Herbal Medicine

Ancient Beginnings

Herbal medicine is where all medicine begins. We know that many of the great civilizations of the past evolved relatively advanced systems of healthcare based extensively on the use of plants. The translation of ancient scrolls, some 5000 years old, revealed the extent of the highly sophisticated medical knowledge of the ancient Egyptians (Hall, 2013). The Ebers Papyrus for example, complied around 1500 BCE but believed to be based on works dating back to 3400 BCE, lists over 700 prescriptions using some 850 plants for a variety of conditions. (Aboelsoud, 2010).

In China the Pen Tsao, written by the Yellow Emperor Shen Nung and dated 2700-3000 BCE, describes the use of hundreds of plants. This ancient manuscript would form the bedrock of TCM (Traditional Chinese Medicine). In India, the early Vedic manuscripts from around 2000-1500 BCE, described the Ayurvedic system in great detail. Plant samples from the Palaeolithic era found in archaeological digs at Shanidar, Northern Iraq in 1960 revealed a number of plants still used in herbal medicine today. These samples are thought to be 60,000 years old (Solecki, 1975) and show a sophisticated use of plants by our Neanderthal ancestors (Henry, Brooks and Piperno, 2011).

All over the world herbal medicine traditions flourished independently of each other and later, through trade, natural disaster and war, began to amalgamate. The ancient Greeks were perhaps the first to refine herbal medicine into a cogent system. The older traditions, such as those of the Sumerian and Egyptian cultures, included magical rituals and incantations often attributing illness to demons or the wrath of gods. It was the Greek physician Hippocrates (460-370 BCE) who began to overcome what he considered the superstitious origins of disease. Essentially Hippocrates believed that diet and lifestyle were the cornerstones of our health; that the closer we were to nature the better our health would be. The term vis medicatrix naturae (the healing power of nature) stems from the teachings of the Hippocratic corpus.

The Western Herbal Tradition

The rise of Greek civilisation is also the beginning of what later came to be known as the Western Herbal Tradition. A number of ‘herbals’ (specialist texts on herbal medicine) appear from this time when Greece had surpassed Egypt as the centre of medical learning. The herbal of Diocles of Carystus (400 BCE), now lost, is thought to be the earliest of these works. Some fragments of the herbal by Crateuas, dated to around 100 BCE, survive but the great work which was to inform medicine for the next millennium was that of Dioscorides (Anderson, 1997).

Pedanios Dioscorides of Anazarba (40-90), compiled the entire knowledge of medicine as it was then known. He had travelled widely and extensively, encountering herbal traditions in many other places, and collecting their knowledge as he went. His major work De Materia Medica, written in the year 65, would dominate the landscape of Western medicine for the next 1500 years. It is fascinating to note that many of the observations made by the eminently practical Dioscorides still inform the herbal tradition to this day (Tobyn, Denham and Whitelegg, 2011).

Pliny the Elder (23-79), a contemporary of Dioscorides, wrote extensively on natural history, again having studied multiple sources. His major work was the Naturalis Historia which documented the natural world as it was then known, and in particular botany. The herbal of Apuleius included plants of African origin, but also drew upon the works of Pliny and Dioscorides. We can appreciate how traditions were beginning to merge and become more refined in these works.

The Origins of Herbal Medicines

So how did our ancestors come to an appreciation of herbal medicine in the first place? Was it simply a case of trial and error – eating various plants to see what did what; or what worked and what didn’t for certain ailments? According to one researcher primates, such as chimpanzees and apes, who use plants in a similar fashion to humans suggests that early observation of how primates dealt with illness may have informed human practice (Halbertsein, 2005). The observation of other creatures would also have contributed.

A study of the plants themselves – their habitat, shape, colour, odour and taste also provided information offering an empirical basis for a tacit understanding of their medical use (O’Rawe, 2015). The term Doctrine of Signatures is sometimes used to denote the idea that the characteristics of a plant can give indications as to its medical uses (Bennett, 2007) but morphological characteristics are only one of several determinants. The mythology of many tribal cultures describe how plants ‘speak’ in this way and that the use of plants in these cultures arose through ‘conversation’ (Buhner, 2004). These various forms of observation suggest that from the earliest times herbal medicine was developed through tacit knowledge and empirical wisdom.

What remains fascinating is that many early human groups discovered the uses of plants independently of each other. These customs became traditions which eventually found their way into the written word. So how did this process develop?

Humoral Medicine: The Great Galen

Several of these early customs, particularly following the advent of herbals, began to develop into distinct schools of thought. The ancient Greeks advanced a constitutional system based on the four elements – earth, air, water and fire – which later helped to establish the individualisation of treatment. Humoral medicine describes four temperaments in a human being arising from these elements – melancholic, sanguine, phlegmatic and choleric which are mediated by an excess or deficiency of four humours – black bile, blood, phlegm and yellow bile respectively. The humoral system of medicine was further refined by the great physician Galen.

Claudius Galen (129-216), along with Pliny and Dioscorides, completes the great triumvirate of Graeco-Roman scolars whose writings form the basis of of Western Herbal Medicine (WHM). Galen’s contributions to philosophy, pathology, anatomy and physiology but also to neurology and pharmacy would be remarkably influential for centuries to come. As a physician he had travelled widely, attended gladiators in the arena and later was the personal physician to a number of Roman emperors including Marcus Aurelius, Commodus and Septimius Severus. Galen synthesized Graeco-Roman medical knowledge, documenting hundreds of herbal remedies.

Arabic Medicine: Alchemists in the Sand

The ideas of the renowned Galen filtered across the then known world as the Roman Empire continued its ascendency. They spread to Alexandria, the great trading centre of the ancient world. They spread to Jerusalem and into the Middle East by the 5th century. They were translated into Arabic, along with the works of Hippocrates and Dioscorides, by Hunayn bin Ishaw-al-Ibadi (809-873AD) following the Arabic supremacy of North Africa in the 7th century. Arabic medicine later became the most advanced of its day. Of note is the physician Muhammad Ibn Zakariyā Rāzī (869-925), known as Rhazes, who promoted the importance of diet and hygiene above the use of drugs. He wrote: Where a cure can be obtained from diet use no drugs and avoid complex remedies were simple ones will suffice (Griggs, 1981/1997). He is also thought to have discovered alcohol and begun the practice of solvent extraction, popular with herbalists to this day in the form of tinctures. The most significant scholar of the Arabic world however was Ibn-Sīnā (980-1037), known in the west as Avicenna, and it was the writings of Claudius Galen in particular which influenced him most.

Arabic physicians had developed the concept of the immune system and the body’s ability to strive towards homeostasis. This principle underlies the concept of vis medicatrix naturae, that the body possess an innate quality to heal itself. By the 10th century Baghdad had become the great centre of learning, and excelled in the field of medicine in particular. Arabic-Islamic medicine also began the use of quarantine, separation of pharmacology as a distinct discipline and laid the foundations for clinical trials (Saad & Said, 2011). Apothecaries, precursors to the modern pharmacy, where plants and minerals were prepared into elixirs, tinctures, salves, ointments and other compounds sprang up in Baghdad by 800 under the Caliphs of Abbasid (Griggs, 1997).

Ibn-Sīnā’s monumental work The Canon of Medicine, completed by 1025, consolidated Arabic and Graeco-Roman medical knowledge, becoming the major treatise of the day and would dominate in medical schools across the world until the 18th Century. Ibn-Sīnā is credited with the manufacture of the first essential oil derived from roses.

Monastic Medicine: Of Saints and Scholars

While Arabic medicine was in the ascendency elsewhere the rise of the Christian monastery would also contribute significantly to the historic development of Western Herbal Medicine. Many monasteries, being largely self-reliant, developed their own herb gardens and apothecaries. It was the Benedictine monks especially who maintained this knowledge. When St Benedict of Nursia founded the monastery at Monte Cassino in 529 he ordered the monks to copy, study and maintain manuscripts and thus preserve knowledge. Another 6th century monk Cassiodorus of Vivarium had encouraged the study of Galen, Dioscorides, Hippocrates and Graeco-Roman medicine in general along with the making of botanical preparations and the use of monasteries as infirmaries for the sick (Suppan, 1915). Many monasteries included an infirmary supplied by a herbarium and were important centres of healing and medical knowledge until the 17th century, however they were naturally influenced by Christian doctrine. The Church taught that illness was a punishment by God returning medicine to the beliefs of the pre-Hippocratic era.

Hildegaard of Bingen (1098-1179), was a Benedictine abbess born at the beginning of the Crusades. Her work on herbal medicine provides an insight into the use of herbs in the monastic infirmaries of the day. The Crusades were opportunistic misadventures into the Middle East from 1095 onwards. They created deep divisions between Islam and Christianity that survive to this day. Yet by the same token they helped to cement the relationship of Islamic-Graeco-Roman medicine with an emerging European tradition.

Although all cultures had assorted varieties of folk medicine no major tradition had yet flourished in Europe. This would soon change however through the establishment of the medical school at Salerno, near the monastery of Monte Cassino in Italy.

The Great School at Salerno

The Schola Medica Salernitana, near modern day Naples in Italy, is thought to be the world’s first medical school and was famed throughout the medieval world. It may have been a development from an earlier establishment at Veila known for its healing waters and possibly an earlier Greek medical centre (Nutten, 1971). Following a disaster the occupants of Veila had fled to Salerno and there established a community by the 9th century. The school flourished between 1000-1300.

In 1027 Constantine the African (1017-1087), a Saracen from Tunisia, came to study at Salerno and there he later translated the Arabic medical texts that would be used in Western medical teaching until the 17th century.

The Salerno library contained all the major works on herbal medicine, including Dioscorides, Pliny, Galen, Ibn-Sīnā, Rhazes and the classics of Arabic and Ayurvedic medicine. Consequently it attracted scholars throughout Europe and beyond as well as those seeking cures. Manuscripts developed in Salerno soon found their ways into the libraries of Europe. The Saliternitan Herbal Circa Istans is attributed to Mattheus Platearius but also contained several translations by Constantine the African and others in subsequent editions such as The Grete Herball of 1526 (Denham, Tobyn & Whitelegg, 2011).

Of the British and Irish Traditions

The famed Physicians of Myddfai were among those who may have travelled to Salerno, amalgamating such knowledge and lore as Salerno offered with local practices in Wales. Folk medicine in Briton combined various strands such as the Anglo-Saxon, Scandinavian, Norman, Celtic and Pre-Celtic. The Myddfai physicians had been instructed by the Prince of Wales, Rhys Gryg, in the 13th century to write down these oral traditions for future generations. The physicians thereafter developed an impressive corpus of herbal knowledge which incorporated classic works with local knowledge. The main source of information on these Welsh herbalists is the Red Book of Hergest (1382), which attests to a lineage of physicians going back to the 10th century and lasting until the 18th century (Cule, 1963). It contains a collection of herbal remedies attributed to Rhiwallon Feddyg.

This is also important when we consider the development of the Irish herbal tradition. The connections between the Irish and Welsh can be noted in the 12th century manuscript Historia Gruffud vab Kenan for example. Gruffud had been born in Dublin with an apparent claim to the Welsh title. Is it possible that during his incursions into Wales that the physicians who accompanied him and his army may have come into contact with the herbalists of Myddfai?

In Ireland the Táin Bó Cuailnge (The Cattle Raid of Cooley), set in the 1st century, tells us that men of medicine treated the warriors Cúchulainn and Ferdia after their battle by applying plants to their wounds. These men of medicine accompanied armies to treat the wounded of both victor and vanquished, for such was the law. The Brehon Law existed in Ireland from the coming of the Celts to the end of the Gaelic Order in the 17th century. The Brehon law tract Bretha Crólige in particular had a system of compensation for the injured but also placed emphasis on diet and subsequent care. These are also features for the care of the wounded in the later manuscripts of the Welsh physicians of Myddfai as well as the medieval Gaelic physicians, suggesting common origins.

We have seen so far how various folk medicine traditions spread and flourished. In the case of Ireland herbal medicine has a similar story. The customs of the pre-Celtic tribes, the Firbolg and Fomorians, are lost to history and little is known of the Celtic/Druidic traditions which followed. Knowledge of these forebears was documented in the monasteries of Ireland, but the works are considered to be largely mythological in character.

Monastic texts from the 8th century mention the leech-god Diancecht for example, a powerful healer. He grew jealous of his son Midach as his son’s medical abilities began to excel his own, so much so that he killed him. The legend has it that from the young physician’s grave grew 365 herbs from the 365 joints and sinews and members of his body, each herb with mighty virtue to cure diseases of the part it grew from (Joyce, 1879/2001). The development of apothecaries attached to monasteries also gave rise to medical schools among whose remit was the translation of classic medical texts.

A commentary on the Aphorisms of Hippocrates was translated into Irish in 1403 by Aonghus Ó Callanáin and Niocól Ó hÍceadha. The Aphorisms manuscript was the best-known work of the Hippocratic corpus, and one of the central texts of the Articella, a collection of treatises that formed the curriculum of advanced teaching in medicine throughout Europe from the twelfth century to the sixteenth (Nic Dhonnchadha, 2000).

From these works we can derive that the Galenic system of the Four Humors formed the constitutional system of Irish herbal medicine at the time: fuil dearg (sanguine); lionn fionn (phlegmatic); lionn ruadh (choloretic) and lionn dubh (melancholic).

The first known Irish herbal was translated from Latin by Tadhg Ó Cuinn in 1415. The original source is considered to be the Circa Istans, a manuscript which originated in the School of Salerno dated to 1190 (Anderson, 1978). The earliest dated extant copy of Ó Cuinn’s Herbal, complied mainly by Donnchadh Ó Bolgaidhe a Leinster physician, was completed in 1466. The manuscript contains 291 alphabetically arranged entries, augmented by the author, mostly concerned with herbal remedies, their properties, preparation and application (Nic Dhonnchadha, 2000). There are over 100 manuscripts in early Irish extant in various libraries, and most have not been translated (Cesiri, 2013; Wulff, 1929).

Ó Bolgaidhe’s augmentations to the original text include 22 herbs not found in the original (Murphy, 1991). Many herbals followed this tradition of taking existing works and developing them with native customs and observations as we have seen.

Irish physicians, known as Liaig or Banliaig, were attached to Gaelic chieftains and kings. They were usually members of hereditary families who maintained medical knowledge until the collapse of the Gaelic Order and the Tudor supremacy. They were responsible for the organisation of medical schools and the translation, composition and transmission of medical texts, such as the Ó Cuinn herbal. Liaigs enjoyed a high legal status in Gaelic society. But it is important to note that common people had knowledge of field and hedgerow and so separate folk practices probably of more ancient lineage, continued alongside the Liaig tradition, and to some extent amalgamated with it as documents of the Irish Folklore Commission would later testify (Kingston, 2009).

Meanwhile in England by the 9th century Alfred the Great (849-899) had instigated educational reforms which paved the way for documentation of Anglo-Saxon herbal medicine complied in manuscripts such as the Leech Book of Bald and the Lacunga now found in the British Library. (A leech was an Anglo-Saxon term for herbalist, a term which has similar etymological origins to the Irish Liaig, again suggesting common origins).

Of New Worlds and New Diseases

We can appreciate the merging of ancient traditions with local customs and new discoveries, each informing the other over time but there were a number of events which saw herbal medicine eventually begin to decline in popularity. The first of these events was the Black Death. The bubonic plague wiped out an estimated 75-200 million people across Europe in the middle of the 14th Century. While herbalists had centuries of herbal wisdom upon which to draw for certain conditions, treatment of the plague had no such background. Treatments for the plague with various herbal preparations, though many and varied, were rarely effective while doubt about their efficaciousness began to creep in. Herbalists in the main did not have an answer while the medical fraternity began to search for newer, more potent forms of medication.

There are other factors. If the Hippocratics had taken superstition out of medicine then the Church would bring it back by pronouncing that the Plague was the wrath of God due to man’s many sins (Thomas, 2008). The witch hunts of the 15th to 18th centuries, a product of mass hysteria, anti-feminist and religious sectarianism, began to associate folk medicine with witchcraft and Satanism. Women were executed in the tens of thousands. An archetypal association of evil witches with cauldrons of bubbling herbs has passed into the popular imagination.

Other new diseases were beginning to appear as the Empires of Europe exploited new territories across the world. The syphilis epidemic which plagued Europe from the late 15th century onwards was likely brought from the Americas by the crew of the Columbus expeditions, though this is contested. The disease was much more lethal than we know it today and caused at least 5 million deaths and untold suffering. Many herbs, compounds and minerals were employed, some to little or no avail, in turn reinforcing a trend towards stronger and stronger medicaments. Once again the herbalists had no tradition upon which to draw for the new scourge, although plants from the New World became especially sought-after as the herbal traditions of the Americas became open to exploitation bringing in its stead an increased desire for the exotic, while suppliers were only too happy to meet demand.

These developments coincided with the rise of new medical schools whose scholars were beginning to re-examine and debate the humoral system of Galen. The older medical philosophies were being challenged for the first time and it was a time of great experiment and new discoveries about the internal workings of the human body. Herbal medicine would have to rise to these new challenges accordingly.

The use of mercury in medications became commonplace as a treatment for syphilis, despite both Galen and Dioscorides having described its toxic qualities if taken internally. At Salerno, and later the great medical school of Montpellier, the use of mercury as an external remedy was already common by the 11th century. Crusaders were also returning from the Holy Land with a new disease called leprosy and the Saracen’s Salve (Unguentum Saracenum) they had discovered during their misadventures proved useful in clearing the sores (Griggs, 1997).

The Saracen’s Salve was a compound formula which included mercury and was soon being used for diverse conditions other than syphilis for which it was not appropriate. Mercury, being powerfully anti-bacterial, did indeed appear to work wonders in cases of skin eruptions but its toxicity was either not well known at the time or ignored as its apparent benefits appeared to outweigh the risks. Dioscorides had warned about inhaling mercurial vapours. Rhazes and Avicenna recommended it for external use only. It was soon being used by physicians and surgeons with ‘wreckless abandon’ as the search for the most potent medicines became de rigueur. By now quicksilver, or Cinnabar as it was also known, was also being used internally in pill form (Norn, Permin, Kruse & Kruse, 2008) and its victims literally began to pile up (Klys, 2010).

The discovery of herbs like Guaiacum (Guaiacum officinale) and Sarsaparilla (Smilax ornata) in the Americas as alternative treatments for syphilis saw a huge industry develop in the 16th century (Griggs, 1997). The importation of promising new plants through the spice trades encouraged the apothecaries to mix various new compounds and created a significant demand for these fashionable remedies. The use of salts of mercury in these new compounds set the precedent for stronger and more powerful medicines and as its reputation initially soared the use of simples (single herbs) became increasingly neglected.

Paracelsus: Of Alchemy and Infamy

The fashionable compounds were often based on the new ‘science’ of alchemy. The rise of interest in the Arabic system of alchemy became extremely popular in Europe especially in the wake of the colourful Philippus Aureoles Theophrastus Bombastus von Hohenheim (1493-1541), better known as Paracelsus. Paracelsus rejected entirely the teachings of the classics, their constitutional systems of healing but also the exaltation of foreign herbs. He put his faith in a more scientific approach yet he also condemned the overbearing use of unprepared mercury. Going against the grain of the times he criticised the industry that had risen from exploiting the misery of syphilis, but the unholy alliance between medicine and commerce was well and truly established. The apothecaries, dispensers of compounds and ancestors of the modern pharmacist, also began to move into general practice, causing consternation among the more learned physicians who had spent years in apprenticeship learning their art (Griggs, 1997).

Paracelsus rejected humoral medicine. A medicine worked against a disease because of its chemistry alone, he figured, not because of humours or evil spirits. For Paracelsus the dose was all important and meant the difference between a medicine and a posion. He thought very small doses of prepared mercury, arsenic or antimony were useful in certain conditions but more often than not the apothecaries were using unprepared forms in high doses internally and it was doing more harm than good. Paracelsus also promoted local herbs above foreign ones. He believed that herbs were being improperly used and that tradition had merely copied the ideas of the previous generation without recourse to scrutiny and debate. However he also promoted the idea that herbs contained an active ingredient, ushering in a new paradigm in medicine. This new paradigm employed a reductionist perspective, that herbs and minerals could be reduced to a single active ingredient. Alchemy offered a new way to open up the secrets of these active ingredients.

Griggs puts it succinctly: Paracelsus had a strong conviction – which would not be shared by any modern herbalist, and which has often been demonstrated by disastrous experiment to be unfounded – that the active principle extracted from the plant and used in isolation will be even more effective, even more powerful medicine, while remaining as safe as its original form. This was the tempting delusion that danced before the eyes of the medical alchemists (Griggs, 1997).

It is hoped the reader will begin to see the shaping of modern biomedical philosophy in these events. The desire for potent medicines to address new diseases; the rise of commercial interests and their influence; the observation that plant medicines could be reduced to single chemicals all began to dominate the world of medicine. But this was not without its side effects.

Of Apothecaries, Surgeons and Physicians

In England, by the reign of Henry VIII (1491-1547), there were competing forces at work. The influx of specialist books such as Rycharde Bancke’s Herball (1525) and the Grete Herball accredited to Peter Traveris (1526) following the development of mass printing saw many, certainly in the middle classes, return to self-medication and the use of local herbs. The herbals of Lyte, Gerard and Parkinson would follow (Barlow, 1913). In some ways this led to a revival of older folk customs which may in part be traced back to early Anglo-Saxon works (Sinclair-Rhode, 1922).

In Henry’s time the apothecaries, surgeons (including the barber surgeons) and physicians, were separate and competing entities in themselves. Medieval medicine was a diverse marketplace. Apothecaries, once wholesale merchants and importers of herbs, had grown significantly in number and skill, causing consternation among the physicians who had attended medical schools (Tobyn, 1997). The physicians were generally well-educated and distinguished practitioners who believed their lengthy apprenticeships afforded them the authority to practice medicine. They were concerned with both the apothecaries and the surgeons, indeed anyone else practicing physick (an old term for herbal medicine), moving into general practice for which they were fundamentally untrained.

There were so many types of practitioner in medieval times – physicians, widwives, empirics, barber surgeons, apothecaries and tricksters. Some were learned like the physicians, but many more were not. The surgeons were two groups. Barber surgeons were generally employed on the field of battle to address the wounded and the dying. Other surgeons performed various surgical operations from the lancing of boils to the extraction of teeth. Their training may have varied enormously. The surgeons had developed more interest in general practice, particularly during the syphilis epidemic, while the apothecaries also grew in confidence.

The physicians pressed King Henry VIII about this untenable state of affairs and in 1512 the regulation of medicine entered the statute books. In 1518 the College of Physicians was established and had statutory authority by 1523 (Tobyn, 1997). For the first time anyone who caused grievous hurt, damage and destruction to their patients could face legal repercussions. Accusations from the physicians began to be leveled at anyone not within their world-view. More legislation followed and by the mid 16th century the Royal College of Physicians, as they were now known were given primacy over both the surgeons and the apothecaries.

The Herbalist’s Charter

The surgeons, smarting from their demotion, took issue with those self-medicating with herbs, or using local herbs to heal the sick. The poor could little afford the services of physicians, surgeons and apothecaries anyway. However, Henry VIII, a keen herbalist himself, issued a Charter in 1542, which enshrined the right of anyone to use herbal medicines, much to the chagrin of the Royal College of Physicians. While the malpractice of medicine was certainly an issue the use of herbal medicines was a fundamental right. The right to use herbal medicine became common law in England and, by extension, Ireland. The 1542 Charter however was rescinded by the 1553 Statutes of the Realm under Mary Tudor so subsequent claims of a historical legal standing for herbal medicine are uncertain.

The Quack’s Charter, as it was known to the physicians and surgeons, in some ways undermined their activities; as rather than use the services of men of high training the public could turn to a herbalist, apothecary or even self-medicate. Griggs mentions the use of herbs to dissolve gallstones as an alternative to surgery for example. The Royal College of Physicians, however annoyed with the Charter, were having difficulties keeping their own house in order. The New Medicine, informed by the ideas of Paracelsus, began to dominate and created a philosophical divide. Meanwhile the apothecaries were happily selling the new medicines alongside the old and were engaging in general practice. Traditional medical authority had been losing its grip since the Black Death.

The Worshipful Society of Apothecaries was formed in 1617. The Royal College of Physicians was thus in a position to establish an official pharmacopoeia and dictate what medicaments the apothecaries could make and dispense. Apothecaries were subsequently restricted into selling only those medicines prescribed by the physicians. The College also exercised its powers against anyone practicing beyond their remit. But the apothecaries continued to be involved in general practice (Tobyn, 1997). One such unlicensed physician practicing from an apothecary shop was the renowned herbalist Culpeper.

The Peoples’ Physician

Nicholas Culpeper (1616-1654) moved beyond the philosophical confines of both the physicians and the apothecaries. Motivated by the plight of the poor, he translated medical works from Latin into English and in so doing opened up a cornucopia of herbal information to the non-scholar including many trade secrets of the physicians, apothecaries and surgeons, who were subsequently not impressed. Culpeper also admonished the physicians for their financially motivated approach to health. Writing about the Royal College of Physicians he scornfully noted that they held a strange opinion that it would do an English man mischief to know what the herbs in his garden were good for. Culpeper was publically attacked and even tried for witchcraft in 1642 but was acquitted. His works remain in print to this day.

The alchemical ideas of the Arabs had filtered into Western medicine, and the use of otherwise harmful substances such as mercury, antimony or arsenic, apparently when correctly prepared, were considered safe and effective. The refinement of plants, animal parts and minerals by alchemical processes was thought to liberate their true potential and purge them of toxicity. However the growing death toll that emerged in their wake suggested otherwise. The use of compounds containing toxic metals along with radical purging and bleeding dominated medicine.

Paracelsus, for all his faults, was correct that physicians should not blindly accept tradition without scholarly debate yet the new medicine was becoming dominated by his reductionist theories. Fresh developments in anatomy and medical theory also challenged the Greek and Arabic classics which eventually began to fall into disuse. More and more new and stronger compounds were being developed as medicine became more single-minded but the emerging biomedical world was riddled with commercial interests from the earliest times. In the new British colonies in America similar trends would unfold.

Of Thomsonians, Eclectics and Physiomedicalists

The colonization of the Americas brought European settlers into contact with various native traditions of plant medicine. The settlers learned of these customs and practices and amalgamated them with their own knowledge and growing experience. Primarily their medical knowledge would otherwise have been based on the British tradition. During the American Revolution (1766) there were approximately 3500 doctors. Only 400 of these doctors had received formal medical training, mostly in Britain (Schultz, 1995). To train in regular medicine required a lengthy apprenticeship or traveling to Britain. The first chartered medical school in the Colonies eventually opened in 1765. In the meantime most of the other ‘root doctors’ or ‘injun doctors’, as they were sometimes called, had evolved out of necessity in a largely developing frontier society.

Early medical training in the American colonies was dominated by Galenic humoral medicine and the teachings of Paracelsus. Regular doctors balanced the humours by blood-letting, emesis (induction of vomiting), purgation (induction of bowels), uresis (stimulation of urine) or diaphoresis (induction of sweating). To do this they often employed various compounds containing mercury, lead, antimony and arsenic among others. A treatment widely used at the time was called the Old Ten and Ten which involved extreme bleeding followed by 10g of calomel (mercury) and 10g of jalop (a purgative which included Ipomoea). Benjamin Rush (1745-1813) promoted this so-called form of Heroic medicine and was the most respected Regular of the times. But many soon became concerned with such extreme and drastic measures (Haller, 1995). Thomas Jefferson demanded reform and spoke out about such a lethal, yet fashionable treatment which damaged many (Cohn, 1979).

Samuel Thomson (1769-1843) whose Thomsonian system of medicine, likely a combination of native Indian customs and his own experiments, became hugely popular and created a demand for herbal medicine. He patented his particular system and many began to practice according to his teachings using his book and patented medicines under license. The Thomsonians, as they were later known, were a reaction to modern ‘regular’ medicine whose extensive use of heroic purging, blood-letting and mercury treatments they considered barbaric. Instead they abandoned blood-letting and mercurial compounds and relied on plant medicines and sweating techniques.

The Eclectic tradition began in 1825 also emerging in reaction to the drastic measures being used by orthodox medicine. It lasted until 1939 and over a century perfected the art of botanical medicine, and practitioners can still learn much from their voluminous works to this day. The main pioneers of the movement were Wooster Beach, John King and John Scudder. Mention must also be made of the eminent chemist John Uri Lloyd whose preparations were widely used by the Eclectics.

Dr Wooster Beach (1794-1868) believed that only the best medicines and the best treatments should be used to treat the sick, but he considered that no one tradition was perfect. Beach, a medically trained doctor, had broken away from both the Regulars and the Thomsonian system but employed only their more useful characteristics in an eclectic approach aimed at the overall reformation of medicine. Beach was outraged at cruelty and misery, administered under the specious pretext of removing disease (Felter, 1830). Beach produced the first American Materia Medica and opened his first infirmary in New York 1825. His journal The Reformed Medical Journal articulated the Eclectic philosophy. In time Beach would receive 7 Medals of Honor from various European heads of state (Haller, 1995).

John King (1813-1893) was a student of Beach. King’s American Dispensatory, published in 1853, built on the works of his teacher and would run to 18 editions. King refined the Eclectic principles of his forebear and devoted a lifetime to refining the American Materia Medica but also made contributions to pharmacy, championing the use of tinctures and fluid extracts.

John Scudder (1828-1924) was passionate about reforming medicine. Three of his children had died from the applications of the Regulars. Scudder’s main contribution to the Eclectic discipline was his Specific Diagnosis (1874) and Specific Medication (1869). Scudder was in fact expanding upon the vis medicatrix naturae and how specific herbs could be used in specific circumstances to restore homeostasis. He called this the Vis Conservatrix and he used the term tonic to describe the specific medications (Scudder, 1883).

When the Eclectic Institute closed its doors in 1939 it had developed a remarkable materia medica with over a century of clinical observations which remain relevant to this day. A second tradition which emerged in the wake of Thomson was Physiomedicalism. The Physiomedicalists were more concerned with using regular science alongside the emerging systems of herbal medicine. Samuel Thomson had promoted the idea of internal heat which the Physiomedicalists considered as the vital force, again returning to the ancient concept that the human body has an innate ability to heal itself given the right conditions; and herbal medicines provided tools to set such a mechanism in motion. Such remedies were known as sanatives; restorative remedies which could encourage the vis medicatrix naturae. Sanatives worked by encouraging detoxification and/or by improving the absorption of nutrients (Caldecott, 2010).

As the Eclectics had done, the Physiomedicalists also rejected much of the philosophy and methodology of the Regulars. Along with the naturopaths they felt that vaccination was an especially ill-conceived practice. Infection was a consequence of living against nature, thereby creating the ideal internal conditions for opportunistic micro-organisms, or so they believed.

Where Samuel Thomson had been steadfast in his opinion that only his patented system should be employed in the teaching and practice of herbal medicine, the early Physiomedicalists felt that a more academic approach should be considered. They felt if modern herbalists were to be taken seriously by their peers then they should be trained to the same level as regular medical school graduates.

Alva Curtis (1797-1881) was the first to open such a school and attempt to professionalize herbal medicine, in some ways going up against the Thomsonians. At this point it is worth noting that 70% of doctors were Regulars. Curtis broke away from Thomson with the notion that a proper system of education must be employed, rather than what was to all intent and purposes a mere purchase of licenses and patented medicines from Thomson. This could hardly be considered professional in a medical world which was becoming more and more institutionalized.

The Physiomedicalists also gave greater interpretation to humoral or energetic concepts. Their clinical observations allowed them to couple the hot and cold or dry and moist actions of herbal medicines with the contraction and relaxation of tissues and the metabolic actions of stimulation and sedation. They were in fact integrating herbal medicine with modern physiology. If herbal medicine appeared antiquated to the Regulars it was often because of its historical associations with ancient superstitions or archaic medical theory which was at loggerheads with the new rationalism of science.

While herbal medicine had a vast if fragmentary tradition upon which to draw it also needed to move with the times, and so the Physiomedicalists embraced modern developments in biochemistry, anatomy and physiology. The Physiomedicalists then were reformers – Haller calls them medical protestants demanding reform in medicine much in the way the protestant faiths had demanded reform from the Church of Rome (Haller, 1994). Reform medicine was especially concerned with the mounting death toll in the wake of the Regulars. The ongoing use of highly toxic materials was causing unnecessary misery.

Mercury, as we have seen was widely used in compound medicine. Mercury is extremely toxic and can cause a range of serious symptoms. It is neurotoxic and a respiratory depressant. It is often said that its toxicity was not well known and yet the ancient Greeks had written of it. Dioscorides urged extreme caution and limited external use. Both the Physiomedicalists and the Eclectics became outspoken on the use of such a dangerous drug, but it was one of many compound medications and procedures which was of serious concern.

Many in the botanical reform movement were uncertain of the vague philosophy of the Eclectic school however – to seek the best from all medical systems could be determined by personal choice and therefore practitioners might also still choose the lance or the calomel. This was the reasoning Curtis and others had for defining herbal medicine within an academical context (Haller, 2000).

Physiomedicalism developed from 1839 onwards in a world of sectional medical theories, cultism and pseudo-philosophies all competing for the American dollar (Adams, 1999). Medicine was coming of age and there were many competing interests. Curtis determined the name Physiomedicalism for the new reformers but it was given philosophical integrity by William Cook. Cook argued that a more systematic and modern approach to herbal medicine would allow Physiomedicalists to meet with educated scientists and physicians and demonstrate the truths of their medicine (Adams, 1999).

William Cook opened the first Physio-Medical Institute in 1859 despite opposition from the Regulars, and his journal the Physiomedical Recorder advanced the new reform philosophy. His Physiomedical Dispensatory (1869) expanded the Thomsonian system of some 70 herbs to around 500 and became the official materia medica of the Physiomedicalist tradition (Caldecott, 2010). The hostility from the Regulars to these reformists continued unabated.

Were the Physiomedicalists over-reactionary? Haller suggests that their fatal flaw was their aversion to germ theory which was of such significance in its day that to reject it was deemed a rejection of science itself. Yet the Physiomedicalists also suffered from an inability to forge a singular identity and institutional structure that might promote their philosophy and support its longevity (Haller, 1994). Cook’s theories were further developed by Thomas Lyle in what was becoming an increasingly hostile environment. Lyle puts it very philosophically:

Medical history is full of therapeutical schemes- some very foolish and some seemingly very wise, some practical, some impracticable, and some a mass of arbitrary dictums. It is not then surprising that some are unreliable. This unreliability has given unrest to the medical mind, and given rise to the assertion that medicine is not a science. Some minds have built up and some have torn down. The dethroning of one opinion has given room for the enthroning of another. The present stands upon the ruins of the past, and man is still searching for truth. (Lyle, 1897)

The Age of Pharmaceutical Hegemony

The American Medical Association (AMA) was incorporated in 1897 and became the powerful voice of the Regulars. It had been founded by medical doctors who had influence at state and national level, and with considerable corporate interest it was vigorously calling for a complete regulation of the medical system in the United States. It’s organ was the Journal of the American Medical Association (JAMA). JAMA’s growing sales were largely built on advertising and inclusion in the journal created a type of medical ‘seal of approval’. It stopped promoting cigarettes in 1953 (Gardener and Brandt, 2006).

The isolation of active ingredients of plant origin had become more common in the 19th century and particularly after the isolation of morphine from the opium poppy (Papavar somniferum) around 1806. In 1820 quinine was isolated from cinchona trees (Cinchona pubescens), and in 1899 aspirin was isolated by the Bayer Corporation from willow trees (Salix spp.). The new pharmaceutical industry grew exponentially with aspirin in particular becoming a fast seller. The fledgling industry grew disparaging of herbal medicine and began to distance itself from its medical ancestor.

It was argued that the constituents of herbs (their ‘active ingredients’ according to the pharmaceutical world view) vary each year due to environmental phenomena and therefore as whole, or crude extracts, it was believed their medicinal effects would be too variable. By standardising herbs, or by isolating perceived active ingredients, pharmacists believed they had created extracts which were consistent and more powerful. This idea was dominated by a reductionist mindset that overlooked the holistic approach so central to healing until that time.

Modern medicine was developing from the desire for standardised medical products controlled by a regulated institution. The raft of side-effects produced by this approach would eventually reveal the short-sightedness of their philosophy. Importantly herbal medicines, despite their excellent safety record, were not patentable, had reduced marketability and so presented a challenge to the growing corporate agenda.

There is no doubt that certain practices in these times were of a dubious nature but the newly established AMA was dominated by pharmaceutical interests (Lisa, 1994). The AMA consolidated medical practice into a singular system – pharmaceutical drugs and surgery – all of which were untested by today’s standards, and many of which did considerable harm.

The AMA drove through the 1910 Flexnor Report, which admonished any medical institution which didn’t meet with its world-view. The report was a review of all 161 medical education institutes across the United States which bent the ear of government. As a consequence of the report the institutes teaching herbal medicine, both Eclectic and Physiomedical, went into decline. The last few schools had closed their doors by the onset of WW2 by which time the AMA had affected complete medical hegemony. In the UK a similar story was unfolding.

The Medical Herbalists

Our story comes full circle. Various exponents of the Eclectic and Physiomedicalist traditions had also traveled to the UK. Albert Coffin (1790-1866) was perhaps the most prominent. Coffin was a charismatic speaker articulating Thomsonian and Physiomedical concepts, and his influence was considerable especially in the North of England. His popular, occasionally theatrical, lectures on herbal medicine and establishment of a number of botanical societies developed into what is now referred to as Coffinism, much to the amusement of his detractors (Griggs, 1997). Coffin, like many of his ilk, was antagonistic to the lethal practices of the orthodox medical profession.

Thousands perish under their hands who would otherwise have survived. Mercury, opium, alcohol, and the use of the lancet, are of themselves sufficient to account for the speedy depopulation of the world. (Quoted in Brown, 1982).

Coffinism’s various converts were similarly vehement. Dr John Skelton (1806-1880) hoped to liberate the poor and needy from “medical bondage”.

Coffin was an obstinate and domineering figure and to some, it seemed, an obstacle to progression. Herbalists were theoretically protected under the Herbalist Charter of Henry VIII (this historically contestable since the Chrater was rescinded by Mary Tudor) but others felt the drive for professional status was primary. William Henry Webb in a bid to modernise began to write of moving traditional herbalism away from the astrology of Culpeper, which modern science had dismissed (Brown, 1985).

Skelton, dissatisfied by the opinionated Coffin, established his own herbal import business in 1852. (One of Skelton’s agents was John Boot, who’s son would later establish a well-known chain of chemists). In 1851 Skelton had encountered Dr Wooster Beach on his travels and gained wider appreciation of the Eclectic system of medicine as it was then practiced in the US.

Coffinism went into decline particularly following a vicious attack by Beach, and the new British Eclectics began to put their stamp on UK herbalism (Griggs, 1997).

As in America, conflicts arose between the various protagonists but Skelton is remembered as a force of moderation with the long view always in mind. In 1854 a Medical Reform Bill threatened and herbalists began to rally. The formation of the National Association of Medical Herbalists (later NIMH) in 1864 was a watershed moment in the history of herbal medicine. In 1905 NAMH published a new British Materia Medica, the National Botanical Pharmacopoeia. Professional journals began to appear from this time, consolidating Western Herbal Medicine’s modern position.

At the outbreak of the First World War one Maud Grieve began to give talks on growing herbs and vegetables, which due to the war effort were soon in short supply. Her courses and pamphlets were the foundation for A Modern Herbal (1931), an encyclopedic and thoroughly up to date account of the herbal tradition compiled by Hilda Leyel who formed the Society of Herblists which later became The Herb Society. Grieve recommended Lily of the Valley (Convalaria majalis) for troops who had been gassed at the front revealing the extent to which science was beginning to appreciate the possibilities of herbal medicines.

Yet the emerging herbal tradition would not have an easy time of it. The Venereal Disease Bill (1917 c-21: 1:1) stated that only qualified practitioners could treat venereal diseases; contravention of which could result in imprisonment! In the House of Lords during the bill’s second reading Mr Hayes-Fisher asked the House to prohibit those not qualified (he mentions a body of 5000 herbalists!) to treat VD because their remedies “are almost as bad as the disease” (Hansard, 23 April, 1917, cc2076-77). The Pharmacy and Medicines Act (1941, Section 12/4a) also significantly limited the scope of herbal practice. The Marquess of Salisbury raised the “detrimental effect” this bill had had on herbalists in a House of Lords debate in 1960 and described it as a “serious injustice” (Hansard, 28th July, 1960, cc944-60).

The Medicines and Pharmacy Act 1941 effectively made herbal medicine illegal. Herbalists continued to practice but it was finally through the efforts of the National Institute of Medical Herbalists (NIMH had emerged from NAMH) and Fred Fletcher-Hyde in particular which afforded herbalists a caveat; the 1968 Medicines Act giving herbalists a modern legal precedent.

If herbal medicine had been a largely underground practice by the mid 20th century it was now beginning to regain its popularity. By the 1960s interest was spiraling especially in America where herbalists such as Michael Moore, Rosemary Gladstar, William Le Sassier and David Winston helped instigate a revival. In the UK the NIMH continued to raise the standard of herbal teaching.

Today herbal medicine has various schools across the world, some training in traditional forms, others leaning towards a biomedical form of herbalism (phytotherapy); others still merging the Western Herbal Tradition with elements of Ayurveda and Traditional Chinese Medicine. Organisations such as the American Herbalist Guild (AHG), the National Institute of Medical herbalists (NIMH) and the Irish Register of Herbalists (IRH) maintain high standards for practicing herbalists. Ultimately herbalists seek to preserve their ancient heritage but also to advance into undiscovered territory and embrace new knowledge so that herbal medicine remains a living, breathing tradition.

More recently herbalism across Europe has once again been challenged. EU legislation has attempted to draw a line between herbs considered foods and those considered medicines, despite the reality that most are both. The differentiation suits the drive for free market forces under Codex Alimentarius. The caveat is that only healthcare professionals (read biomedical practitioners) should have access to any herbs deemed ‘medicines’. In the UK the EHTPA began a drive for the statutory regulation of herbalists as a consequence. This was promised in 2011 by the then Health Secretary and remained on the political back-boiler until 2015 when it was rejected by The Walker Report. Others maintain that a recognition of existing professional associations which already have rigorous membership criteria is the way forward. There is concern that the drive for professionalisation will erode the more traditionl aspects of herbal medicine. While these debates ensue orthodox healthcare remains in an unsustainable condition. Research in Northern Ireland has shown the potential for alternative therapies like herbal medicine to help relieve this untenable situation (McDade, 2008).

The story of modern herbal medicine has unfortunately been dominated by a defense against biomedicine’s epistemological appropriation of the healing arts. Despite marginalisation the practice of herbal medicine has survived for centuries. In stark contrast biomedicine is struggling after 150 years. It has undoubtedly excelled in the area of acute and emergency medicine especially but in the treatment of chronic conditions questions continue to be asked.

Evidence Based Medicine

As the foregoing narrative reveals, herbal medicine has centuries of evidence based on empirical observation. From ancient folk practices to the establishment of the great traditions; from the specialisation of herbals through centuries of clinical observation to modern clinical research herbal medicine has a formidable background like no other system of healing. Its ongoing popularity is a testament to its safety, efficacy and effectiveness though this requires further scrutiny. Today’s student of herbal medicine has an immense evidence base upon which to draw. But ‘evidence’ has taken on new meaning in biomedical philosophy.

In modern biomedicine the advent of EBM (Evidence-Based Medicine) and a particular interpretation of it has gained widespread acceptance and become the dominant creed. Accordingly any medication, or medical device, in order to be rubber-stamped must undergo randomized clinical trials. Essentially EBM is intended to eliminate bias from observed evidence by using a placebo along with the medicament in question. Participants in each trial don’t know if they are getting the real medicine or a placebo. The results are then accessed using quantitative systems working in percentage terms to see if a medicine is more active than placebo. Adverse reactions are also accessed. Incidentally most surgeries and many drugs have not been trialled according to these standards.

This rigid interpretation of EBM method and philosophy is deeply flawed on a number of levels (Davidson, Vlachojannis, Cameron and Chrubasik, 2013; Firenzuoli and Luigi, 2007; Gomory, 2013; Lexchin, 2012; Raymond-Khoury, 2012; Sehon and Stanley, 2003). The system was designed principally for pharmaceutical drugs and therefore works within the philosophical confines of the reductionist perspective. Herbal medicines are not pharmaceutical drugs though some drugs are made from plant extracts. Herbal medicines, whole or crude extracts, contain multiple constituents whose collective activity has a number of effects as has been noted for centuries. The randomised controlled trial is therefore ill-equipped to work with a traditional herbal remedy as dispensed by a herbalist. A traditional remedy not only contains a plant with multiple constituents, but more often contains a combination of many herbs in an individualised complex. This is also incorporated into a wider protocol which involves nutritional and lifestyle advice with a holistic, patient-centred approach. This process contains a significant tacit knowledge which cannot be quantified.

There has been considerable clinical research into herbal medicine (see McClure, Flower & Price, 2014 for example). New possibilities of use continue to be explored while traditional use is often vindicated. Yet in some cases research data is at odds. This can be due to the use of isolated extracts as discussed, poorly identified preparations, lack of traditional herbal knowledge and other factors. The use of clinical trials in contrived conditions can never replicate what happens in the real world. The external validity of data from such research remains questionable at best. The limitations of quantitative research also need clarification and subjection to scholarly debate.

The real crux of the matter is that commercial interests continue to dominate medicine; the science behind this is controlled by a particular set of values which are sectarian. A greater concern is iatrogenesis. Iatrogenesis is a term used to describe deaths or serious adverse reactions attributable to pharmaceutical drugs and surgery, and it remains a significant issue because it is a leading cause of death ( Lau, 2012; Lazarou, Pomeranz and Corey, 1998; Null, Dean, Feldman and Rasio, 2005).

Conclusions

Herbal medicine should not be seen as a panacea and nor should biomedicine be seen as the devil but that a consilience between the best in each field, and indeed other fields, might be merged in an eclectic new vision of medicine (Wilson, 2001). Biomedicine remains the main port of call in acute and emergency medicine, though it can be complemented; while herbal medicine may have much to offer the field of chronic medical conditions.

The World Health Organisation’s Traditional Medicine Strategy (2013) recognises that the sustainability of world healthcare is dependent on the traditional forms of medicine. It urges member states to preserve and integrate traditional medicine because the burden of chronic disease is crippling world economy. Herbal medicine remains a vital component of the medicine of the future.

In essence this is what true medical science is about – the consideration of all and any phenomena which has a favourable outcome even if not understood within the remit of a particular paradigm, so the claim scientific can be seen to have meaning and to have done its utmost to eliminate bias. This requires a fundamental paradigm shift in the epistemology of biomedicine which to date has not been forthcoming. It requires recognition of the tacit knowledge which underpins traditional medicine as centuries of wisdom cannot simply be overturned because it does not fit quantifiable criteria. Despite this the popularity of herbal medicine continues to soar as people choose what works for them and yet the choices people ultimately make are also influenced by their dissatisfaction with other systems despite the ‘science’ and the rhetoric.

[This essay is presented as an overview of herbal medicine and is the opinion of the author. It is not intended to suggest that herbal medicine can or should replace the biomedical system. Herbalists are not doctors. Anyone with a serious medical condition should consult a doctor. Herbalists treat people not diseases.

My work in herbal medicine began over 25 years ago. I hold an MSc in herbal medicine. I am a member, consultant and former president of the Irish Register of Herbalists, the leading professional association for traditional herbalists in Ireland.]

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