relationships were then either proven or disproven through experience and refined over centuries.

In Ayurveda and TCM, this system of sensory relationship between nature, humans, and medicines, is still actively applied by almost all herbal practitioners and has been integrated somewhat by some western herbalists. It is this very system that uniquely correlates qualities of nature, with qualities possessed in plants, with qualities reflected in anatomy, physiology, and pathology, creating a unified system based on natural principles of human health that is, itself, a microcosm of nature and is the traditional antecedent to individualized medicine.

This is yet another stark differentiator between traditional and modern systems whose diagnostic systems seldom look at the nature of the person but rather defer the understanding of human health and pathology to machines that generate often arbitrary values that reflect symptomatic changes in a statistical norm but says little about the individualistic needs of the human being.

This is one of the very reasons why there is a rapid and increased recognition of traditional herbal systems worldwide. It is not a fad, but a universal need to restore humanistic values to human health. The relationship with the plant itself is reflected in numerous herbal traditions as follows:

“The crude drug is the foundation of the pharmaceutical preparation… the [pharmacognosist] must be able to judge of the intrinsic qualities of drugs. This last is the most important part of the art of pharmacognosy, for while it is easy to learn to identify different drugs it is difficult to obtain the experience necessary to judge of quality shades….The study of crude drugs is most important.” – John Uri Lloyd (1849-1936)

 “Visual inspection provides the simplest and quickest means by which to establish identity, purity and, possibly, quality. If a sample is found to be significantly different, in terms of color, consistency, odor or taste, from the specifications, it is considered as not fulfilling in the requirements.” – WHO (1998)

“The way of using herbs, there is one way, there is no other. That is to master the herb’s nature and flavor, and to understand its yin and yang. Only with this understanding, even if the herbs are many, can you achieve desired results.” – Zhang Jingyue (1563–1640) Jingyue Quanshu (Complete Works of Jingyue)

A number of examples of traditional herbal medicines illustrate their value based on modern research supporting historical indications, despite a lack of understanding of the pharmacological mechanisms associated with the activity. St. John’s wort (Hypericum perforatum) is one of the most ancient of herbal remedies in Western civilization and continues to be used today in much the same ways as in ancient times. Dioscorides wrote: a decoction of the fruit (taken as a drink with a pint of honey water) is available for sciatica. It expels much bilious excrement… Smeared on, it is good for burns (Osbaldeston and Wood 2000).

Today, St. John’s wort is routinely used topically by modern medical herbalists for burns, scrapes, and neuralgic pain and internally for the treatment of depression, all traditional uses that are scientifically supported (Upton et al. 1997).

While St. John’s wort was introduced into modern Western medical practice by homeopaths, who regarded it as “arnica for the nerves”, a dictum attributed to Paracelsus (Jones 1880) and arnica being a highly regarded healing agent for tissue damage, St. John’s wort became widely accepted by non-homeopaths. St. John’s wort has historically been one of the most relied-upon botanicals for the treatment of wounds. Part of this activity is due to Hypericum’s antimicrobial activity, which modern research attributes to the essential oil, phloroglucinols, and flavonoids.

In a relatively modern study, a St. John’s wort oil, one of the oldest of Galenical St. John’s wort preparations, was shown to facilitate the healing of second and third degree burns (Saljic 1975) and successfully treat infection with Staphylococcus aureus (Negrash and Pochinok 1972) to a degree greater than standard treatment with sulfonilamide (Aizenman 1969). In another study of St. John’s wort, a tincture (1:10) of the herb was studied for its wound-healing properties and compared with calendula, another widely used vulnerary.

The effect of orally administered tincture of St. John’s wort was greater than topical application of Calendula tincture in the healing of incision, excision, and dead space wounds as evidenced by an increase in epithelization and wound-breaking strength (Rao et al. 1991). Another randomized, double blind, placebo-controlled clinical trial demonstrated efficacy for St. John’s wort to facilitate the healing of wounds in women who had undergone Cesarean section.

Significant reductions were observed in scarring, pain, and pruritus (Samadi et al. 2010). In recognition of the ancient use of St. John’s wort as a healing balm, St. John’s wort oil was listed in the Pharmacopoeia Augustana (1612) and in the first Pharmacopoeia Londinensis (1618).

Gerard (1633) wrote that St. John’s wort’s use as a balm for wounds, burns, ulcers and bites was without equal, stating; “for I dare undertake to cure any such Wound as absolutely in each respect, if not sooner and better, as any Man whatsoever shall or may with Natural Balsam”. Linnaeus (1749) in his Materia Medica reported on the use of the flowers and herb of St. John’s wort (Hypericum vulgare) to stop bleeding of the lungs and urinary tract and as a anthelmentic. In total, there are approximately 2000 years of empirical medical observation of the efficacy of St. John’s wort as a vulnerary (wound healing agent) and modern research to support this use.

Today, in much of Europe and the US, St. John’s wort is heavily marketed by phytopharmaceutical companies for depression and “improving mental health”. The Latin name Hypericum was derived from the earlier Greek eikon as recorded in the second century BCE by Nikander (Alexipharmaca V, line 603) and then later by the noted Greek physician Euryphon (upereikon; 5^th century BCE) as yperikon, which meant “over an apparition”(Hobbs 1990; Robson 2003).

Paracelsus also recommended St. John’s wort for “phantasmata”, which referred to psychoses and hallucinations, and for “healing of the soul”. In early times, depression was undoubtedly considered a form of possession, and from a humanistic perspective versus medical diagnostic perspective, depression can very much be described as a “disease of the soul”.

In more modern times, formal clinical trials including meta-analyses, demonstrate St. John’s wort’s efficacy in the treatment of mild to moderate depression (Andreescu et al. 2008; Linde et al. 1996; 2008). In one of a few trials in which significant benefit was not demonstrated with either St. John’s wort or the approved anti-depressant imipramine, the herb performed better than the pharmaceutical both in patient outcome and side effect profile (Davidson 2002).

Thus, even in a study where the herb presumably was not statistically significantly better than placebo, it never the less showed great efficacy than a formally approved pharmaceutical agent. More importantly, there are 1900 years of empirical experience of the use of St. John’s wort and more than 20 years of clinical data, including positive meta-analyses demonstrating efficacy for depression.

Ayurvedic medicine provides us with a particularly poignant example of a traditional herbal drug that has similarly stood the test of time and modern research—the three-fruit combination triphala. Triphala was first written about and used extensively more than 1000 years ago in the seminal text of Ayurveda the Caraka Samhita (~100 BCE).

This formula is a mainstay of the practice of virtually every modern Ayurvedic practitioner today and, for many, it is the first therapy given before any others can be considered effective. Additionally, triphala is regarded as a rasayana, a rejuvenative tonifier used to preserve life (Ponnusankar et al. 2011).

Much of the modern research of the individual herbs in triphala, as well as the combination itself, focuses on cytoprotective, immunomodulating, and antioxidant activity (Jagetia et al. 2004; Naik et al. 2005; Sairam et al. 2002; Srikumar et al. 2005), three pharmacological actions that can be considered to be associated with preserving life.

A last example is provided by a classic Chinese herbal formula known as si wu tang (four substance decoction). The formula was first written about in the Tai Ping Hui Min He Ji Ju Fang (Imperial Grace Formulary of the Tai Ping Era) between 1078–1085 CE. The formula was originally described for its use in menstruation, among other indications.

Regarding menstrual difficulties, Western conventional medicine has few therapeutic options regarding gynecological health and fewer good therapeutic options. In 2003 in the US alone, there were approximately 602,457 hysterectomies performed, 538,722 (~89%) of which were for benign conditions (Wu et al. 2003). Some studies show that many hysterectomies are deemed unnecessary by second opinion or when alternative treatments are offered (BMJ 2014; Tan 2014).

Some experts suggest that up to 90% of hysterectomies are not medically necessary (NWHN 2014). Hysterectomy rates differ between countries, ranging from a high of 5.4 per 1000 women in the US (Farquahr and Steiner 2002); intermediate rates of 3.7 per 1000 in Italy (Materia et al. 2002); and a low of 1.2 per 1000 in Norway (Mepherson et al. 2002). The conditions for which hysterectomies, which are often accompanied by removal of the ovaries as prophylaxis against ovarian cancer (oophorectomy), are performed are predominantly to relieve symptoms of difficult menstruation that generally do not threaten lives.

Current scientific evidence suggests that elective oophorectomy is not advisable for the majority of women as it may lead to a higher risk of death from cardiovascular disease and hip fracture and a higher incidence of dementia and Parkinson’s disease (Rocca et al. 2009). Recently, it has been concluded that preserving ovaries until at least the age of 65 years was associated with higher survival rates.

Conversely, women who had a bilateral oophorectomy had a higher incidence of risk of all-cause death, fatal and nonfatal coronary heart disease, stroke, and lung cancer. Markedly, none of the groups in which oophorectomies were performed showed any correlation with increased survival (Parker et al. 2009) suggesting that alternatives, such as those offered with botanical medicines, such as si wu tang, offer a completely different therapeutic strategy with tremendous potential for reduction of harm and benefit.

And, each of these examples offers clear evidence regarding the lack of evidence of some of the most common of medical procedures, despite Western’s medicine belief of adhering to principles of ‘evidence-based medicine’, even when these procedures cause irreparable harm or are ineffective.

While the botanical medicines discussed provide only a select view of the breadth of herbal medicines used worldwide and that have been supported by scientific study, the list can easily be multiplied by hundreds. More importantly, a review of the scientific literature reveals relatively few new discoveries regarding the uses of herbal medicine. Rather, studies mostly support the medical uses of the herbs that were known historically.

For example, of all the plant-derived products currently available as prescription products, 72% are used in a manner, which parallels their ethnomedical use.

Similarly, bioprospecting in the traditional herbal medical literature for potentially medicinal compounds has been demonstrated to yield more positive findings than random screening (Cordell and Colvard 2005; Tempesta and King 1994). Moreover, noted medicinal plant researcher Geoffrey Cordell (2002), underscores the need for humans to pay close attention to the preservation and investigation of traditional knowledge and natural resources that provide traditional and modern medicines for future generations, a message that should be taken to heart.

Historically there were two primary arms to the study of traditional herbal healing modalities; therapeutics and materia medica. Therapeutics provides the theoretical framework by which health and disease is understood, the second the medicinal agents used, materia medica. Therapeutics provide the diagnostic principles that form the basis for which materia medica is to be applied.

Today, the majority of herbal medicines are researched in a way that takes little or no consideration into the therapeutic framework in which herbal medicines should be used. Rather, individual herbs (relatively rarely, formulas) are investigated from a western pharmacological perspective for Western disease endpoints, completely removed from any cultural diagnostic context, such as of Ayurveda or TCM.

The primary reason that Chinese medicine offers potentially effective treatments for functional gynecological problems, as discussed above, is due to the theoretical basis of understanding the physiology and pathology of the gynecological system.

In Western medicine there is little understanding of the cause of functional gynecological imbalances. There are metrics with regards to identifying hormonal imbalances, growths, and abnormalities, but little to no understanding of the cause (see Goodman and Gilman).

Conversely, Chinese medicine offers unique perspectives on promoting the health of the gynecological system through a myriad of theories of the causative factors of gynecological imbalances that correspond directly to therapies to address those imbalances.

Whereas Western medicine offers hormonal replacement therapy (HRT) that itself increases mortality, along with palliative medications, surgery, and ablation therapies, TCM offers a host of therapies that include dietetics, baths, exercise, moxabustion, acupuncture, and a myriad of diverse herbal prescriptions, such as si wu tang, some of which have been in continued use for several hundred years.

Many of these therapies have been demonstrated to have high rates of efficacy relative to controls for a wide range of gynecological imbalances including infertility, endometriosis, polycystic ovarian syndrome, dysmenorrhea, and pelvic inflammation, to name only a few (Jue and Fan 2009; Robinson and Wiczyk 2011, among others).

Whether we consider evidence from cuneiform medical recipes from 3400 BCE, the birch fungus in the pouch of the Neolithic Oetzi the Iceman (circa 3300 BCE), or the writings of the 1^st century physician-herbalist Dioscorides, whose writings remained the medical authority for more than 16 centuries, it is clear that medicinal plants have been the primary medicinal agents used throughout human history. The WHO has a long history of promoting the responsible use of herbal medicines worldwide.

As a non-regulatory body, WHO is in a unique position to offer relatively unbiased guidance for how herbal medicines should be integrated into health care systems, both at the community and national levels, with the express purpose of what is in the best interest of the communities. This is a distinctly different position than national regulatory authorities, which have a myriad of social and economic biases that drive national health care policy.

First and foremost, it is important to recognize that healing is a reflection of cultural belief whether that belief is based in indigenous traditions or modern paradigms. Therefore, the true integration of traditional healing practices, including the use of traditional herbal medicines, must be considered from the perspective of how traditional- and technologically-oriented healing systems differ, as discussed above.

Encompassed in traditional medicine are those practices that are based on indigenous theories, beliefs, and experiences that are passed from generation to generation. These traditions reflect well-established and nationally accepted systems of medicine such as Ayurveda and TCM, as well as more localized practices and philosophies of healing by minority communities such as Native American, South American, and indigenous aboriginal healers in Australia, to name only a few.

In contrast, ‘modern’ or ‘conventional’ medicine is reflected in the concept of Western ‘allopathic’ medicine, a term ironically coined by the founder of homeopathy Samuel Hahnemann (1755–1843), and as generally applied to modern technologically oriented (Western) healing practices.

Traditional herbal medicines are more generally and specifically defined within WHO documents and are categorized into four main groups as follows (WHO 2004):

• Category 1: Indigenous herbal medicines: These medicines are used by local communities indigenous to a specific region and within a framework of cultural knowledge that may or may not be accessible to those outside of the community. WHO recommends that these medicines be allowed to be used freely by the communities. However, WHO stipulates, rightfully or wrongfully, that if these medicines enter the dominant market or go beyond the community boundaries, then those medicines must meet safety and efficacy requirements established in national regulation.
• Category 2: Herbal medicines in systems: These medicines have a long history of use within a formalized system of medicine that are accepted by the country(s), for example, traditional Ayurveda, Chinese medicine, Unani-Tibb.
• Category 3: Modified herbal medicines: These are medicines used in the above-mentioned categories but have been modified in some way that is no longer completely consistent with traditional systems. WHO contends these medicines should comply with national regulatory standards for safety and efficacy.
• Category 4: Imported products with a herbal medicine base: These medicines represent imported raw materials or finished products that are registered for use in the country of origin. Again, WHO contends that these products have to meet the safety and efficacy requirements of the recipient country.

WHO more specifically defines herbal medicines as follows:

“For the purpose of these guidelines, the Consultation agreed that Herbal Medicines should be regarded as: Finished, labeled medicinal products that contain as active ingredients aerial or underground parts of plants, or other plant material, or combination thereof, whether in the crude state or as plant preparations.

Plant material also includes juices, gums, fatty oils, essential oils, and any other substances of this nature. Herbal medicines may contain excipients in addition to the active ingredients. Medicines containing plant material combined with chemically-defined active substances, including isolated constituents of plants, are not considered to be herbal medicines.“

These categories clearly articulate the basis in which herbal medicines are to be allowed for use by indigenous communities, by practitioners of well-developed healing traditions, or integrated into the fabric of the national health care system.

Moreover, the last definition of herbal medicine makes a clear differentiation between a traditionally prepared herbal medicine, a modern chemical isolate, and the combination of both. This is poignant as an herbal substance such as St. John’s wort has several centuries of accumulated data regarding indications, efficacy, and safety, and numerous modern studies documenting relative safety and efficacy, must be considered differently than the newly developed drug of the year that has no history of ever even existing let alone any data regarding safety and efficacy.

While some countries (e.g., Japan, India, People’s Republic of China) have worked diligently to represent traditional healing practices, including herbal medicine, as part of their national health care systems, as of 2005, approximately 60% of WHO member countries had no policy on traditional healing practices (WHO 2005).

Moreover, while it is largely public interest that is driving the desire for greater access to herbal medicines, and thus driving policies, oftentimes, national policies are established with little or no input from the traditional medicine practitioner community.

For example, neither the EU traditional medicines Directive 2001/83/ECnor the Dietary Supplement Health and Education Act (DSHEA), the latter that constitutes the primary access by which traditional herbal agents are allowed in the US, had formal input from the most well established of the traditional medicine practitioners, namely, Ayurvedic, Chinese medicine, or naturopathic practitioners.

Thus, in both the US and the EU, it is industry with vested interests in specific herbal remedies that drive both health care policy and herbal medicine approval. This is a significant impediment to traditional healing practices as the availability of materia medica is often dependent upon the availability of crude herbs or herbal preparations through industry.

The 2006 banning of the Chinese herb ephedra (Ephedra sinica) in the US is a clear example of how the misuse of an herb by industry, and subsequently by consumers, in stimulant and weight loss products led to significant adverse events. This resulted in both perceived and real concerns regarding the herb’s safety that resulted in a complete restriction from public and practitioner use, losing one of the most important articles of both Chinese and Western herbal materia medica, and losing access to an herb that, when properly used, had been used with a high degree of safety for more than 5000 years.

Similarly, national policies regarding herbal medicines tend to focus predominantly on supply and manufacturing issues, with relatively little resources expended on human clinical trials, and fewer resources expended to investigate botanicals medicines in the manner in which they were traditionally used; as part of a multifaceted healing program that included dietary, stress, and behavioural modification.

As begun by Paracelsus, too much emphasis is placed on studying herbal drugs in the same way that conventional drugs are studied, thus, often investigating the herbal drug out of the cultural and medical context in which it was historically used.

“To talk about pharmacognosy is to follow the evolution of man’s knowledge during the various civilizations, i.e. the evolution of mankind from the dawn of time to the present.” – DePasquale (1984)

Historically and until relatively recent times, pharmacognosy, the study of drugs derived from natural products, represented an intersect between traditional herbal medicine, ethnobotany (the traditional and cultural use of plant medicines and textiles), and scientific inquiry.

In ancient times, the predecessors of modern pharmacognosists, represented by early medical scholars such as the Greek physician Dioscorides (1^st century CE), were more closely linked with the practice of medicine than their descendents of the 20^th century, many of whom were influenced by the chemical revolution taking place at the time and became more aligned with the business of drug development rather than the practice of medicine.

With its formal beginnings in the writings of the Austrian professor of medicine Johann Adam Schmidt (1759–1809), the original focus of pharmacognosy was on ensuring the identity, quality, and purity of plant-based drugs (Schmidt 1811). A principle focus at the time was on the source and quality of the raw material used in the manufacture of herbal drugs.

This was prior to the advent of modern analytical chemistry and so the morphological and organoleptic characters of the crude plant drug, and later, the cellular structures of the plant as observed with a compound microscope, were the primary analytical tools used for quality evaluation. As analytical chemistry and the manufacture of synthetic drugs advanced, the science of pharmacognosy evolved into the field of pharmaceutical biology with an emphasis on natural products chemistry, molecular biology, and biotechnology.

The modern pharmacognosist, rather than applying the skills of classical botanical pharmacognosy to ensure the identity, quality, purity, and integrity of plant drugs, which were being replaced by chemical drugs, were employed to search for novel compounds that could be exploited as drugs for commercial purposes. This change in scientific focus paralleled the changes in the medical profession described previously.

According to a 1941 article in the magazine Science, “The desertion of the study of vegetable drugs soon became almost complete…at the present time researches dealing with plant medicinals are relatively rare and are becoming more so. Today is the heyday for organic synthetic chemicals.” (Griggs 1981).

Evolving medical theories similarly had significant impact on traditional healing modalities. The focus on the germ theory in Western medicine as a primary cause of pathology paralleled earlier medical philosophies of China’s Zhang Ji (Zhang Zhong Jing; ~150–210 CE) in his Shang Han Za Bing Lun (Shang Han Lun; Treatise on Cold Damage Disorders) that recognized pathogenic factors as a cause of epidemics.

Germs and their destruction through the subsequent advent of antibiotics, an incredible life-saving but one-sided facet of disease treatment, became the primary focus of 20^th century medicine that employed a militaristic strategy to search and destroy disease, a strategy that has persisted. This is in stark contrast to the vitalistic principles of Chinese and Ayurvedic medicine, whose primary focus was and is on the health of the host.

The earliest text of TCM, the Neijing Suwen (475 BCE–221 CE) records; “Uneducated practitioners behave very aggressively, believing they can launch an attack. Before the old disease has ended, a new disease emerges in addition.” (Unschuld and Tessenow 2011). The myriad of serious negative side effects that are an inherent part of modern iatrogenesis provide ample evidence of the consequences of aggressive treatments.

According to traditional systems of healing, a healthy host, it is reasoned, is less susceptible to external pathogenic influences and has the greatest chance of health restoration, for example, from chronic degenerative diseases, for which modern medical constructs have little to offer.

This realization was articulated in the historical TCM literature of Chinese herbalist and acupuncturist Li Dongyuan (1180–1252 CE). Li broke from the earlier traditions of the Shang Han Lun that focused on external pathogenic factors as the cause of disease and noted that if a person’s core health, as embodied in the health of the spleen and stomach (earth engendering school), is strong they will have resistance from external invasion no matter how strong the pathogen (Yang and Li 2002).

This was a revolutionary concept in medical history that has yet to be practically applied in Western medicine. Most importantly, these two concepts, the Shang Han and Earth Engendering traditions, along with several other principle philosophies (e.g., yin-yang, four levels, seven emotions, and eight principles) reflect a system that embraces a myriad of medical philosophies that are applied according to the needs of an individual patient. This is in stark contrast to the single-minded focus of western medicine on a pathogen.

As modern pharmaceuticals increased in isolation, potency, and pharmacological exactness, herbal medicines largely vanished from use in Western countries. Conversely, Ayurvedic and traditional Chinese medicine remained relatively strong up until the 20^th century. There were periods in the history of China and India (e.g., while under British rule) when traditional medical practices were formally discouraged in favor of European medicine.

However, for example, after decades of influence of western medical theories in China, traditional Chinese medicine practitioners began to identify deficiencies in western theories and argued that traditional Chinese medicine had much to offer the totality of medical care and began a process of integrating Western and traditional Chinese medical theories (Chen 1999) that continues today.

Subsequently, as of a 2005 survey conducted by the WHO, 1242 herbal medicines were listed on China’s essential drug list (WHO 2005). Similarly, after the end of British rule in India, Ayurveda once again regained its popularity and today, there are more hospitals of Ayurvedic care than there are conventional Western medical hospitals and the government actively supports the development of Ayurveda, as does the Chinese government for TCM. There are approximately 960 plants species used by the Indian herbal industry (Sahoo et al. 2010).

Herbal medicine in Europe experienced a resurgence for more practical reasons; after World War I, a number of drug patents, such as aspirin and heroin, were lost to the Allied Forces under the Treaty of Versailles (Jeffreys 2005).

Similarly, during World War II, much of the infrastructure for drug development was destroyed in major cities throughout Europe. This forced many, most notably Germans, to once again look at traditional herbal medicines and began a trend of cultural use and research that has persisted to the present day.

While herbal medicine in the US survived in pockets of minority groups (African Americans and Caucasians from the rural south, certain Christian sects, Mormons, Native Americans, etc.), a true resurgence did not occur in the US until the 1960’s with the back to nature ‘hippy’ movements occurring then.

This movement was overlaid with experimental use of a variety of hallucinogens, a number of which were of plant origin (e.g., Psilocybe, Datura, Lophora, Cannabis). At the same time, America was introduced to all the isms of the rest of the world such as Buddhism, Confucianism, Daoism, Hinduism, Shamanism. All of these philosophies emphasize an individual’s relationship within the context of the greater world as well as one’s responsibility to the world.

This was in contrast to the dominant Christian constructs that suggest that “man has dominion over the earth”, a philosophy rejected my many as new thoughts from the east and from Native Americans were introduced.

Regarding traditional medicine, these emerging philosophies partially established the foundation of nature being the primary healer and the recognition or belief that humans and plants have co-evolved and, because of that, plants were the optimal form of medicine for human health; a philosophy firmly held by many herbalists and natural health care practitioners today.

The practice of herbal medicine, historically followed two paths. The first of these was rooted in relative simplicity; an herbalist gathering plant medicines and attending to the needs of the sick in a system that can be defined as community-based health care. These were, and in many countries today, are, the folk healers, grandmothers and grandfathers learned in the use of medicinal plants.

The second path was that of professional practitioners. In ancient times, some of these were among the most learned of their generation and are well represented from the 1^st to 15^th centuries CE in works such as De Materia Medica of Dioscorides and the Hippocratic Corpus of Hippocrates, both of Greece, the Charka Samhita of India, and the Shennong Bencao of China, followed a few centuries later by the Canon of Medicine byIbn Sīnā (Avicenna) of Persia and several centuries later by the Renaissance herbal writers such as Fuchs, Gerard, Mattiolis, Parkinsons, and Salmon, and the later Chinese authority Li Shizhen’s Bencao Gangmu, to name only a few.

The use of herbs within these formal medical traditions was integrated with very sophisticated theories of anatomy, physiology, and pathology. Conversely, folk healing traditions predominantly represented an empirical use of herbs passed down through families, community knowledge, and fragments of the more formalized medical practice. While the humoral system of Hippocrates, Galen, and to a great degree, Avicenna, was the ancestor of today’s medical theories, today’s conventional Western medical practitioners have no relationship to these past theories, with a belief of the scientific superiority of current theories.

In contrast, the medical theories of Ayurvedic and Chinese herbal medicine remain intact, continue to evolve, and continue to be practiced according to their same historical foundational principles, and often with correlative understandings informed by western science. Inherent in both Ayurveda and traditional Chinese healing systems is the belief that humans are an extension of nature and therefore, the theoretical principles developed were inherently designed to mimic nature and facilitate healing by adhering to vitalistic principles reflected in nature.

These principles include the tri-doshic and five element (wu xing) systems of Ayurvedic and TCM, respectively, both of which relate human anatomy, physiology, pathology and dietary and herbal therapies to, in Ayurveda, vata (air), pitta (fire), and kapha (water) (which themselves consist of earth, water, fire, wind, and ether); and in TCM huo (fire), tu (earth), jin (metal), shui (water), and mu (wood).

In contrast, current western medical traditions possess no principles that inherently link human health with the living biological principles of nature, and only tangentially as an after thought, attempt to link health to behavior or lifestyle. Traditional healing systems inherently seek to bring human beings into a healthful balance with self in relation to their environment. In contrast, the focal point of Western medicine is symptom suppression, inhibiting the very healing response meant to restore homeostasis to the organism.

Traditional healing systems are commonly regarded as vitalistic or holistic, while Western medical philosophy is often described as mechanistic, reductionist, or rationalistic (Coulter 1975). This latter rationalistic perspective is based on the perception that development of modern medical theory and drug development was founded on rational scientific principles, implying that traditional herbal medicine knowledge lacked a rational basis, a premise countered by noted medical historian John Riddle (Riddle 1997).

The belief in traditional healing systems that human health is an extension of environmental health and that it is the relationship between the two upon which health is dependent, is in stark contrast to the philosophical basis of modern anatomy and physiology. Harvey’s (1578–1657) articulation of the circulatory system in the 17^th century provided fertile soil for new mechanistic theories that challenged old humoral theory.

However, the concept of circulation was described in the foundational text of TCM, the Neijing and by Galen centuries before. Noted French physiologist Claude Bernard (1813–1878) posited that the human environment (milieu intérieur) was separate from the external environment.

Others, such as the noted German physician Rudolf Virchow (1821–1902) stated the cell was the basic unit of the body that had to be studied in order to understand disease. Bloodletting and purging with Paracelsun-type mercury compounds, the primary medical therapies of the 18^th and 19^th centuries employed by allopaths, were being used with little documentation of their clinical effects (Riise 1997).

While traditional health practitioners gave focus to the macrocosm of all that makes up an individual’s life and health status (constitution, diet, lifestyle, environment, physical activity, stress, sleep) (Risse 1997), modern medical research gave focus to the microcosm of cellular biology. The visualization of microbes with the advent of the microscope by Holland’s Anton Van Leeuwenhoek (1632–1723), Pasteur’s (1822–1895) confirmation of the potential pathogenicity of germs, and Fleming’s (born 1881) discovery of antibiotics, further concretized the material cause and cure of disease, which in turn solidified the reductionist, militaristic, search and destroy approach typical of western medicine today and completely ignored the intimate relationship between human and environmental health.

In both Ayurveda and TCM, as well as naturopathic medicine, patient therapies are very much individualized and have remained physician- and patient-centered, the practitioner predominantly making their assessment through observational means reflected in the eight methods of diagnosis of Ayurveda (astavidha pariksa) and four examinations (si zhen) of TCM.

Similarly, the traditional health practitioner takes into consideration the cause of disease, which for chronic illnesses, is almost always due to unhealthy lifestyle practices, and then work to correct the underlying causative factors while providing therapeutic options to address both cause and symptoms, codified in TCM as biao and ben or treating the “root and branch”.

This is in stark contrast to research-based Western medical practices, which develop “standards of care” for diseases, in contrast to individualized healing protocols for patients.

Rather, western diagnostics is not guided by any understanding of the individual’s lifestyle that initially led to the disease state, but rather relies on mechanized diagnostic tests of specific biomarkers that reflect the end result of the disease process not the cause. This results in an almost exclusive focus on the symptom and an almost complete neglect of the cause. This perhaps represents the primary differentiation between traditional and conventional healing philosophies.

Prior to the 15^th century, the majority of medicinal agents were plant-based. While numerous medicinal agents of mineral and animal origin were also used, the overwhelming majority of medicines, as reflected in the De Materia Medica of Dioscorides, were plants (Gunther 1934; Riddle 1985).

In the 15^th century, the Swiss-German physician Philippus Aureolus Theophrastus Bombastus von Hohenheim, otherwise known as Paracelsus (1493–1541), pioneered the use of concentrated and relatively pure (for the time) chemicals in medicine. Perhaps more importantly, Paracelsus challenged, what at the time, was a relatively strict adherence to the medical philosophies of ancient texts, including those of Galen, Avicenna, and others, books of whom he actually burned at the University of Basel, Switzerland on St. John’s Day in 1527. The earlier teachings of Galen posited there were four physiological humors (blood, phlegm, yellow bile, and black bile) originally taught by the Greek philosopher Pythagoras (570 BCE-495 BCE) and that when in balance, there was health.

The humoral theory persisted as a prominent medical theory until the middle 1800s (Estes 1997). Paracelsus argued there were three humors; salt representing stability, sulfur representing combustibility, and mercury representing fluidity. While both theories are considered by today’s theories as archaic and inherently limited, this shift marked a significant divergence in medical thought that has great impact today. In contrast to the foundational principles of Galenic thought that were physiologically based, Paracelsus shifted medical thought by giving focus to the actions of drugs, in other words, a pharmacological basis of understanding medicine, which predominates today.

Another seminal change credited to Paracelsus was that, while Galenists believed that a disease of a certain character or nature would be cured by a remedy possessing the opposite effect, a precept similarly espoused by the famed Chinese Tang Dynasty physician and alchemist Sun Simiao (581–682 CE), Paracelsus and his followers argued that “a poison in the body would be cured by a similar poison”. While contemporaries of Paracelsus felt the substances he was recommending were too toxic to be used safely, Paracelsus defended his position with his oft quoted:

“Alle Ding sind Gift, und nichts ohne Gift; allein die Dosis macht, daß ein Ding kein Gift ist.”
(“All things are poison, and nothing is without poison; only the dose permits something not to be poisonous.”)

His challenging of the medical authority of the day resulted in the banishment of  Paracelsus from Basel and the revolutionary physician died at the young age of 48 (Borzelleca 2000). Never-the-less, the teachings and writings of Paracelsus took on many adherents and charted a path in medicine that was alternative to the current medical thinking of the day and can be characterized as the progenitor of the modern, chemically refined, and highly toxic pharmaceutical medicines of today.

Other seminal events in medical history charted the course that led to today’s medicine. In 1805, a German apothecary apprentice named Friedrich Wilhelm Adam Sertürner isolated what was to become the first pure, presumably “active” compound of a plant—the alkaloid morphine from the opium poppy (Papaver somniferum) (Kapoor 1997).

With the isolation, of morphine, an alkaloid making up approximately 10% of the total alkaloids of the plant (Kapoor 1995), medical researchers suggested that the whole plant need not be used as a medicinal preparation but rather that one could extract an active constituent. Sertürner referred to his new compound as principium somniferum or “sleep making principle”, later naming it morphium, after Morpheus the Greek God of dreams or sleep (Booth 1996).

Subsequent decades witnessed the isolation and eventual synthesization of pure compounds and the race for “active” constituents began changing medicine from whole plant-based to individual chemical-based entities.

Whereas Serturner posited that the whole plant was no longer needed, the emergence of synthetic chemistry posited that the plant was not needed at all changing the nature of drug development that has persisted to the present day.

Traditional herbalists wonder what effects the other 90% of compounds in poppy contribute to either the safety or efficacy of the drug, while traditional herbalists and WHO continue to regard the whole plant as representing the activity of a traditional medicine.

During the same time period, the medical and pharmacy professions were undergoing rapid changes. Originally, it was physicians, often referred to as “medical botanists”, who were the primary teachers of materia medica and founders of early pharmacopoeias.

As the pharmacy profession evolved, pharmacists began assuming an oversight role on the quality control of medicines. Later, pharmacognosy evolved as a sub-discipline of pharmacy, initially with an emphasis in the quality of crude drug materials. In modern times, this focus changed to searching for compounds in plants that were candidates for modern drugs.

Subsequently, physicians became the sole prescribers of medicines, pharmacists became the primary and formal dispensers of medicines, and pharmacists and pharmacognosists assumed the primary role of drug development and quality control, as represented in the development of early pharmacopoeias.

The switch from botanical- to chemical-based medicine is clearly evidenced in the evolution of the United States Pharmacopeia (USP), which in the first edition of 1820 included approximately 150 herbal drugs, or 50% of the total approximately 300 listed drugs at the time (USP 1820). By 1950, herbal drug monographs in the USP numbered approximately 50 of the more than 1100 preparation entries (a little more than 4%) (Boyle 1991; USP 1950). This lack of representation of herbal drugs is in sharp contrast to the almost exclusive inclusion of herbal medicines that comprised the Pharmacopoeia Augustana of 1564 (Husemann 1927).