Elderflower
A Chinese Medicine Perspective
Peter Holmes, L.Ac., M.H.
© Peter Holmes 2004

The elder tree is a familiar sight in both town and country, and a good seasonal marker. It is said that the 'English summer is not here until the elder is fully in flower, and that it ends when the berries are ripe' (Grieve 1971). This common pan-European tree with its 'flat-topped masses of creamy-white, fragrant blossoms', has provided several traditional herbal remedies since prehistoric days: Elder flower, berry, bark and leaf. The most versatile and widely used of these, however, is the flower, which therefore deserves a fresh look as a potential neo-Chinese medicinal herb. Elderflower is the whole flower corymb of Sambucus nigra in the honeysuckle (Caprifoliaceae) family. Its pharmaceutical name is Flos sambuci (using the Chinese method of pharmaceutical nomenclature).

The traditional European usage of Elderflower is centered around its ability to promote sweating (diaphoresis) and its specific affinity for the respiratory tract. Its primary indications are the onset of colds and flus, especially with fever present, as well as bronchitis and asthma (Weiss 1985, Schauenberg 1977 et al.). With the rise of the toxicosis and elimination theories in Western herbal medicine during the seventeenth centuries, its diaphoretic action has also been put to service to promote general detoxification, i.e. toxin elimination (Valnet 1983, Willfort 1986). In North America Eclectic doctors also utilised Elderflower's diuretic, anti-inflammatory and depurative actions for chronic edema and urinary and skin infections in particular (King 1902, Fyfe 1909 et al.). More recent physiomedical usage in America and England has also included application for acute upper respiratory discharges (Lyle 1897, Mills 1978) because of its pronounced anticatarrhal or mucostatic effect.

Since time immemorial, Elderflower has provided countless cherished culinary and domestic medicine products, both in England and overseas, including elderflower wine, cordial, vinegar (for sore throat), floral water (for eye and skin lotions) and ointment (for skin conditions). The berries too have been made into syrups, purees or robs, jams, jellies, chutneys and kechups. Many of the recipes for these originated in the Tudor still-rooms of larger households. Maud Grieve devotes a full 11 pages to the many traditional uses of the elder tree in construction, ritual, medicine and cooking, setting out with the statement that 'a wealth of folk-lore, romance and superstition centre round this English tree'. I would refer the reader to this excellent compilation for further information-and recipes-in these various areas.

Energetic Properties and Functions
As regards its toxicity category, Elderflower is considered a mild remedy that possesses minimal to no chronic cumulative toxicity. It may therefore safely be used over long periods of time, all the more so as it will be combined-more often than not-with other herbs in a formula.

The taste is pungent, sweet and somewhat aromatic. Pungent and aromatic give it the potential for dispersing pathogens and promoting sweating, as well as for activating the Qi and transforming phlegm and damp. Meanwhile, its sweet taste allows it to strengthen the Spleen and drain damp.

The warmth/thermal quality is cool. As a light flower, its directional tendency is floating upwards (fu) when drunk hot, allowing it to enter the Lung, diffuse Lung Qi and then disperse the surperficies and expel pathogens. Its floating movement also means that it can treat local problems in the skin, eyes and upper regions in general, such as fire toxin symptoms and rashes. When taken at room temperature or cold, however, its Qi tendency is definitely more neutral and moderate, and includes a draining action on water and damp-heat through the Spleen and Bladder.

The channels entered are the Lung, Spleen and Bladder. In terms of the three warmers (san jiao), Elderflower actually affects all three warmers, although it is most pronounced in the upper and lower warmers. In the upper warmer it disperses wind and heat pathogens from the surface, and transforms phlegm, damp and Qi stagnation in the Lung with its pungent-aromatic quality. In the lower warmer the herb clears heat and drains damp through its sweet property.

These qualities and essential actions in concert now provide us with grounding for a modern application of this herb in Chinese medicine.

Clinical Functions and Indications

1. Releases the exterior, dispels wind-heat and stops discharge
Elderflower eliminates external pathogens with its pungent and aromatic properties that enter the Lung channel. The mechanism of this is by causing sweating to release the exterior. This is its strongest action. Cooling by nature, Elderflower treats external wind-heat, particularly with fever, nasal discharge and congestion, and sore throat. The nasal discharge and congestion could be described as damp-heat invading the head, and it would not be wrong to say that Elderflower actually dispels wind-damp-heat in the exterior.

Unfortunately there is no exact equivalent in the Chinese materia medica to this first action. On one hand Elderflower is an unequivocal external wind-heat herb like Ju Hua (Fl. Chrysanthemi), Jin Yin Hua (Fl. Lonicerae), etc.-all of them flowers too-that adresses typical wind-heat symptoms. On the other hand, this herb has the additional specific function of stopping nasal discharges that are due to damp and heat invading the sinus passages. In that sense it acts like a cooling version of Cang Er Zi (Fr. Xanthii) and Xin Yi Hua (Gemma Magnoliae), but with a far greater emphasis on drying up the discharges (rather than opening the sinuses, as in the case of these two herbs).

Western combining herbs for external wind-heat with just fever and sore throat include Yarrow (Hb. Achilleae) and Linden (Fl. Tiliae). For wind-heat with damp-heat nasal discharge, Eyebright (Hb. Euphrasiae) and Plantain (Fm. Plantaginis) are good choices. Note here that the old Western standby combination of Peppermint, Yarrow and Elderflower for the onset of colds actually is somewhat of a catch-all formula that adresses external wind-cold as well as wind-heat (Peppermint being the main wind-cold agent here)-although it works better, on the whole, for external wind-heat because of the two relaxant diaphoretics Yarrow and Elderflower.

Because of its great tropism for the Lung, and as it dispels wind-heat, Elderflower is also appropriate for Lung wind-heat syndromes with fever, sore throat and cough, where it could be combined with such similar herbs as Burdock seed Niu Bang Zi (Fr. Arctii), Bo He (Hb. Menthae haplocalycis), Spearmint (Fm. Menthae spicatae) and White horehound (Hb. Marrubii).

Elderflower is traditionally also used for treating fevers in general. It works best in most fevers that are still in the early stages, when the skin is dry. Elderflower can break the fever by causing sweating, including Qi-level heat or 'warm fevers' in the early-stages (see also below).

2. Dries damp, transforms phlegm and diffuses Lung Qi
Pungent, aromatic and dispersing, and focusing on the Lung, Elderflower also dries damp and transforms phlegm in the upper warmer, while at the same time regulating Lung Qi to dispel the Qi accumulation resulting from the stagnant damp-phlegm excess. It therefore treats sputum production and cough from phlegm-damp in the Lung, while relieving the wheezing from the Qi accumulation in the Lung.

In this sense Elderflower is both like Ban Xia (Rz. Pinelliae praeparata) (for transforming phlegm-damp) and like Xuan Fu Hua (Fl. Inulae) or Bai Qian (Rx. et rz. Cynanchi) (for regulating Lung Qi and dispersing Qi accumulation). The only difference here is that Elderflower is cooling, not warming. Again, unfortunately here there is no exact TCM equivalent.

Similar Western herbs that offer combining possibilities here include the equally aromatic herbs Thyme (Hb. Thymi) and Hyssop (Hb. Hyssopi) (with pronounced phlegm-damp). With wheezing and coughing present, Coltsfoot (Hb. Tussilaginis) and White horehound (Hb. Marrubii) would be more appropriate.

Because it is both heat-clearing and dispersing, Elderflower can also be also useful in Lung phlegm-heat patterns with Qi accumulation present. Typical symptoms adressed here would be fever, sputum, wheeze and cough, where it will benefit from similar-acting herbs such as Gua Lou (Fr. Tricosanthis), Dong Gua Ren (Sm. Benincasae), Zhu Ru (Cs. Phyllostachis), White horehound (Hb. Marrubii) and Pleurisy root (Rx. Asclepiadis tuberosae). Note here that although Elderflower is useful for Lung wind-heat and Lung phlegm-heat patterns, which include the symptom of cough, it does not actually expel phlegm or stop coughing (nor do these three Chinese herb examples). It simply transforms phlegm-damp, moderately clears heat and diffuses the stagnant Lung Qi.

Likewise, note also that Elderflower could not be said to descend Lung Qi in the sense of Xing Ren (Sm. Pruni armeniacae), Bai Qian (Rx. et rz. Cynanchi) or Sang Bai Pi (Cx. radicis Mori). These herbs posess a much stronger action which expresses itself as downward moving and therefore strongly wheeze and cough relieving. Elderflower is just not in this league. We should think of Elderflower simply as a gentle yet effective Qi mover in the Lung when either wind, phlegm or heat pathogens obstruct Qi flow-as simple as that. This is why Elderflower is excellent for treating mild cases, for when two or more of these pathogens are present, as well as for treating children in general.

3. Strengthens the Spleen, promotes urination and drains damp
With its sweet taste quality, and when drunk cold, Elderflower can drain accumulation of water-damp and relieve edema by strengthening the Spleen. It mainly treats chronic edema, particularly around the waist or generalised water retention in the tissues, arising from Spleen Qi deficiency. Here the clear equivalents are the sweet-bland herbs Fu Ling (Scm. Poriae) or Fu Ling Pi (Cx. Poriae), Yi Yi Ren (Sm. Coicis) and Ze Xie (Rz. Alismatis). Western possibilities include Nettle (Hb. Urticae), Goldenrod (Hb. Solidaginis), Juniper (Fr. Juniperi) and Lovage (Rx. Levistici), although the last two are warming, not cooling.

4. Clears heat, drains damp and harmonizes urination
Elderflower also has an excellent affinity for the urinary tract, the Bladder. Being heat clearing and damp transforming, the herb is also indicated for Bladder damp-heat syndromes, including those presenting strangury or otherwise difficult urination, and including those seen in damp and Stone lin syndromes.

Similar Chinese herbs for this clinical function include Che Qian Zi (Sm. Plantaginis), Mu Tong (Cs. Akebiae seu Aristlochiae) and Bian Xu (Hb. Polygoni avicularis), while Western additions might include Horsetail (Hb. Equiseti), Cleavers (Hb. Galii) and Goldenrod (Hb. Solidaginis).

Elderflower can also be chosen for damp-heat syndromes that present urinary stones and irritation, and in this sense is a good damp-heat drainer for the lower warmer in general, like Che Qian Zi (Sm. Plantaginis). Other suitable herbs here include Shi Wei (Fm. Pyrrosiae), Jin Qian Cao (Hb. Lysimachiae) and Dong Kui Zi (Sm. Abutili seu Malvae); while Cleavers (Hb. Galii), Hydrangea (Rz. Hydrangeae) and Gravel root (Rx. Eupatorii purpureii) provide some Western options.

5. Clears fire toxin and benefits the skin
This last function divides into three main clinical applications.

First, fire toxin such as boils, ulcers, abscesses, especially when found in the upper regions (remember this is a dispersing and floating herb). Chinese equivalents here include (once again) Jin Yin Hua (Fl. Lonicerae), Lian Qiao (Fr. Forsythiae) and Ye Ju Hua (Fl. Chrysanthemi indici); while Western possibilities include Marigold (Fl. Calendulae) and Echinacea (Rx. Echinaceae).

Second, fire toxin with eye inflammations. Good equivalents for this usage include Selfheal Xia Ku Cao (Spica Prunellae) and Ye Ju Hua (Fl. Chrysanthemi indici); as well as Camomile (Fl. Matricariae seu Anthemis) and Eyebright (Hb. Euphrasiae).

Third, fire toxin and/or damp-heat in the skin causing chronic eczema (pustular, suppurative) and ulcers. Similar herbs here include Bai Xian Pi (Cx. radicis Dictamni), Di Fu Zi (Fr. Kochiae) and Ku Shen (Rx. Sophorae flavescentis); as well as Red clover (Fl. Trifolii), Burdock (Rx. Arctii) and Walnut leaf and hull (Fm. et pm. Juglandis) among Western options.

Elderflower and Jin Yin Hua (Fl. Lonicerae) are both in the botanical honeysuckle family, so it is worth pausing for a moment to see whether this natural link will translate to a therapeutic connection that may be useful as a mnemonic aid, if nothing else. Certainly, we have seen that Jin Yin Hua has equivalent functions in many of Elderflowers'. But exactly how far do their similarities extend, and where do their functions clearly diverge?

As flowers both herbs are clearly similar in their sweet, light and floating qualities; however Jin Yin Hua is cold, whereas I consider Elderflower cool. Both flowers release the exterior to dispel wind-heat, and both clear fire toxin. However, Elderflower releases the exterior mainly through causing sweating, whereas Jin Yin Hua does so mainly through clearing heat and dispelling toxin-or, in microbial terms, through a stronger anti-infective action. In this sense, the two would form an excellent mutual assistance (xiang shi) if not mutual enhancement (xiang xu) combination for treating wind-heat onsets. For treating fire toxin conditions, Elderflower treats more superficial, milder and upper-region heat toxin (such as eye infections), whereas Jin Yin Hua treats more internal and more severe fire toxin such as intestinal abscesses, severe sore throat from laryngitis, and so on. Also, Elderflower treats damp-heat skin lesions (in common with its theme of transforming damp), unlike Jin Yin Hua. Here again, the two would form a nice duo.

Would Elderflower also treat Qi-level heat in early-stage warm fevers, like Jin Yin Hua? Provided this was a dry fever/heat without sweating, yes definitely. Being still in the beginning stage with a rising temperature, Elderflower would easily break the fever by causing sweating.

And here their functions part ways. Elderflower with its dispersing energy goes on to transform phlegm-damp and 'ventilate' the Lung, as well as drain water-damp and Bladder damp-heat. Jin Yin Hua on the other hand, with its colder nature moves to the nutritive and Blood level to clear the heat of epidemic warm fevers. In summary, I would say that Elderflower is better at releasing the exterior, while Jin Yin Hua is better at clearing fire toxin.

Precautions
Elderflower is a mild remedy with no chronic toxicity and may be used freely. However, because it promotes sweating when drunk warm or hot, contraindicated in sweating from external deficiency or Yin deficiency (like Ma Huang, in fact), and in Qi-level heat with sweating already present.

Preparation
The basic preparation for releasing exterior conditions is the hot water infusion. Because this preparation is dispersing, it is excellent (with or without other wind-heat dispelling herbs-see above) for releasing the exterior at the onset of symptoms. The cool or cold infusion is preferable for all other uses, which engages a more descending effect.

Elderflower can also be given in the convenient tincture form and is available as such from various suppliers. The tincture is an alternative to the cold infusion for its other functions, as this is more activating on the interior.

When used in conjunction with a decoction formula, such as Yin Qiao San or Cang Er Zi San, Elderflower can be added 5 minutes before the end of decocting time or, better still, stirred into the hot finished decoction and allowed to infuse for another 15 minutes with the lid on before straining. Elderflower does contain an essential oil that will evaporate in the decocting or infusing process if the lid is not put on!

Local preparations with Elderflower for fire toxin symptoms, such as eyewashes, skin compresses, creams, ointments, and so on, are also good options in adition to internal intake. Topical and internal administration will always reinforce each other's action.

Remarks
Elderberry (Fr. Sambuci) has similar qualities to the flower and can be used in a short decoction, especially to dispel wind-damp obstruction and open the bowels. Because modern research has shown Elderberry specifically to possess antiviral properties, it is today an important remedy for viral onset of flu. Elderberry can be used preventively in case of a flu pandemic, and when taken during an infection has shown to speed up recovery time. The flower and the berry can of course always be used together in external conditions.

Elder bark (Cx. Sambuci) (using the inner bark) strongly drains downward. In a decoction it strongly drains water-damp (for edema) and purges accumulation (for severe constipation).

Dosage
The dosage is average: 6-16 g for the hot infusion; 2-5 ml for the tincture.

References
Bergzabern, Johann Jakob Theodor von (1588). Neu Kreuterbuch. Francfurth am Main

Fuchs, Leonhardt (1542). De Historia Stirpium. Basel

Fyfe, John W. Specific Medication (1909). Cincinnatti, Scudder Bros.

Grieve, Maud (1971). A Modern Herbal. London: Dover

Holmes, Peter (1997). The Energetics of Western Herbs, 3rd revised edition. Boulder, Snow Lotus Press

Holmes, Peter (2003). The T.C.M. Materia Medica Clinical Reference and Study Guide. Boulder, Snow Lotus Press

King, John, Felter, H. and Lloyd, U. (1898). King's American Dispensatory. Cincinnati, Scudder Bros.

Lyle, T.J. (1897). Physiomedical Therapeutics, Materia Medica and Pharmacy.Cincinnati, Physiomedical College

Mattioli, Pierandrea (ed. J. Verzascha) (1611). Kreutterbuch. Basel
Mills, Simon (1978). N.I.M.H. Pharmacology Lectures. Tunbridge Wells, N.I.M.H.

Schauenberg, Paul, and F. Paris (1977). Guide to Medicinal Plants. New Canaan, Inner Traditions

Valnet, Jean (1983). Phytotherapie. Paris, Maloine
Weiss, Fritz (1985). Lehrbuch der Phytotherapie, 6th revised edition.
Stuttgart, Hippokrates

Willfort, Richard (1986). Gesundheit durch Heilkraeuter. Linz