It’s Goldenrod Time!
The wheel of the year is turning once again and the season of Fall is beginning her gentle emersion with first few leaves descending toward the turning Earth. There is a new chill wafting on the morning air and the Canadian Geese have us in their flight path as they embark on this year’s journey South. These signs and more tell us that the times they are a-changing. Many of us, including myself, experience seasonal allergies in the late summer and early Fall that will continue until the first hard, killing frost. Growing up in the Northeast I was always told that my allergies could be attributed to the Goldenrod as these bright yellow flowers are in blossom everywhere we look right now. If I look out to my back field it appears as if there is a sea of yellow flowing flowers that stretches into eternity.
It seems only obvious that a field full of blowing flowers would be the allergy culprit of Fall, but in my herbal studies I discovered that Goldenrod is a highly medicinal plant and one of its main uses is for the runny, drippy, sinus symptoms related to these very allergies. Also, in studying the reproductive cycle of plants, Goldenrod is NOT wind pollinated and if you get up close and personal with a Goldenrod plant you will notice that there are always bees dipping down to draw out the rich, procreative pollen inside the flower. If a plant is not pollinated by the wind then there are not pollen grains blowing around in the air and into your sinuses. If you get even closer and look beneath the yellow canopy you’ll also see another, quiet, inconspicuous, yet volatile, smaller and, yes, wind pollinated green flowered plant called Ragweed. It is Ragweed that is responsible for many of our allergies and Goldenrod just gets the blame because she is so showy and bold. For more on Ragweed and seasonal allergies go to this previous post
Goldenrod(Solidago canadensis, spp.) is in the Asteraceae family and is one of the most prolific plants in Central New York and all of North America with 40-60 species existing worldwide. It flowers from July through September and is prevalent in open fields, along roadsides and any open space. All species can be used interchangeably with species differentiation being tricky as Goldenrod has mixed, matched and cross-bred to make infinite varieties. The most reliable key is to learn a few of the most common shapes such as (from left to right below)Plume-like, flat-topped, Elm-branched,Club-like or showy, and wand-like or slender. These forms each correspond to different species. Photos from A Field Guide to Wildflowers of Northeastern and North-Central North America by Roger Tory Peterson and Margaret McKenny
The Latin name Solidago is derived from Solidare or from the medieval Latin word soldago meaning to make whole or solid indicating its use as a wound healing herb. Also derived from Solidare is the English word solid that is related to the Old French word solide that goes back around to another Latin word, Solidus and means to make whole, undivided, firm and genuine. The Latin translation of Aster means star and symbolizes flowers that hold star-like qualities. The small, sparkly flowers of Goldenrod definitely remind me of twinkling stars and it was once thought that holding Goldenrod in the hand will reveal secret riches. It is also considered to indicate the location of springs which has proven to be true in my backyard. Our Goldenrod grows thickest right where our springs are found!
Energetics and Actions: Bitter, Pungent, Astringent, Cold, Dry, Aromatic, Slightly diffusive
Main constituents: Essential oil containing salicylic acid, tannins, saponins and flavonoids
Also known as: Woundwort, Blue Mountain Tea, Liberty Tea(used as an ingredient in the tea the colonists made themselves to replace English tea)
Parts used: Leaf and flower
Goldenrod is used as a digestive bitter and bitter it is. This bitter quality is present due to the tannins and the astringent action which tightens tissues making it especially useful for drying up mucus discharge from the sinuses during allergy season It can be taken as a tea, tincture or by simply chewing on a leaf. If I am starting to feel my allergies coming on I will often simply go outside, grab a Goldenrod leaf and chew it in my mouth for a bit. It is also known as a specific for cat allergies and I have used it repeatedly and always with success when I have visitors who are allergic to my cats. I learned this from Matthew Wood who says:
“I know of no better remedy for cat allergy. Boericke describes the characteristic eye symptoms: ‘red, injected, watery, stinging, burning.’ The eyes of the Solidago patient look like a person who has just gotten out of a swimming pool. There is a generalized redness of the conjunctiva. There are not the bright red blotches of Euphrasia, or the bloodshot appearance of Ambrosia. With this there is congestion, sneezing and running of the nose, redness and irritation of the skin. Solidago often has welts from allergy, a fact not mentioned in the literature I have seen.”
Goldenrod is also a diuretic and is nourishing and strengthening to the kidneys and entire urinary tract relieving edema, low-grade chronic Urinary tract infections, and kidney Qi stagnation. Basically, relieving dampness that is occupying space within the kidney.blocking the natural flux of fluids and reducing overall efficiency. It can prevent kidney stones and any other symptom that is associated with a lack of sufficient elimination of waste from the kidneys including hypertension, skin rashes, eczema, psoriasis and inflammation of the urinary tract.
One of my favorite uses for Goldenrod is as a poultice or liniment for bruises, strains, sprains or other soft tissue injury. It works like a charm as a pain reliever and anti-inflammatory while promoting deep and thorough healing by draining and eliminating excess fluid and dampness which allows for fresh, oxygenated and nutrient full blood and lymph to rejuvenate and repair damage. The image I have envisioned for this process is that of a flushing or cleansing that clears out congestion at the same time tightening and toning. This prepares the injured tissue to full access of its natural regenerative capacity. The toning action strengthens to create a flexible yet stable container for new, healthy cells.
These shining flowers that usher in the change of seasons and the darkening of our days are some of the years last blossoms to hold their small faces to the fading sun. These concluding light holders have an important use in alleviating Seasonal Affect Disorder, a common human reaction to small amounts of sunlight. Goldenrod carries the sun’s grace over the winter as an effective uplifter of mood, a nervine for chronic fatigue, nervous exhaustion, depression, stress, shock and disappointments. Particularly those that are correlated to a buildup of unprocessed emotions which, again, refers to that stagnation and heavy dampness that Goldenrod is so adept at releasing whether in our kidneys, respiratory tract or psyche.
Goldenrod grows in great abundance and can be gathered freely, although always with respect and thanks. The different species all contain similar properties and may all look alike at first glance, but as you get to know them better you will begin to observe the subtle variations in not just form but taste and effect. New Mexico herbalist Kiva Rose has determined a few important species characteristics:
Special consideration should be given to the variability of the flavors and scents within the great many spp. of Solidago. If you have multiple species near you (and you probably do) take the time to taste the leaf and flower of each kind, and get to know the subtle differences. The most aromatic tend to be more helpful for mood elevation, kidney problems and external use, while the more bitter or bitter/aromatic spp. are especially nice for digestive issues and the astringent/aromatic types are great for upper respiratory issues and general mucus membrane over-secretion. These type of subtleties apply to all herbs, but Goldenrod tends to be a great example of it because of the many spp. and sensory variances even within a single species or subspecies.
Tincture-2-4 ml 3x per day
Tea-1/2-1 tsp. of dried or fresh leaf and flower per 1 cup of boiling water steeped for 5-10 minutes. You may want to add honey to this as it will be bitter.
References and resources:
The Earthwise Herbal by Matthew Wood
The Energetics of Western Herbs by Peter Holmes
The Medicine Woman's Roots blog by Kiva Rose, just put Goldenrod in the search box and you'll get a list of excellent posts!
The Wild Ways of American Sarsparilla~Aralia Nudicaulis
Botanical Name: Aralia Nudicaulis. A member of the Araliaceae or Ginseng family
Status: Native to North American in boreal forests. It is found beneath hardwoods in rich soil.
Common names: Wild Sarsparilla, American Sarsparilla, Small Spikenard, False Sarsparilla, Wild Licorice, Rabbit Root
Description: A perennial that grows in the woods of the Northern United States and Canada. The leaf stalk grows up to 18” tall with compound leaves that branch out into 3 groups of 5 each. The flower is an umbel that comes up beneath the leaves in groups of 3.The leaves die back in the summer leaving the flowers to ripen into purplish black berries. The root is gathered although all parts of the plant can be used. The main root grows vertically down just a few inches but there are secondary runners that grow horizontally. New plants emerge from these underground rhizomes forming interconnected colonies. Gather in the Spring or Fall.
Taste: sweet, pungent, aromatic
Energetics: Cool, moist, oily
Actions: tonic, alterative, antisyphilitic, diaphoretic
Preparation: decoction of dried root or alcohol tincture. Tincture dose- 15-30 drops 3-4 x per day
Metaphysical pattern-Aralia Nudicaulis provides nourishment for the body and soul in a gentle but profound way. It has roots(actually underground stems) that grow laterally. This signifies communication that is dispersed in a web of synapse alongside the mycelial network. This transmits information in a matrix that, instead of being concentrated up and down, is dispersed outward where it is less centered, more continuous and evenly distributed. This offers sensory intelligence that is less polar, more insulated and therefore less interrupted. This contiguity allows for easy networking from plant to plant providing steadily accessible nutrients, perception and expression. This patternis different in contrast with American Ginseng, another aralia, that has a solid, centered root and conveys a strong message and presence. Wild Sarsparilla has less compact energy and is much more celestial in presence with its horizontal connection being held by the Earth's magnetic field as a wave instead of as a solid, directive force. When standing among a patch, or really it’s a sea, of Wild Sarsparilla there is always a feeling of aliveness, awareness and alertness but without feeling over- stimulated, as if my cells are being provided just the precise amount of energy required that can be effectively metabolized and released. When we can facilitate our energy laterally it offers us the opportunity to disseminate it outward while still being able to hold it in our field for further access and reflection.
Wild Sarsparilla was used by the Haudenosaunee(Iroquois) as “Blood medicine”, for upset stomach, rheumatism and diabetes. The recommendations are to steep a handful of the root in 4 quarts of water and “drink any quantity anytime”. It was one of nineteen plants used in one woman’s(Sarah Snow) special blood tonic formula. Her gathering practice was sacred and offerings of tobacco were made to each plant:
“It takes about a pound and a half of tobacco to make this medicine. The tobacco is used at every plant that is taken for the formula. She gathers the plants during the last part of September, in the Fall of the year. She always sprinkles tobacco at the side of the first plant of a variety, and this plant she does not take, but takes the next one. She makes a little hole with her hand parting the brush to clear a space on the ground next to the plant, and then covers it over afterward by placing the brush so that other people do not see it. Then she says a prayer.” ~Iroquois Medical Botany
Wild Sarsparilla is well known as an alterative or a blood purifier and is often considered correlative to Sarsparilla of the Smilax genera that grows sub- tropically. Both are considered to be alterative, but Aralia Nudicaulis has a stronger affinity to normalizing hormones, particularly excess androgens because it has the ability to enable efficient cellular metabolism. Being in the Ginseng family it is nourishing and can provoke our internal capacity to maintain dynamic equilibrium and it this quality that also helps to balance hormones. Because it is particularly helpful in regulating excess androgen levels it is a good choice for acne in teenagers and those with polycystic varian syndrome
Wild Sarsparilla is highly nourishing with significant amounts of calcium, potassium, magnesium, iron, and zinc along with starch, sugars, resins, saponins, pectin and volatile oils. The impressive mineral content makes this plant a good choice to improve bone growth, increase the flexibility of connective tissue and as a treatment for arthritis. Being that it is considered to have the nourishing qualities of rabbit medicine by the Cree, it is indicated where disease or lack of nutrition has led to muscle wasting, weight loss, and general weakness. It’s saponins contribute to it’s effect on arthritis as they provide an anti-inflammatory quality. Wild Sarsparilla has been used for rheumatoid arthritis, not only because it is anti-inflammatory, but also because it also seems to modulate immune function and therefore may down-regulate auto-immune response. It’s blood purifying action contributes by encouraging the removal of stagnant waste products that often build up in the joints and tissues with this condition.
Wild Sarsparilla and the Smilax variety are both considered useful in the treatment of Syphilis, with Smilax now being used in modern herbal medicine as a primary remedy for Lyme disease; both Lyme and Syphilis being infections by spirochetal bacteria. Smilax Sarsparilla is used presently as an anti-sprirochetal and anti-bacterial. Both of these plants, are alterative and will bind endotoxins in the blood protecting against the Herxheimer reaction that is caused by spirochetal die off during treatment. Aralia nudicaulis itself has been shown in recent research to be anti-mycobacteria with its two constituents, falcarinol and panaxydol, being identified as the active elements. Mycobacteria are gram positive and cause a variety of illness, the most common being Tuberculosis.
“It is relaxant and gently stimulant; mild and moderately slow in action; and expending its properties chiefly upon the skin and kidneys, and moderately upon the mucous structures of the lungs and uterus. It is mainly valued for its influence upon the first-named secernents, for which it enjoys a just repute as an alterant. It is principally used in mild secondary syphilis, and in cutaneous affections connected with irritability. It is seldom employed in pulmonary difficulties; yet is good whenever the lungs need a mild expectorant with stimulation. In the same way, it may be used in simple cases of leucorrhea and weakness of the back. Boiling impairs its properties. A decoction may be made by steeping an ounce of the root in a pint of boiling water; one half of which may be used in twenty-four hours. In preparing it for sirups, it is oftenest combined with such articles as arctium, celastrus, and menispermum; and treated by percolation.” The Physiomedical Dispensatory
It has other known uses as an external remedy for skin conditions of any nature including burns, shingles and fungal infections such as ringworm. It is considered useful as an expectorant and used for coughs, colds and irritated mucus membranes.
Although Wild Sarsparilla is not a widely used plant it was one that I have come to cherish and value. I use it often and it is a primary member of my apothecary. It’s major uses are a just a few of many and I hope to explore its finer qualities in the future. It is quite common and prolific in our Northeastern forests and, although it doesn’t provide the intensity of action that it’s relative American Ginseng offers, it’s therapeutic ability is equally as capable of re-organizing patterns of imbalance and resolving obstacles to optimal health and resilience.
The Earthwise Herbal by Matthew Wood
A Modern Herbal by Mrs. M. Grieve :http://botanical.com/
The Physiomedical Dispensatory by William Cook, M.D., 1869
Anti-mycobacterial diynes from the Canadian medicinal plant Aralia nudicaulis,. J Ethnopharmacol. 2012 Mar 6
Iroquois Medical Botany by James W. Herrick
Muscle-Skeletal Pain and the Gut Connection
Pain is a word that is used to describe a wide range of experiences that all humans encounter. There are many different patterns that occur throughout life that are considered to be painful and, ‘pain’ itself is not a disease, illness or syndrome but is a symptom of many. In the most literal sense, pain refers to any physical sensation that is unpleasant and causes one to take evasive action. It is also a signal that communicates to our brains that we must become aware of some dysfunction and make the necessary changes to make it stop. As herbalist and bodywork Tammi Sweet says, "Pain is a signal to change your behavior". That can mean many things including lifestyle and diet, but also mental and emotional behaviors, attitudes and thought processes. Evasive action is not always the most appropriate either. Changing our behavior can mean to stop evading something and explore more deeply into the core of any issue or injury in search of hidden or repressed feelings or matters. Sometimes what is called for is for us to actually move more deeply into ourselves and embody our unique Earthly form more completely. I taught Yoga for many years and always encouraged my students to find their 'edge' where they were not in pain but were stretching themselves, gently, beyond their comfort zone. This requires that we move our awareness into tight and sometimes scary places and re-associate or, some would say, occupy places that we may rather ignore.
Muscle-skeletal pain, in its physiological manifestation, is a message that indicates that tissue damage has occurred or is imminent without behavioral change due to injury, prolonged spasm or constriction, or buildup of metabolic waste and is sometimes mixed in with related nerve pain. When we sit in one position for an extended period of time, like while typing on the computer, we often begin to feel the discomfort of pain that signals us to change position or get up and move around before tissue damage results. It is also well documented and scientifically proven that the brain can project pain anywhere in the body without any apparent physiological condition.
Conventional treatment for muscle-skeletal pain predominately focuses on alleviating the physical sensation by palliating the pain pathway that sends the neurological signal from the point of injury to the brain. Although sometimes pain relief is appropriate and merciful, it does not address the underlying cause and, when solely relied on for any extended period of time, can actually exacerbate the condition. Traditional Herbal Medicine responds to pain from a holistic perspective by not only attending to the physiological discomfort, but by seeking the underlying pattern that has created the dis-ease. From a vitalist perspective, pain is produced by the vital force and is a function of our internal self-healing mechanism. (For more on Vitalism go here: http://clinicalherbalism.com/about/vitalist-tradition/)
An herbal perspective on pain will take into account the type of pain, the tissue state at the site, and how that stands in relationship to all of the other systems and functions of the entire individual including the psychological, social and cultural settings. The pain is generally not the focus of the herbal protocols I offer although, I will always do whatever is possible to ease the discomfort as stress is a major contributor to the cycle of chronic pain and anyone who is in pain is under stress. Along with stress, the major factors to consider initially are nutrition, constitution, metabolism, past memory of pain and , first and foremost, gut integrity. The condition of the tissues of the digestive system can play a major role in many illnesses because of what is known as “Leaky Gut”
Leaky gut is unrecognized by conventional medicine but well-conceived in Western Herbalism as a significant component of muscle-skeletal pain and its corresponding illnesses. In fact, some famous herbal doctors of history have contended that leaky gut is the source of all human dis-ease. Leaky gut, in its simplest terms, refers to dysfunctional gut permeability. The delicate meshwork of epithelial cells that line the small intestine allowing digested food to be assimilated into the bloodstream becomes loose and the mesh becomes more porous allowing undigested particles back into our system. These accumulate in the tissues overwhelming our cells and swamping our metabolic and eliminatory processes. This inhibits our cellular fire that is required to transform and receive nutrition and release waste, and impedes the smooth flow of life force. In an attempt to alleviate the situation our immune system is called in via the inflammatory process whereby fluids build up in an attempt to flush and eliminate. When this is ongoing and consistent, the transaction becomes ineffective and we develop what is known as Damp Accumulation. This is basically pathological stagnation or as would be said in Chinese medicine, stuck blood or Chi and results in chronic pain and inflammation.
The health and balance of the digestive system is of primary importance when we seek to identify the source of any muscle-skeletal condition and it is necessary to attend to. Anything else that we attempt to do will not be sustainable or permanent if there is a continuous assault of toxins entering the system through the gut. Customarily, any herbal formula for pain will be complex and include an individualized set of herbs that address the symptoms of pain, the nervous system, a diuretic to increase fluid metabolism, sometimes and anti-spasmodic, and alteratives all of which I will discuss further in future posts. For now we’ll focus on re-creating digestive integrity as a first step to creating overall health and well-being
We are all born with a porous membrane lining our digestive tract as this allows for optimum absorption of colostrum from our mothers and a fertile environment for colonization by lots of friendly bacteria. When this happens effectively we can absorb nutrients quickly and establish a protective microbial community that will ensure a healthy immune system and provide a formidable defense against ‘bad’ bacteria. Shortly after birth the permeability of this cellular matrix begins to tighten up to provide a barrier that will only allow fully digested and optimal foods to be accepted into the blood stream. .When this doesn’t happen or when we acquire ‘leaky gut’ later in life there are several factors that contribute. Food allergens are major subsidizers of digestive irritation as are food preservatives and NSAIDS(non-steroidal anti-inflammatory drugs). Anything that decreases the healthy bacteria in the gut also leaves the tissue exposed and open to irritating food particles, bad bacteria, and irritation from digestive secretions. Eliminating any possible allergen is tantamount along with re-introduction of beneficial microbes with a good quality pro-biotic supplement along with ‘prebiotics’ or substances that will provide food for the bacteria such as miso. Symptoms of leaky gut can be subtle or severe but often appear as constipation, diarrhea, gas, bloating and can further manifest into colitis, irritable bowel and acid reflux.
Herbs that will encourage the healing of the digestive tract:
Plantain grows prolifically on lawns, in meadows and backyards everywhere. Plantain is soothing to mucus membranes and appropriate for all wound healing. It is cooling, moistening, softening and astringent tightening tissues and reducing the possibility of leakage while maintaining a healthy moisture level. It is also a drawing agent as it can draw out any infection or foreign material leaving any wound soothed and free of microbes. The leaves can be gathered anytime but some herbalists say that they are stronger after the first frost. Leaves can be dried or used fresh for tea or made into tincture.
Dose: Tea-1/2 tsp. of dried leaves or 1 tsp. of fresh steeped in one cup of boiling water. Drink 2x per day.
Tincture: 20-40 drops 2-3 x per day
Calendula has a long history of use as a wound remedy and is anti-inflammatory, anti-spasmodic, astringent, anti-microbial and lymphatic. It’s anti-spasmodic properties are particularly helpful when there is intestinal spasm or colic as in Irritable bowel or colitis. It’s great for any cramping where there is irritation and need for soothing. Its lymphatic properties can help remove stagnation a improve the movement of debris and undigested food particles in the digestive system It’s slightly warm and this too can encourage movement although if someone is particularly hot in their digestion it can create further irritation. This is more of an issue with the juice or tincture and is less so if it has been dried and taken as tea.
Dose: Tea of dried flowers-1/2 tsp. to a cup of boiling water. Juice or sucuus of flowers-1 tsp-tbsp. 1x per day. Tincture-20-30 drops 2-3 x per day
The best remedy for any stomach issue at all as far as I’m concerned. Meadowsweet normalizes hydrochloric acid secretion whether it’s too high or too low. It also contains salicin or salicylic acid which provides pain relief in the same manner as aspirin but without the stomach irritation. Meadowsweet is actually soothing to the stomach provide compounds that buffer and synthesize its pain relieving properties. Meadowsweet is also astringent and so can be used to tone and tightening the digestive meshwork. It is anti-inflammatory and cooling so can be used for diarrhea, chronic gastritis, colitis and ulcers. It also tastes sweet and lovely and makes a great addition to any tea.
Dose: ½ teaspoon of dried leaf and flower for tea in 1 cup of boiling water. Tincture-20-30 drops 3x per day
Skullcap/American Skullcap-Scutellari lateriflora
Skullcap is a bitter mint and great in addressing any stress related issues regarding the digestive tract, which there almost always is. Stress can create irritation in the stomach and irritation in the stomach can create stress. Skullcap sedates, soothes and calms nervous irritation and relieves colic, spasm and flatulence due to nervousness and excess fire in the small intestine. It combines well with Chinese/Baikal Skullcap.
Dose: Tea made with warm(not boiling) water. 1/2 dried Skullcap leaf to 1 cup of warm water. Tincture: 15-20 drops 2-3x per day.
Baical Skullcap/Chinese Skullcap-Scutellaria Huang Qin
Baikal Skullcap is a cooling, anti-inflammatory and antibacterial and does not have many actions in common with Scutellaria lateriflora but makes a great formula when combined. It is also an excellent astringent and digestive bitter so it will tighten tissues, prevent leakage and promote digestive secretions increasing the likelihood of complete assimilation of food. It is also an immune regulator and will treat allergies so being an excellent choice for anyone with any food sensitivity. It is great in combination with American Skullcap.
Dose: tincture-20-40 drops 2-3 x per day or in a formula of half Baikal Skullcap and half American Skullcap
Is an all-around wound healer and regulator of blood flow. It is cooling and drying and it is considered and astringent, tightening tissues, so is one of the top herbs employed to stop bleeding. It is also a blood decongestant and so helps to breakup clots and removes stagnation. This makes it excellent for the digestive tract as it will heal irritation, reduce inflammation and promote the healthy flow of fluids to and from the surface tissues that will bring in fresh oxygen and nutrients and eliminate waste. It is also an appetite stimulant and promotes the secretion of bile encouraging optimal assimilation.
Caution: Avoid during first trimester of pregnancy
Dose: Fresh juice-2 tsp. per day
Tea- ½-1 tsp. dried or fresh yarrow to one cup of boiling water
Tincture:20-40 drops 2-3 x per day
Wise Water is a formula made from a combination of three herbs specifically to encourage health and healing in the digestive tract. It also supports and nourishes the immune and nervous systems.
Cumin Seed-Cuminum cyminum: Promotes digestion and helps you absorb and use nutrients. It is antioxidant, cooling and is high in Vitamin C and A
Coriander-Coriandrum sativum: promotes the elimination of toxins and metabolic waste via the kidneys while it’s bitter and pungent flavors stimulate digestion, relieve gas, bloating, and stomach cramps. It is anti-inflammatory and cooling yet regulates digestive and metabolic “fire”.
Fennel Seed-Foeniculum vulgare- Reduces gas, bloating and regulates autonomic contractions of the small intestine relieving abdominal spasm. Useful for irritable bowel, colitis, heartburn and any general digestive discomfort
Recipe: Combine a ¼ teaspoon of each and add to 1 ½ quarts of water. Boil for 5 minutes. Turn off heat. Place in a non-plastic thermos, pan or vessel and let steep at least 15 minutes before drinking. Drink throughout the day. Can be taken daily for up to 3 months
Kate Gilday: Lectures and conversations over many, many years
David Winston, Herbs for Digestion-Audio Cassette
Tammi Sweet: Lecture at 2013 Women's Herbal Conference, A&P online course-http://tammisweet.com/
Paul Bergner: Audio CD, Vitalist Treatment of Acute Symptoms