Endless variation
There are few plant groups as confusing to botanists as hawthorns. A genus in the rose family, Crataegus, as botanists call it, is now recognized to have about 280 species found in northern temperate regions, including North America, Europe, and northern Asia. The plant group embodies the concept of endless variation, with numerous hybrids and other variants, that in the late nineteenth century led to the naming of upwards of 1,000 species of hawthorn for North America alone! Botanists would do the world a favor if they reduced the entire genus Crataegus to a single species. The group is a taxonomic nightmare. Sixty or more species are known from Europe and Asia, so North America is certainly the center of distribution and diversity for the genus. The generic name Crataegus is derived from a Greek word kratus, or strength, referring to the hardness of the wood.

Hawthorns are large shrubs or small trees usually with dark brown bark, flaking in scales. A prominent feature of the branches is stout or slender, solitary or branched spines. The white, and sometimes red, usually foul-smelling flowers are born toward the end of leaf branches in round-top clusters. The delicate, small rose-like flowers are beautiful and abundant, helping to earn the tree a place of ornament in parks and lawns despite the nasty spines protecting the trunk. The fruits, perhaps more showy than the flowers, are rounded, oblong, or pear-shaped, relatively small (the size of a large cultivated blueberry), range from orange-yellow, scarlet, red, yellow, blue or black in color. The flesh is mealy and dry, like that of rosehips.

Ironically, in eastern North America, the part of the world with the greatest diversity and number of Crataegus species, one of the most extensively planted hawthorn species is the English hawthorn, Crataegus laevigata (C. oxyacantha). It is distinguished by its three to five-lobed leaves and blossoms with a purplish tint. This, too, is the species most often listed as a medicinal plant in herbals of European and American tradition, though many species are used interchangeably for medicinal purposes. Most herb books list Crataegus oxyacantha, an older name synonymous with the currently recognized name C. laevigata.

Several species of hawthorns are recognized as sources of medicine. In Europe, one-seed hawthorn, Crataegus monogyna is used along with C. laevigata. Both the leaves and flowers as well as the fruits of these two species are used in European herbal traditions. Both of these species occur throughout Europe. Occasionally other hawthorns species are used such as Crataegus pentagyna, native to the Balkan Peninsula. A common species of the eastern Mediterranean region Crataegus azarolus is sometimes used in herbal medicine. Black hawthorn, Crataegus nigra has been the species of choice in eastern European countries where it is grown on a commercial scale. In traditional Chinese medicine, hawthorn fruits are known asshan-zha. The fruits are derived from a number of species, most notably C. pinnatifida, as well as C. cuneata, both of which have been grown in American gardens.

Use by Native Americans
Hawthorns have a fascinating history of use. A number of North American hawthorns were used as medicine by indigenous groups. The fruit of Crataegus chrysocarpa was used by the Potawatomi to treat stomachache. The Ojibwa used a root decoction of one hawthorn to treat diarrhea and dysentery. The Chippewa used a root decoction as a tonic and strengthener for female diseases. The fruits were used by the Fox as a diuretic for kidney and bladder ailments. The Meskwaki also used hawthorn fruits for bladder ailments. They used it as a general tonic, astringent, and a cardiac strengthener. The Omaha-Ponca and the Winnebagos ate the mealy hawthorn fruits as food during times of famine. The Cherokee ate the somewhat bitter fruits as an appetite stimulant, as well as to improve circulation and relieve cramps. One of the western North American species, C. Douglasii, was used by the Thompson Indians for stomach ailments. The bark, wood, or sap was decocted for this purpose. The Kwakiutl chewed the leaves and used them as a poultice for wounds and sores.

Use in China
In traditional Asian medicine, as well as herbal medicine in the European tradition, the fruits have been widely used in prescriptions, taken over an extended period of time, to treat hypertension, associated with cardiac weakness, arteriosclerosis, and angina pectoris. It stimulates blood circulation, improving flow to the coronary arteries.

In China, the fruits of Crataegus pinnatifida have been eaten to cure scurvy, taken as a mild laxative, and for stomach ailments. The leaf and twigs have been used as an antidote to poisoning with varnish. In Oriental medicine the fruits are considered to have sour, sweet, slightly warming qualities. They are utilized in prescriptions to dissolve food and resolve stagnant digestion caused by accumulations of meat, characterized by abdominal distention and pain, or diarrhea. The fruits resolve congealed blood and are used for post partum abdominal pains and heart pains. The charred fruits are taken in prescriptions to relieve diarrhea and chronic dysentery. Hawthorn was first mentioned as a drug in the Tang-Ben-Cao, a Chinese herbal attributed to Su-Jing and others, dating to 659 AD. This work is considered the worlds' first official pharmacopoeia. In modern China, clinical experiments have shown that hawthorn fruit preparations lowers blood pressure, affects systemic vasodilation, lowers serum cholesterol levels, and is useful in the prevention and treatment of arteriosclerosis.

Hawthorn emerges in America
In Western traditions, hawthorns are recognized for their utility in heart ailments in relatively recent times. It is mostly absent from the works of the famous Greek and Roman herbal writers, who mention it only in passing for its edible, though less than delicious fruit. The famous authors of English herbals such as Gerard give it little attention. One is hard-pressed to find any historical Western references beyond mention of the use of the fruits for stomach ailments or to treat diarrhea. There is an interesting thread through the plant's scant historical record. If uses in China are compared with American Indian use and European folk use, cultures on opposite sides of the world were in essence using hawthorns for very similar purposes.

A curious article by J.C. Jennings of Chicago was published in an 1896 issue of the New York Medical Journal, which for the first time brought to light the serendipitous use of hawthorn in the treatment of heart conditions. He wrote, "There lived in the city of Ennis, County Clare, Ireland, until about two years ago, a prominent physician named Greene, who was well and favorably known over the greater part of Ireland and parts of England and Scotland for his reputed ability to cure heart disease.

"It was found after his death that he had accomplished these cures solely with a fluid extract made from the Crataegus Oxyacantha, or hawthorn fruit. My brother, who resides with in a few miles of Ennis, having informed me of these things, I immediately wrote him, requesting that he send me some of the fruit, to be used for testing the efficacy of the remedy, which he did. I made a fluid extract according to the British Pharmacopoeia, and have used it up to the present on forty-three patients suffering with various forms of heart disease, and I must say with the most gratifying results. . . . From these results my deductions are that Crataegus Oxyacantha is superior to any other of the well known and tried remedies at present in use in the treatment of heart disease, becuase it seems to cure while the other remedies are only palliative at best. "

Based upon Jennings enthusiasm for the herb, by 1898, John Uri Lloyd, the most important pharmacist in the history of American medicinal plants and owner of Lloyd Brothers Pharmacists, Inc. of Cincinnati began manufacturing hawthorn drugs.

In a Treatise on Crataegus (1921), John Uri Lloyd recalls, "At first, we made only a tincture, or fluid extract of the imported hawthorn berries, but comparative investigations finally led us to the conclusion that this berry is inferior to one of the American species, and accordingly we finally placed the Specific Medicine of that Crataegus berry on the market".

Unfortunately, Lloyd does not tell us which American Hawthorn he found to be most superior. . .

John Uri Lloyd, himself, admits to delaying the introduction of important drug plants including Crataegus and echinacea because of his own personal prejudices. He and his brothers in Lloyd Brothers Pharmacists, Inc., had dismissed hawthorn's potential in the treatment of heart disease as nothing more than old wife's tales.

"My own delay in its general introduction is to me now a subject of self-criticism. I am now more pronouncedly of the opinion, as experiences multiply, that a person who is restricted to laboratory experiments, especially if he be more or less adversely prejudiced (as I was against Echinacea [and hawthorn]), is not in a position to judge with discretion. Nor is a laboratory man to be considered as "authority" in clinical directions, which applies no less forcibly to inadequate drugs introduced under laboratory propaganda than to those worthy decried thereby."

Footnoting those comments, he mused, "Seemingly, a number of 'experiences' were necessary to teach me this lesson. Crataegus, commended first in the New York Medical Journal for heart disease, was not only for months kept out of Lloyd Brothers' list, but was even satirized by Mr. C.G. Lloyd [younger brother and partner of J.U. Lloyd], in the following words: 'If there be anything in Crataegus, the hogs should have long since discovered its value, because hogs eat the fruit in quantities.' One correspondent asked, 'Well, did you ever know a hog to be affected with heart disease?'"

Once introduced into the medical profession in the late 1890s in the United States, physicians began singing the praises of using hawthorn preparations in their practices. In the Lloyd's Treatise on Hawthorn, Dr. H.P. Whitford of Bridgewater, New York reflected, "I do not consider it a 'cure-all', but no one agent has given better results in its sphere of action. In weak hearts, with consequent capillary congestion, with effusion, even where valves are so diseased as to eventually cause death, it has proved of great benefit."

Active constituents?
Hawthorn was used clinically both in the United States and Europe in the first half of this century for the treatment of heart disease. Modern scientific investigations of the herb did not begin until the 1960s. A number of classes of compounds including sterols, triterpenes, flavonoids, catechins, proanthocyanidins and amines, all of which have been shown to effect the cardiovascular system, were isolated from the flowers and leaves as well as the fruits. However, no single compound was found to be responsible for hawthorn's heart tonic effects.

In Herbal Medicine, the late Dr. Rudolf Fritz Weiss, write, "Again it was found that the complete effect is achieved only through the combination of a whole number of active principles. . .the sum of these individual constituents, in the combination offered by natures, has unique and valuable properties. It is obvious that the actions of the individual elements are not merely additive or synergic, but that genuine potentiation occurs."

Today, commercial preparations, primarily manufactured in Europe are calibrated to contain flavonoids, oligomeric procyanidins, and chlorogenic acid, among other constituents. Timing of harvest as well as plant part used have been found to be important factors to consider when developing hawthorn drugs. For example, as much as three times the amount of procyanidins are found in the fall leaves, compared with those harvested in spring.

From Folk Medicine to Modern Phytomedicine
As a modern drug for the treatment of heart disease, hawthorn preparations are widely recognized in European countries such as Germany and Asian countries, including China. Hawthorn preparations are the subject of German Commission E monographs. These monographs which serve as the basis for regulation of herbal medicines in Germany were first instituted in 1978, when the Commission, consisting of professionals in pharmacy, medicine, industry, as well as lay persons, was instituted. One of the first monographs produced was on hawthorn. At the time, hawthorn drugs consisted of the flower and leaves and/or fruits of hawthorn. Since the first monograph was published in the late 1970s, it has been revised several times. The most recent revision was in spring of 1996. Today, hawthorn drugs approved for use in heart conditions in Germany consist of preparations of the leaf with flowers of Crataegus monogyna or Crataegus laevigata. Drugs made solely from the fruits or the leaves or the flowers are no longer allowed to carry drug claims. Presumably, the reason for this change is that most clinical studies with hawthorn have involved preparations including the leaf with the flower.

Hawthorn preparations are prescribed by physicians in Germany and elsewhere for the treatment of diminished heart performance at the early stages of congestive heart failure, for angina pectoris, and to help in long-term recovery from heart attacks. It is also used to reduce a sensation of pressure or anxiety in the heart area, age-related heart problems not requiring digitalis, and mild forms of arrhythmias. Pharmacological and clinical studies have shown that it helps increase the efficiency of the heart by helping to improve the blood supply to the heart muscle itself and by strengthening contractions. The heart is then able to pump more blood to the rest of the body, while helping to dilate blood vessels at the same time. Hawthorn extracts have also been shown to improve circulation to the extremities by helping to reduce resistance in the arteries.

Preparations and caveats
Various European hawthorn products, including those made from the fruits as well as the leaves with flowers, some of which are available on the American market as dietary supplements are standardized to oligomeric procyanidins and flavonoids. The dose is 160 mg per day (divided into two doses), or under a physician's supervision as much as 160 mg three times daily may be prescribed in Europe. The pleasant-flavored, slightly tart, astringent tea of the berries is traditionally made using about a teaspoon of the powdered fruits to a cup of water.

No side effects or contraindications are reported for hawthorn. However, heart disease is the number one killer in the United States, and cannot be self-diagnosed of self-treated. Heart disease or factors contributing to heart disease should be identified and treated by a physician.

Here we have a medicinal plant that has proved effective in the treatment of heart disease among Europeans and Asians. Ironically, in North America, the land with the largest number and greatest diversity of hawthorn species, its use for heart conditions is relegated to historical obscurity.

References

1. Brown, D. Herbal Prescriptions for Better Health. Rocklin, Calif.: Prima Publishing, 1996.

2. Foster, S. Herbal Renaissance. Layton, Utah: Gibbs Smith Publisher, 1993.

3. Foster, S. Herbs for Your Health, Loveland, Colorado: Interweave Press, 1996.

4. Hamon, N.W. Herbal medicine: Hawthorns (Genus Crataegus). Canadian Pharmaceutical Journal . 121: 708-9; 724, 1988

5. Hobbs, C. and S. Foster. Hawthorn - A Literature Review. HerbalGram 22:18-33, 1989

6. Lloyd, J.U. A Treatise on Crataegus Drug Treatise No. 29. Cincinnati: Lloyd Brothers Pharmacists, Inc., 1921.

7. Tyler, V. 1994. Herbs of Choice - The Therapeutic Use of Phytomedicinals. Binghamtom, New York: Pharmaceutical Products Press, 1994.

8. Weiss, R.F. Herbal Medicine (translated from German by A.R. Meuss). Beaconsfield, England: Beaconsfield Publishers Ltd., 1988.