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Historical Perspective of Traditional Indigenous Medical Practices: The

Current Renaissance and Conservation of Herbal Resources

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DOI: 10.1155/2014/525340 · Source: PubMed

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Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2014, Article ID 525340, 20 pages
http://dx.doi.org/10.1155/2014/525340

Review Article
Historical Perspective of Traditional Indigenous Medical
Practices: The Current Renaissance and Conservation of
Herbal Resources

Si-Yuan Pan,1 Gerhard Litscher,2 Si-Hua Gao,3 Shu-Feng Zhou,4 Zhi-Ling Yu,5
Hou-Qi Chen,6 Shuo-Feng Zhang,1 Min-Ke Tang,1 Jian-Ning Sun,1 and Kam-Ming Ko7
1
School of Chinese Medicine, Beijing University of Chinese Medicine, Beijing 100102, China
2
Research Unit for Complementary and Integrative Laser Medicine, Research Unit of Biomedical Engineering in Anesthesia and
Intensive Care Medicine and TCM Research Center Graz, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
3
School of Basic Medicine, Beijing University of Chinese Medicine, Beijing 100102, China
4
College of Pharmacy, University of South Florida, Tampa, FL 33612, USA
5
School of Chinese Medicine, Hong Kong Baptist University, Hong Kong
6
American Academy of Natural Medicine, Costa Mesa, CA 92627, USA
7
Division of Life Science, Hong Kong University of Science & Technology, Hong Kong

Correspondence should be addressed to Si-Yuan Pan; [email protected] and Gerhard Litscher; [email protected]

Received 30 November 2013; Revised 1 February 2014; Accepted 23 March 2014; Published 27 April 2014

Academic Editor: Kelvin Chan

Copyright © 2014 Si-Yuan Pan et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In recent years, increasing numbers of people have been choosing herbal medicines or products to improve their health conditions,
either alone or in combination with others. Herbs are staging a comeback and herbal “renaissance” occurs all over the world.
According to the World Health Organization, 75% of the world’s populations are using herbs for basic healthcare needs. Since
the dawn of mankind, in fact, the use of herbs/plants has offered an effective medicine for the treatment of illnesses. Moreover,
many conventional/pharmaceutical drugs are derived directly from both nature and traditional remedies distributed around the
world. Up to now, the practice of herbal medicine entails the use of more than 53,000 species, and a number of these are facing the
threat of extinction due to overexploitation. This paper aims to provide a review of the history and status quo of Chinese, Indian,
and Arabic herbal medicines in terms of their significant contribution to the health promotion in present-day over-populated and
aging societies. Attention will be focused on the depletion of plant resources on earth in meeting the increasing demand for herbs.

1. Introduction parts used in herbal therapy include seeds, berries, roots,

leaves, fruits, bark, flowers, or even the whole plants. Man was
Herbalism is a traditional medicinal or folk medicine practice mainly dependent on crude botanical material for medical
based on the use of plants and plant extracts. Herbs/plants, needs to retain vitality and cure diseases [3] prior to the
the major component of traditional materia medica in the introduction of aspirin derived from Spiraea ulmaria which
world, are of the main forms of life on earth. It is estimated was already prescribed for fever and swelling in Egyptian
that there are about 350,000 species of existing plants (includ- papyri and recommended by the Greek Hippocrates for pain
ing seed plants, bryophytes, and ferns), among which 287,655 and fever.
species have been identified as of 2004 [1]. Herbal medicine Although written records about medicinal plants dated
(HM), also called botanical medicine, phytomedicine, or back at least 5,000 years to the Sumerians, who described
phytotherapy, refers to herbs, herbal materials, herbal prepa- well-established medicinal uses for such plants as laurel,
rations, and finished herbal products that contain parts of caraway, and thyme [4], archeological studies have shown
plants or other materials as active ingredients [2]. The plant that the practice of herbal medicine dates as far back as
2 Evidence-Based Complementary and Alternative Medicine

60,000 years ago in Iraq and 8,000 years ago in China [5, (CHM, e.g., Zhong-Yao in Chinese) were already described as
6]. With the advent of western medicine (or “conventional” distinct disciplines. More than 85% of Chinese materia med-
medicine) over the past century, herbal medicine has been ica (CMM) originates from plants, but animal parts/insects,
challenged by practitioners of mainstream medicine because minerals, and crude synthetic compounds are also prescribed
of the lack of scientific evidence in the context of contem- by TCM practitioners. In addition, the term “CHM” also
porary medicine, despite its long history of effective use. encompasses a number of ethnic herbal medicines and folk
Interestingly, things change with time. In recent years, there medicines in China.
has been a resurgence of the use of herbs due to the side
effects of chemical drugs, lack of curative modern therapies
2.1. Literature Overview of CHM. CHM is traditionally one
for several chronic diseases, and microbial resistance, as well
of the most important modalities utilized in TCM. It has
as the unprecedented investment in pharmaceutical research
an extremely valuable, rich, lengthy, and extensive treatment
and development (R&D) [7]. For example, only about 1,200
history. CHM was firstly described by a legendary figure
new drugs have been approved by the US Food and Drug
called Shen-Nong, who is said to have lived from 2737 BCE
Administration (FDA) since 1950 [8]. As a result, the use of
to 2697 BCE, nearly 5,000 years ago [25, 26]. It is said
herbs and herbal products for health purposes has increased
that Shen-Nong, by tasting hundreds of herbs on one day,
in popularity worldwide over the past 40 years, in both the
found more than 70 herbs that had medicinal value, selected
developing and the industrialized countries [9]. Moreover,
those that were suitable as remedies, and described their
global pharmaceutical companies armed with modern sci-
properties [27]. As a result of his efforts, numerous herbs
ence/technology and ideas have begun to rediscover herbs as
(“herbal” medicine) became routinely used for health care
a potential source of new drug candidates and renewed their
in ancient China [28]. Shen-Nong-Ben-Cao-Jing, the first
strategies in favor of natural product drug development and
known user guide to CHM, was written by authors who lived
discovery [10–13].
during the period immediately following the fall of the Han
Nowadays, many practitioners of “conventional”
dynasty (202 BCE–220 CE). The compendium documented
medicine do not hesitate to recommend herbs, herbal
365 Chinese herbal preparations, including 252 kinds of plant
products, or complementary and alternative medicine
parts, 67 kinds of animal parts, and 46 kinds of minerals for
(CAM) therapy to their patients for the effective treatment
medication, and it also described their therapeutic effects.
of certain diseases [14, 15]. A survey in 2007 indicated that
about 40% of adults and 11% of children used CAM therapy Prior to the time of Shen-Nong-Ben-Cao-Jing, some
(CAMT), and among the adult users, white and black adults ancient Chinese scripts, such as Shang-Shu, Shi-Jing (The
constituted 43.1% and 25.5%, respectively [16]. In addition, book of songs), Shan-Hai-Jing, Zhou-Li, Li-Ji (The book of
CAM and herbal medicines are more commonly used by rites), and Zuo-Zhuan, recorded the use of herbal remedies.
people with higher levels of education and income [17, 18]. Shi-Jing, which first recorded the use of herbal remedies,
In this context, a 2012 study indicated that the use of CAM illustrated not only the therapeutic effects of the herbs,
significantly correlated with higher education level, with a but also the places where the herbs were grown and their
trend towards greater use in younger patients with breast harvesting season. It recorded 170 kinds of CHMs, including
cancer [19]. Although at present, we do not fully understand 80 plant species and 90 insect species [29]. Shan-Hai-Jing,
the exact facts and mechanisms underlying most traditional the oldest Chinese book dealing with geography, recorded
remedies and/or how they prevent disease that does not affect 9 species of plants with food value, 45 species of plants
the enthusiasm of the public to accept CAM/CAMT [20]. with medicinal value, 6 plants with some kind of efficacy,
Although there is a wide variety of CAM and CAMT around 6 plants poisonous to animals and pests, 6 species of plants
the world, they can all be divided into two main categories, with mood-elevating effects, 6 plants with health-promoting
namely, drug-based CAM/CAMT and non-drug-based properties, 19 species of plants for the treatment of diseases,
CAM/CAMT [21]. and 2 plants that are poisonous for humans [30].
Our earlier endeavors, which focused on discussing More than 240 herbal drugs and 52 prescriptions were
the current research and development of Chinese herbal described in the book named 52 Bing-Fang (Recipes for 52
medicine (CHM), and the trend in drug discovery, as well Ailments), which was unearthed in an ancient tomb (Ma-
as a variety of CAM, aimed to promote the utilization of Wang-Dui) in China [31]. Xin-Xiu-Ben-Cao (Newly revised
natural and traditional resources for contemporary health materia medica), which was promulgated in 659 CE and
care, including food/diet therapy [7, 21–24]. As a continuing recorded 850 kinds of herbal drugs, was the first pharma-
effort, the current paper will give an overview on herbal copoeia in China, even in the world [32]. Oracle bone, a
medicine from China, India, and Arabia, which are the three form of divination in ancient China, recorded more than 60
most influential traditional medicine systems to improve kinds of plants and animals, but they were not described as
public health problems. medication.
The epic book of materia medica in TCM history, Ben-
Cao-Gang-Mu (Compendium of Materia Medica) written by
2. Chinese Herbal Medicine (CHM) Li Shi-Zhen (1528–1593), was published in 1596 in China.
This book recorded 1,892 kinds of herbal medicines and
In ancient Chinese times “medicine” (traditional Chinese 11,096 herbal formulae. After Charles Darwin (1809–1882)
medicine, TCM, e.g., Zhong-Yi in Chinese) and “pharmacy” had read the book, he stated that The Compendium of Materia
Evidence-Based Complementary and Alternative Medicine 3

Table 1: Some important texts in the historical developmental process of Chinese materia medica [33, 34].

Lectures Issued date Total Plant Animal Mineral Processing products Formulae Other
52 Bing-Fang 200 BCE 247 115 48 21 63
Shen-Nong-Ben-Cao-Jing 202 BCE–220 365 252 67 46
Xin-Xiou-Ben-Cao 659 850 635 128 87
Zheng-Lei-Ben-Cao 1082 1,746 1,151 342 253 >3,000
Ben-Cao-Gang-Mu 1596 1,892 1,094 443 161 11,096 194
Znong-Yao-Da-Ci-Dian 1977 5,767 4,773 740 82 172
Zhong-Hua-Ben-Cao 1999 8,980 7,815 1,051 114
Chinese Pharmacopoeia 2010 2,165 680 36 18 1,384 47

Medica was the encyclopedia of 16th century in China. This one, also possesses neuroprotective, cardioprotective, antidi-
book was later translated into different languages, including abetic, antioxidant, and anticancer properties, as well as the
Japanese, Korean, English, French, Russian, and Latin, and it ability to alleviate symptoms of the common cold [37, 38]. The
has become a major historical reference on CMM. proven similarities between American ginseng and Chinese
The founding of China has brought about a hitherto ginseng have been instrumental in boosting the market of the
unprecedented development of CHM in Chinese history. The American product. From 1960 to 1992, both the demand and
holistic and systematic development of CHM has resulted the price for American ginseng increased, with the export
in an increase in the number of approved CHMs. Zhong- value being over US $104 million in 1992 in the USA alone.
Hua-Ben-Cao, the most authoritative Chinese book with a During the period from 1997 to 2007, the average export
complete record of CMM issued in 1999, lists 8,980 kinds price of cultivated ginseng from the USA was US $19.30/lb
of CHMs that are divided into 34 volumes and summarizes and that of wild ginseng was US $84.50/lb [39]. The Panax
the contemporary research of Chinese medicine with modern family consists of at least nine species, including ginseng,
science and technology. Zhong-Yao-Da-Ci-Dian (a dictionary panax quinquefolium, panax notoginseng (Sanqi), and Panax
of traditional Chinese medicine), published in 1997, recorded japonicus (Japanese ginseng) [40]. If Chinese ginseng had not
5,767 CHMs; when it was reprinted in 2006, the number of served as a reference herb, the Panax family would certainly
CHMs had increased to 6,008. The Chinese Pharmacopoeia not have become so popular and might still be treated as
(2010 version) listed 2,165 CHMs and their products. About ordinary grass. Similarly, if the Chinese had not recognized
300 of them are commonly used in clinical practice, and many the medicinal value of bezoars (gallstones from cattle), they
others are used locally as folk medicines. In terms of the would only have been treated as waste. Currently, China
literature on CHM, the theoretical aspects and practical expe- imports more than 100,000 kilograms of gallstones each year,
riences of several thousand years of usage are documented in about 60% of which comes from Africa, and the total value
more than 8,000 books; the total number of ancient literature amounts to US $100 million. A good quality gallstone sells
about both CHM and TCM reached 13,000. Therefore, the for between US $15 and 20 per gram [41].
documentation of knowledge in CHM is unique in the world In the winter of 753, Jian Zhen (688–763), a famous
(Table 1). Chinese master of Buddhism in the Tang Dynasty, arrived
in Nara, Japan, after several unsuccessful attempts, and he
2.2. The Contribution of CHM to the World’s Pharmacy. CHM brought with him a number of CHMs. To date, more than
has been influencing the world since ancient times. The 60 kinds of CHMs are still kept in the Nara Shosoin.
famous Italian traveler Marco Polo (1254–1324) described According to the official body of Japanese kampo medicine
a scene of merchants shipping Chinese herbs in Aden and (the practice of CHM in Japan), 36 kinds of CHMs were
Alexandria in his Travel Book. During the sea voyage of Zheng brought by Jian Zhen for use in Japan; they include ephedra,
He between 1405 and 1433, China exported a large number asarum, peony, monkshood, polygalaceae, astragalus, licorice
of herbs including rhubarb, angelica, velvet, poria, taurine, root, angelica, bupleurum, Chuanxiong, scrophulariaceae,
ginseng, and cinnamon to other Southeast Asian countries. scutellaria, platycodon, anemarrhena, pinellia, schisandra,
In return, over the past 2,000 years, more than 40 kinds and eucommia [42]. To recognize the contribution of Jian
of foreign herbs were imported into China and eventually Zhen, he was renowned as the father of kampo medicine by
adopted by TCM; they include kelp from Korea, turmeric and the Japanese. The 14th edition of the Japanese Pharmacopoeia
styrax from Southeast Asia, and others such as borneol, clove, (JP), issued in 1993, listed 165 herbal ingredients, the majority
frankincense, myrrh, benzoin, senna, and saffron [35]. of Chinese origin, that are approved to be used in kampo
In the 18th century, with reference to Chinese ginseng, remedies [43]; the 16th Japanese Pharmacopoeia, published in
Panax quinquefolium (also called American ginseng) was first 2012, listed 276 kinds of crude drugs (e.g., herbal medicines
discovered. It is indigenous to the southern regions of Ontario and/or their extractions) [44].
and Quebec in Canada and the midwestern, southern, and All in all, the development of CHM has emerged from
eastern parts of the United States [36]. In recent decades, thousands of years of Chinese civilization. It is therefore no
studies have shown that American ginseng, like the Chinese surprise that CHM is of great worth for mankind.
4 Evidence-Based Complementary and Alternative Medicine

2.3. Species in China and CHM. Nature has endowed China Table 2: Ethnic materia medica (EMM) in China.
with a vast landscape with varied geographical features and
Ethnic group EMMs
a resultant wealth of medicinal plants. Geographically, China
(from south to north) covers equatorial, tropical, subtropi- Han 11,146
cal, warm-temperate, temperate, and cold-temperate zones. Tibetan 1,085
Therefore, Chinese climatic conditions are suitable for the Miao 718
growth and reproduction of various animals and plants. In Dai 707
China, there are 499 kinds of mammals, 1,186 kinds of birds, Yi 564
376 kinds of reptiles, 279 kinds of amphibians, and 2,084 Li-Su 494
kinds of fish, which account for 12.5, 13.1, 6.0, 7.0, and 12.1% of Zhuang 473
their respective species in the world [45–50]. China has more Mongolian 397
than 31,000 higher plants, 256 endemic genera, and 15,000–
Wa 332
18,000 endemic species (50–60% of the total on earth), many
Tu-Jia 330
of which are living fossils, such as dawn redwood (Metase-
quoia glyptostroboides Hu and Cheng), ginkgo (Ginkgo biloba Ha-Ni 302
L.), silver fir (Cathaya argyrophylla Chun and kuang), and De-Ang 272
tulip tree (Liriodendron chinense (Hemsl.) Sarg.) [51]. The A-Chang 263
increasing demand for herbal products in the global market is Ji-Nuo 250
likely to challenge herbal resources in the world. In the China Du-Long 165
Plant Red Data Book published in 1992, 388 species of plants She 161
are listed as threatened, which include 121 as endangered Mu-Lao 152
(i.e., first grade national protection), 110 as rare (second La-Hu 151
grade national protection), and 157 as vulnerable (third Uighur 143
grade national protection). Among these plant species, 77 are
Shui 129
typical CHMs that account for 19.86% of the total threat-
Korean 121
ened species [52]. Besides, 257 kinds of animal medicine
appear in the national key protection name list of wild Na-Xi 103
animals (Figure 1). Bai 90
In CHM, there are 11,146 different kinds of plants, 1,581 Mao-Nan 75
kinds of animals/animal parts and insects, 80 kinds of Pu-Mi 49
mineral drugs, and more than 50 kinds of crude chemical Bu-Lang 44
preparations, as well as 5,000 (total one million) clinically Bu-Yi 32
validated herbal formulations. Unlike other herbal medicines Beng-Long 28
and western medicines, CHMs are often prescribed as formu- Jing 20
las under the guidance of TCM’s theories and practice. Each Ge-Lao 18
herbal medicine prescription (formula, Fang-Ji in Chinese) is Daur 14
a cocktail of many herbs tailored to the individual patient. It Kazak 14
allows us to blend herbs to enhance their positive effects and O-Lun-Chun 12
reduce or eliminate any negative side effects they may have, Hui 11
when they are used each alone (Figure 2). Manchu 9
Because of the differences in geographical and climatic Li 9
conditions, residents in various geographical regions in Yu-Gu 5
China have distinctive lifestyles, customs, and cultures, as Gao-Shan 4
well as disease spectra. These variations have brought about Tajik 1
the development of a wide variety of traditional medicine Russian 1
practices. China has 56 ethnic groups, meaning that there
Nu-Jiang 1
are 56 kinds of culture, language, and herbal medicine. CHM
Wei-Xi 1
(also called Han medicine) was developed by the Han ethnic
group. Table 2 shows the number of plant-derived herbal Total 18,891
medicines in various ethnic medicines as recorded in the Data from “scientific database of China plant species. http://apps.searo
database of China plant species. In fact, the number of herbal .who.int/PDS DOC”.
medicines is far bigger than that recorded in the database.
For example, Tibetan herbal drugs have 2,172 rather than
1,085 varieties, not including 214 kinds of animal drugs and 2.4. Pharmaceutics of CHM. Dosage form, also known as
50 kinds of mineral drugs [53]. There is no doubt that routes of administration, is a mixture of components with
CHM, together with other ethnic herbal medicines in China, medicinal properties and nondrug components (excipient
comprises a gold mine of potential modern medicines and or vehicle). It describes the physical form in which medi-
health products. cation will be delivered into the body. Currently, there are
Evidence-Based Complementary and Alternative Medicine 5

More than 10 and 20 animal There are 422 species threatened by

species are considered extinct extinction, including 81 species of
and become endangered, mammals, 75 birds, 48 fishes, 31
respectively. reptiles, and 184 plants.

Animal species Plant species

Grade I: 96 species Grade I: 121 species
Grade II: 161 species Grade II: 110 species
Protected species in China Grade III: 157 species

488 kinds of
invasive alien 279 amphibian species
species (IAS)

1,186 bird species 2,084 fish species

Species in China

499 mammal species 28,000 marine species

35,000 plant species

31,000 higher plants 256 endemic genera

15,000–18,000 species
of endemic species

Figure 1: Species and protected species in China.

more than 40 available dosage forms of CHM products times, the rationale underlying the traditional processing of
in the market. They include decoction (Tang-Ji, hot water CHM has been supported by scientific evidence in modern
extract), tincture (Ting-Ji, ethanol extract), powders (San- research. Figure 3 shows the traditional processing methods
Ji, powder form), bolus/pills (Wan-Ji, boluses or small pills of CHM, together with their pharmaceutical processing
containing herbal ingredients), pastes (Jin-Gao, extracts from procedures, which are still employed in the pharmaceutical
organic solvents), granules, tablets, oral liquids, and injection industry of CMM in China [57].
liquids. Liniment, poultices, plasters, and ointments are
adopted for external use of CHM. Recently “nanomized”
and “aerosol” herbs have emerged as new dosage forms of 2.5. The Status Quo of CHM. The CHM industry has always
CHM [54–56]. been one of China’s traditional competitive industries. In
Unlike synthetic drugs, CHMs are usually subjected to 2010, CHM manufacturing assets in China exceeded 300
specific treatments (processing, the process of preparing billion RMB, an increase of about 18%, nearly 5 percentage
CHM), also known as Pao-Zhi in Chinese, prior to use. Pao- points higher than the year before; the number of CMM
Zhi is a very ancient part of the practice of Chinese medicine, pharmaceutical enterprises amounts to more than 2,300, total
dating back at least 2,000 years. There are more than 30 kinds investment in fixed assets totaled nearly 500 billion RMB, an
of procedures involving stir-frying (Chao), calcining (Daun), increase of about 16% compared to the previous year [58].
steaming (Zheng), boiling (Zhu), and so forth. The herbal As of today, there are 8,000 products related to CHM in the
effects and compositions/ingredient structures are changed China market. In 2010, China manufactured 2.384 million
after Pao-Zhi, as compared to the unprocessed version. Expe- tons of Chinese herbal products, with sales amounting to
rience has shown that the effectiveness and security of some 417.875 billion RMB [59].
CHMs are dependent upon their correct Pao-Zhi before being More than 8,000 varieties of CHMs or related herbal
used in clinic. This is one of the reasons why CHM is different products are now exported from China to more than 130
from the plant drug and/or natural drug. Regardless of the countries and regions worldwide; each year, more than 50
primitive processing technology that was used in ancient kind of CMMs are exported to the United States, including
6 Evidence-Based Complementary and Alternative Medicine

5,000 formulas in
common use in clinic

Statutory formula Nonstatutory formula

Ancient formula Folk formula

Formula
Empirical formula Modern formula
(up to 1,000,000)

Animal medicines Mineral drugs

(1,581 species) (80 species)
CHMs

Plant medicines Crude chemicals

(11,146 species) (up to 50 species)

Ethnic medicine Folk medicine

(4,000 species) (7,000 species)

2,136 CHMs listed

in the 2010 Chinese 500-600 CHMs
Pharmacopoeia in common use in clinic

Figure 2: Chinese herbal medicine (CHM) in China.

berberine, angelica, licorice, Fritillaria, turmeric, frankin- “everything can be a drug” is deeply rooted in Indian culture,
cense, Tianma, rhubarb, Eucommia, cloves, wolfberry, Panax, Ayurvedic physicians made use of an extensive collection of
fresh ginseng, and pinellia [60]. Over the past few years, medications, herbs/plants, even the urine of animals, and
herbal exports have steadily increased from US $1.09 billion described their effects meticulously. Currently, 70 percent of
in 2006 to US $1.46 billion in 2009 [61]. Indians still rely on IM for their primary health care [66].
More importantly, in recent decades, China has put a
great deal of human efforts and financial resources to promote 3.1. Literature Overview of IHM. In India, the history of using
research and development in the area of CHM in a systematic plant resources for treating diseases can be dated back to
manner, and this enormous effort is unmatched by other 6,000 to 4,000 BCE, the Buddhist period. AYM has a vast
traditional medicines around the world. In this context, literature in Sanskrit and various Indian languages, covering
we have published reviews on the status of CHM research various aspects of diseases, therapeutics, and pharmacy.
and development as well as drug discovery in China [24]. The earliest references to such plants, minerals, and animal
In China, 3,563 extracts, 64,715 compositions, 5,000 single products with their usage for medical purposes are found in
compounds, and 130 kinds of CHM-related chemical drugs the Rig veda, an ancient Indian sacred collection of Vedic
have been developed [22]. From the marketing perspective, Sanskrit hymns, and the Atharvaveda, the fourth and last
currently, four models of application and five types of Chinese Veda of Hindu literature [67]. Bhava Prakasha, written by
herbal products can be adopted in the international arena. Bhava-Mishra, is the most important text on herbs/plants and
The same approach may also be applied to other herbal is held in high esteem by modern Ayurvedic practitioners
medicines (Figure 4). [68–70].
The oldest text of AMM, the Rasa Vaisesika of Nagarjuna,
3. Indian Herbal Medicine (IHM) who is considered the most important Buddhist philosopher
after Buddha’s death [71], was composed during the 5th cen-
Indian medicine/materia medica/herbal medicine tury CE. In this text the various concepts of drug composition
(IM/IMM/IHM), also called Ayurvedic medicine/mate- and action were described [72]. The Charaka Samhita is
ria medica (AYM/AYMM), belongs to the traditional the first recorded treatise fully devoted to the concepts and
health care and longevity systems. Because the belief that practice of Ayurveda, with a primary focus on therapeutics
Evidence-Based Complementary and Alternative Medicine 7

Nanomized Injection liquid

herb

Oral
Decoction liquid
Tincture Powders

Liniment Ointment
Dosage forms
Plaster
Granule

Aerosol Poultice

Tablet Bolus Pills Paste

CHM

Pharmaceutical
Stir-frying techniques Boiling

Calcining Steaming

With
With liquid additives
With Edible mother liquor
Yellow rice wine With solid additives of mineral salt
Vinegar Water
Salt-water preparation
Salt-water Bran
Refined honey Without Medicinal juice
Rice Rhizoma zingiberis
Ginger juice additives Vinegar
Sand recens and alumen
Refined suet Yellow rice wine
Fine powder of terra

Figure 3: Dosage forms and pharmaceutical techniques in Chinese herbal medicine (CHM).

[73]. In the Charaka Samhita, plant-derived drugs are divided are obtained from cultivation in farms [80]. The western
into 50 groups according to their pharmacologic/therapeutic Himalayan region provides about 80% of herbal drugs in
actions. The next landmark in Ayurvedic literature was the Ayurveda, 46% of Unani, and 33% of allopathic systems [81];
Sushruta Samhita. Although the text places special emphasis 50% of drugs recorded in the British Pharmacopoeia are
on surgery, it also describes 395 medicinal plants, 57 drugs related to medicinal plants growing in this region [82].
of animal origin, and 64 minerals or metals as therapeutic In India, approximately 25,000 plant-based formulations
agents [74] (Figure 5). In ancient times, Ayurvedic texts were are used in traditional and folk medicines [83]. The number
very respected in the neighboring countries, and they were of plant species used in various IM is as follows: Ayurveda,
also translated into Greek (300 BCE), Tibetan and Chinese 2,000; Siddha (a type of ancient traditional Indian medicine),
(300 CE), Persian and Arabic (700 CE), and so forth [75]. 1,300; Unani (a system of alternative medicine first developed
by the Islamic physician Avicenna in about 1025 CE), 1,000;
homeopathy, 800; Tibetan, 500; modern, 200, and folk, 4,500
3.2. Plant Species in India and IHM. India possesses almost [84]. More than 7,500 plant species are currently used in IM,
8% of the estimated biodiversity of the world with around including tonics, antimalarials, antipyretics, aphrodisiacs,
126,000 species; there are about 400 families of flowering expectorants, hepatoprotectants, antirheumatics, and diuret-
plants in the world, at least 315 of these can be found in ics [85, 86], as well as for the therapy of certain central
India [79]. Currently, about 45,000 species (nearly 20% of the nervous system disorders [87, 88].
global species) are found in the Indian subcontinent: ∼3,500 The IHMs are derived either from the whole plant or from
species of plants are of medicinal value; 500 medicinal plant different organs, like leaves, stem, bark, root, flower, seed, and
species are used by the contemporary Ayurvedic industry; so forth, but also include animals and minerals. Some drugs
∼80% of the medicinal plant species are procured from wild are prepared from excretory plant products such as gum,
areas; and 10% of medicinal plants involved in active trade resins, and latex. Commonly used spices, herbs, and herbal
8 Evidence-Based Complementary and Alternative Medicine

Traditional model: decoction is made from a Quasi-chemical model: a mixture of active

mixture of crude herbs by extraction in boiling constituents is extracted from herbs by modern
water at home. This dosage form of CHMs is techniques. A good example is Ginkgo leave
commonly used in households and mainly extract which contains 24% ginkgo-flavonol
popular among the Chinese worldwide. glycosides and 6% terpene lactones.

Modern model: different Full-chemical model: single

dosage forms of CHMs such compound is isolated from the
as granule, tablet, and oral liquid Patterns herbal materials or chemically
are manufactured by modern synthesized. Good examples
pharmaceutical technology in include artemisinin, taxol, and
Japan and South Korea. arsenious acid.

Exporting 260,000 Importing about 7,735

tons in 2005 Global market tons annually
of CHM

Therapeutic herbal Therapeutic herbal

products products
(Zhong-Cheng-Yao in Chinese) Products (Zhong-Cheng-Yao in Chinese)
containing multiple herbs containing single herb

Skin care and Crude herbs

cosmetics products (Yin-Pian in Chinese)
Health care
products

Figure 4: Styles of Chinese herbal medicine (CHM) in the global market (see also [62] of quasi-chemical model and [63–65] of full-chemical
model).

Paniyadi Varga liquids like water, milk, Over 500 ingredients

alcohol, and urine
Iksukadi Varga sugar-cane, products of Karpuradi Varga 84 aromatic ingredients
sugar-cane juice and honey Suanadi Varga 44 metals and minerals
Dhanya Varga cereals corns and pulses Saka Varga 56 plants used as vegetables
Dhanyaktannadi Varga food preparations Abhayadi Varga includes description of 165 drugs
Mamsa Varga birds and animals meat Sunthyadi Varga 39 drugs
Misraka Varga anupana (post prandial drinks)
and other regimens

Materia medica of
Vatadi Varga 50 ingredients Phala Varga 56 edible fruits
Ayurveda
(2008 version)

Rig Veda Currently, 8,000 herbal Bhaa Prakasha

(5000 BCE) remedies are codified in (1550)
described 67 AMMs Ayurvedic medicine described 470 IHMs

Athara Veda Sushruta Samhita

(4500-2500 BCE) Yajureda (∼ 600 BCE)
Charaka Samhita
recorded 290 IHMs (1000-600 BCE) (∼ 900 BCE) described 516 IHMs
recorded 87 IHMs listed 526 IHMs

Figure 5: Some important texts of Indian herbal medicine [76–78].

Evidence-Based Complementary and Alternative Medicine 9

Indian pharmacopoeia (2010 version)

listed 88 IMMs/products

Formulae Folk
(up to 25,000) (4,500 species)

Registered formulae Registered single herb

(3,000) (up to 1,000 species)

Siddha (1,300 species) Modern (200 species)

IHMs
Tibetan (500 species) Unani (1,000 species)

Ayureda (2,000 species) Homeopathy (800 species)

16 different agroclimatic 28 are considered extinct

zones There are 45,000 124 endangered species
10 vegetation zones plant species in India 81 vulnerable species
25 biotic provinces 34 unknown species
426 biomes 100 rare species

4,000–10,000 species 15,000–20,000 plants 71 medicinal plant

face extinction locally, have medicinal value in India species classified as
nationally, or regionally “rare”

Ayurveda Only 7,000–7,500 Unani

(700 species) (700 species)
species are used

Siddha Amchi
(600 species) (600 species)

Modern
(30 species)

Figure 6: Plant species in India and Indian herbal medicine (IHM).

formulae are utilized for therapeutic interventions in about which are properly processed for pharmaceutical application,
28 kinds of chronic diseases in humans [89]. Special herbal are chosen to balance the three humoral doctrines (“Vata”,
preparations, known as Rasayans, are used for rejuvenation “Pitta,” and “Kapha”). Herbs used in AYM include essential
and retarding the aging process, thereby promoting longevity oils extracted from plants, fruits, vegetables, and common
[90]. spices. The crude herbal material may be ground into pow-
Of the 700 plant species commonly used in the Indian ders and put into capsules, cooked into teas, used topically,
herbal industry, 90% of them are collected from the wild. taken raw, and so forth. IMM preparations on the market
About 50% of the tropical forests, the treasure house of plant, and/or Ayurvedic medical practice are complex mixtures
and animal diversity have already been destroyed. Many including plant- and animal-derived products, minerals, and
valuable medicinal plants are on the verge of extinction. The metals, as well as involving several specific preparatory steps
Red Data Book of India in 1997 has 427 entries of endangered or manufacturing processes.
species of which 28 are considered extinct, 124 endangered, 81 Kasthoushadhies (herbal preparations) and Rasaoushad-
vulnerable, 100 rare, and 34 insufficiently known species [91]. hies (herbo-bio-mineral-metallic preparations) are the two
The Red Data Book of India released in 2012 described 3,947 major groups of IMM preparations [93]. The latter has a
species as “critically endangered”, 5,766 as “endangered”, and metallic base but ordinarily does not contain active metal,
more than 10,000 species as “vulnerable” [92] (Figure 6). since the metal is converted into an ash or oxide and forms
an organometallic compound with a number of organic
materials used for trituration as Bhavana Dravya [94, 95].
3.3. Pharmaceutics of IHM. Compared to those of CMM, Medicinal principles are present in different parts of the
AYM possesses very complex formulae consisting of 30 or plant such as root, stem, bark, heartwood, leaf, flower, fruit,
more ingredients. In the formula, a number of ingredients, or plant exudates. Generally, the herbal remedies can be
10 Evidence-Based Complementary and Alternative Medicine

in various crude dosage forms like pills, powders, essential India not only has a great role to play as a supplier of
oil, infusions, or poultices. AYM believes that Sandhana herbal products for the domestic market, but it can also
kalpana (biomedical fermented formulations), a unique and benefit from the tremendous potential afforded by overseas
complex dosage form containing acidic and alcoholic fer- markets. Currently, the Indian herbal market is valued at
mented components, is one of the most effective dosage 70 billion Rs., and over 36 billion Rs. worth of raw herbal
forms of Ayurveda in practice for thousands of years [96]. materials and herbal products is exported [106]. The export
During the fermentation process of liquid basic drugs, such of crude herbal extracts amounted to US $80 million, and the
as juices or decoctions, alcohol is produced by in-source total sales of herbal products added up to US $1 billion [107].
material used in pharmaceutical procedure. Thus, extraction Among the exported herbal products, 60% are processed
of active principles of the herbal drugs is done through plant materials that are unique to India, 30% are plant
self-generated alcohol. This formulation has longer shelf extracts, and 10% are Ayurvedic preparations [108]. The
life, quick absorption and action, and excellent therapeutic plant-derived pharmaceuticals exported from India include
efficacy as compared to other preparations [97]. isabgol, opium alkaloids, senna derivatives, vinca extract,
The specific media are usually used in the manufacturing cinchona alkaloids, ipecac root alkaloids, solasodine, dios-
process of IMM products according to the different prepara- genin/16DPA, menthol, gudmar herb, mehdi leaves, papian,
tion. This plays a very important role in either breaking down rauwolfia guar gum, jasmine oil, agar wood oil, and sandal
the chemical compound(s) that is not required or forming the wood oil [109]. However, the export of 29 medicinal plants,
novel active ingredient(s) that is of value to the people, for including plant parts and their derivatives/extracts, obtained
example, Shodhana (purification/potentiation) of particular from wild sources, is prohibited by the Indian government
poisonous herbs, like Gomutra (cow’s urine) for Shodhana [109]. Indian herbal medicine has now become a rich source
of Vatsanabha (Aconitum ferox Wall.) and Godugdha (cow’s of innovative drug discovery [110].
milk) for kupeelu (Strychnos nux-vomica Linn.) [98]. On the In India, the turnover of IHM industry is estimated to
be more than 88 billion Rs; the domestic market is of the
other hand, Ayurvedic drugs are usually administered orally
order of 40 billion Rs with a total consumption of all IMMs
along with vehicle materials (Anupana) such as honey, sugar,
to a figure of 177,000 metric tons (MT). India has 9,493 HM
jaggery, ghee, milk, warm water, and juice of some medicinal
manufacturing units, but 8,000 of them are small scale, one
herbs. These Ayurvedic Anupana (i.e., drug vehicles serving having an annual turnover of less than 10 million Rs. Some
as a medium of administration) can improve acceptability of the well-known units (with an annual turnover of more
and palatability and help in absorption of the main herbal than 500 million Rs.) include Dabur, Zandu, Himalaya, Shree
remedy; moreover, they may also act as an early antidote Baidyanath, and Arya Vaidya. They consume about 35% of the
(Figure 7). total raw IHMs [111].

3.4. The Status Quo of IHM. The treatment of disease by 4. Arabic Herbal Medicine (AHM)
Ayurveda is highly individualized and depends on the psy-
It is well known that ancient Hippocratic-Greek medical
chophysiologic status of the patient, particularly in relation
knowhow was adapted and improved by Arabian herbalists,
to the season of the year [101]. Currently, more than 600
pharmacologists, chemists, and physicians in the Middle
herbal formulas and 250 single plant drugs are included in the
Ages. Furthermore, the majority of Arabs are Muslims,
“Pharmacy” of Ayurvedic treatments [102]; about 1,000 single and Arabic culture and Islamic ideology are closely related.
herbal remedies and 3,000 compound herbal formulations As such, Arabic medicine/materia medica/herbal medicine
are registered in India. More than 600 herbal formulae and (AM/AMM/AHM) may also be called Greco-Arab or Islamic
250 single plants are included in the “Pharmacy” of Ayurvedic medicine.
treatment [103]. The 6th Indian Pharmacopeia released in
2010 recognized 55 crude herbal drugs, 26 extracts, 3 finished
formulations, and 2 pharmaceutical aids that are marketed 4.1. Achievements of AM. The Arabic world used to be the
[104]. center of scientific and medical knowledge for many centuries
(from 632 to 1258 CE) after the fall of the Roman Empire.
According to a study commissioned by the Associated
The Legacy of Islam (published in 1931; edited by the late Sir
Chamber of Commerce and Industry, the Indian herbal
Thomas Arnold and Alfred Guillaume) states, “Looking back
industry is projected to double to 150 billion Rs. by 2015, from we may say that Islamic medicine and science reflected the
the current 75 billion business [105]. In the 1990s, the annual light of the Hellenic sun, when its day had fled, and that
sales of the Indian herbal industry were about 23 billion they shone like a moon, illuminating the darkest night of the
Rs. (as compared to 145 billion Rs. in the pharmaceutical European Middle Ages; that some bright stars lent their own
industry), with a growth rate of 15% [106]. By the end of light, and that moon and stars alike faded at the dawn of a
2012, the domestic market is expected to reach 145 billion Rs. new day: the Renaissance. Since they had their share in the
and the export market 90 billion Rs., with compound annual direction and introduction of that great movement, it may
growth rates of 20 and 25%, respectively [105]. The export reasonably be claimed that they are with us yet.” [112].
market for medicinal plants appears to be growing faster than During the middle ages, AM contributed greatly to the
the Indian domestic market. development of modern medicine and pharmacy in Europe.
Evidence-Based Complementary and Alternative Medicine 11

Sandhana kalpana
(biomedical fermented formulations)

Bhaana Murchana
(impregnation/levigation) (transformation)

Jarana Pharmaceutical
(roasting) techniques

Shodhana Marana
(purification/potentiation) (incineration/calcinations)

IHM

Powders Infusions

Essential oil Dosage forms Poultices

Pills Juice

Rasaoushadhies Kasthoushadhies
(herbo-bio-mineral-metallic preparations) (herbal preparations)

Vehicles: honey, sugar, jaggery, ghee,

milk, warm water, and juice

Figure 7: Dosage forms and pharmaceutical techniques in Indian herbal medicine (IHM) [99, 100].

For instance, the European pharmacopoeia relied on Muslim modern natural sciences. Alchemy was invented during the
writings and information therein until the late 19th century. period of Warring States in ancient China, but it vanished
Despite the scarcity of medical knowledge in the Koran, for no apparent reason in the middle of the Tang Dynasty.
Arabs adopted the ancient medical practices that originated Nevertheless, the spirit of exploration of the ancient Chinese
from Mesopotamia, Greece, Rome, Persia, and India (or is praise-worthy. Several inventions by Taoist alchemists, such
even China) [113, 114]. In the early 11th century, Avicenna as cinnabar (Zhu-Sha), orpiment (Ci-Huang), and realgar
(980–1037), a great philosopher and physician, incorporated (Xiong-Huang) in CHM, particularly gunpowder, have had a
a number of Chinese herbal preparations in his book Phar- far-reaching impact on modern medicine and on the world
macopoeia. Ancient Arabs established their “Pharmacy” on in general [115].
the basis of physicochemical techniques such as evaporation, Although AM was at the forefront of medical knowledge
filtration, distillation, sublimation, and crystallization used in in Renaissance Europe of the 15th century, unlike CM and
“alchemy” which was invented by the Chinese [115]. IM, its herbal medicine was not well developed from the start.
Alchemy is the predecessor of chemical discipline that The theory of AM is based on the “humours” of Hippocrates
led to the development of natural science in modern times. and Galen. There were more “modern” than “traditional”
Therefore, China is regarded as one of the key players in elements in AM; therefore, it played a pivotal role in the
advancing modern civilization, particularly in the area of early formation and development of modern medicine. AM
scientific methodology. It has been stated that if Greece was mainly integrated various herbal medicines and related tech-
the theoretical founder of modern civilization, the Qin/Han nologies that originated from other countries and regions and
dynasty in ancient China was the technical founder of established the foundation for the development of medicine
12 Evidence-Based Complementary and Alternative Medicine

Modern medicine
(conventional medicine)

Discovery of the immune Published a lot of medicinal books

system Establishing the hospital and medical education systems
Discovery of the Introduction of microbiological science
pulmonary circulation Separation of medicine from pharmacological science

Surgery and surgical

equipment Bloodletting and cauterization were techniques widely used

Medical achievements The period of translation of

Greek scientific and
Phase I, Greek into Arab philosophical works into
China Arabic (8th century CE).

Rome
The flourishing period
Ancient Arabia Phase II, Arab in hospitals and medical
Persia schools (850–1050).

European scholars set about

India
Phase III, Arab into Latin studying Arab works in these
disciplines and translating
Pharmacy achievements the chief of them into
Latin (12th century CE).

Published books on Extract compounds from herbs

the use of plant drugs Poppy use was restricted to the therapeutic realm
Introduced around 350 new plant species as medicinal herbs

Modern pharmaceutical industry

Figure 8: Achievements of Arabic medicine and pharmacy [118, 119].

and pharmacy in modern medicine [116, 117]. Therefore, AM region is inhabited by more than 2,600 plant species, of which
carried on the past heritage and opened up the future in the more than 700 species are noted for their use as medicinal
history of the development of human medicine (Figure 8). herbs or botanical pesticides; however, only 200–250 plant
species are still in use in traditional Arab medicine for the
treatment of various diseases [124]. Plant species from the
4.2. Past and Present of AHM. During the 8th century, Arabs western Mediterranean coastal region (from Alexandria to
in the Baghdad region were the first in history to separate Sallum, Egypt) comprise 230 species belonging to 48 families;
medicine from pharmacological science. The world’s first 89% of the species had medicinal value, 62% of the species
drug stores were established in the Arab world (Baghdad, were common, approximately 24.9% were occasional, and
754 CE). The forms employed in that period are still used 13% were rare [118].
in therapy, and some formulations of drugs can be found Until now, 236 plant species, 30 animal species, 29 organic
in pharmacopoeias even today [120]. The earliest records substances, and 9 materials of other or mixed origins are still
of herbs, which were written on clay tablets in cuneiform, being used in treating human diseases and are sold or traded
were from Mesopotamia (dating back to 2600 BCE). The in the Mediterranean region and/or in the global market
best known Egyptian pharmaceutical record is the Ebers [124]. A survey of the plant species in the Mediterranean
Papyrus (dating back to 1500 BCE), which documented some region by ethnopharmacologists indicated that 250–290 plant
700 herbal medicines (mostly from plants), with dosage species are still in use [125, 126]. In Israel, 129 plant species
forms including gargles, snuffs, poultices, infusions, pills, and are used in AM for the treatment of various diseases.
ointments and vehicles using beer, milk, wine, and honey Among these plants, there are 40 species used for treating
[121]. skin diseases, 27 species for treating digestive disorders, 22
Since the 8th century, the practice of AHM has been using species for treating liver diseases, 16 species for treating
natural remedies, both organic (such as camel urine) and respiratory diseases and coughing, 22 species for treating
inorganic types, for the prevention and treatment of diseases various forms of cancer, and 9 species for weight loss and
[122]. Interestingly, pharmacological studies have revealed lowering cholesterol [127]. However, more than 1,400 kinds
that camel urine treatment caused a significant cytotoxic of herbal medicines were used by Islamic physicians during
effect on bone marrow cells in mice [123]. The Middle East the period of the Arab Empire (632–1258).
Evidence-Based Complementary and Alternative Medicine 13

700 herbs were >1,400 herbs were

used in Ebers Papyrus used in Arab Empire
(1,500 BC) (632–1258)

Dosage forms: pills, snuffs, Dosage forms: oil, juice,

gargles, poultices, infusions, >2,600 plant smog, syrup, decoction,
ointments species in roasted materials, macerated plant,
Vehicles: beer, milk, wine, Middle Eastern region paste, salads, infusion,
and honey steaming, and poultice milky sap

129 herbs are 150 herbs are

used in Israel used in Jordan
230 herbs are 10 herbs are
used in Egypt used as pesticides
>700 species are used
as medicinal herbs
23 herbs are used or pesticides
in pharmaceutical industry 34 herbs are used
in food industry

55 herbs are used

286 herbal-derived
in cosmetics
substances

30 Current 236
animal species AHMs plant species

9 29
mixed materials inorganic substances

Figure 9: Past and present of Arabic herbal medicine [130].

The dosage forms utilized in AHM include decoction, to conventional drugs. Here, we attempt to describe the
infusion, oil, juice, syrup, roasted materials, fresh salads or feasibility and superiority of herbal medicine containing
fruits, macerated plant parts, milky sap, poultice, and paste, of complex and multicompounds as medication using logical
which some formulations of herbal drugs are still used today concepts in philosophy.
[128]. Although AHM is the first choice for many people Currently, multidrug therapy or polypharmacy, also
in dealing with ailments in the Middle East, most of the known as multiple drug intake or cocktail treatment, which
herbalists (such as those in Jordan), who acquire the expertise involves therapeutic interventions using combinations of
from their predecessors, are not properly trained in herbal drugs (herbal versus chemical, herbal versus herbal, and
medicine [129] (Figure 9). chemical versus chemical) through pharmacokinetic and
In contrast to CHM or IHM, the physical characteristics pharmacodynamic pathways or both [133–136], is commonly
of the herbal size, shape, color, texture, and taste traditionally practiced in clinical situations. It is believed that multidrug
served as important criteria in their selection for therapeutic therapy produces beneficial effects that do not occur when
purposes. For example, seeds with kidney shape are used for using each drug alone. Due to the additive and/or syner-
treating kidney stones; roots shaped similar to the human gistic interactions among the drugs, or the suppression of
body or fruits that resemble human testicles are traditionally adverse effects, multidrug therapy appears to be effective in
used to stimulate sexual desire or treat sexual weakness; a treating diseases such as cancer, AIDS, malaria, diabetes,
yellow decoction or juice obtained from herbal leaves is used hypertension, MRSA, and chronic diseases associated with
for treating jaundice and liver diseases [131, 132]. old age. Nevertheless adverse drug reaction (ADR), another
important public health problem, may be enhanced after mul-
5. Discussion tidrug combination treatment through not only drug-drug
interaction, but also herb-herb or drug-herb interaction [137,
In this section, two important issues related to herbal 138]. For example, as a monotherapy, St John’s wort extract has
medicine are discussed. an encouraging safety profile. However, in some cases, life-
threatening interactions were reported when used together
5.1. The Theoretical Advantages of Herbal Medicine. Due to with other drugs [139]. Therefore, the possibility of drug-drug
shortage of scientific evidence on the molecular mechanism interaction (DDI), including both beneficial effects and ADR,
of herbs, it is often considered as only an alternative choice has caused the FDA and European Medicines Agency (EMA)
14 Evidence-Based Complementary and Alternative Medicine

to encourage the industry to perform drug interaction studies fight against diseases. The concept of synergism in modern
[140]. In the new postgenomic era DDI can be predicted pharmacology encompasses two aspects: (1) pharmacody-
with the data from pharmacogenetic information which namic synergy results from the enhancement of action when
may have an important implication for the development multiple biologically active substances are directed at related
of personalized medicine and drug R&D for clinic and targets in a physiological system, which are often linked to the
pharmaceutical industry, respectively [141]. pathogenesis of a disease and (2) pharmacokinetic synergy
More often than not, the pathogenesis of diseases is can result from alterations in drug absorption, distribution,
related to multiple targets rather than a single target. Asai metabolism, and/or elimination (Figure 10).
et al. found that nonsteroidal anti-inflammatory drugs,
cholesterol-lowering statins, and 𝛽- or 𝛾-secretase inhibitors
can produce additive effects on the reduction of A𝛽-amyloid 5.2. Resource Conservation in Herbal Medicine. Excessive
levels in cultured neuronal cells [142]. Combination therapy medical treatment and medication, including the consump-
of PA-824-moxifloxacin and pyrazinamide can kill over 99% tion of herbal medications, is a global trend, especially in
of drug-sensitive and multidrug-resistant Mycobacterium developed countries. Countless facts have indicated that
tuberculosis in patients with tuberculosis (TB) within 2 weeks. herbal preparations or formulations can be used for the
However, at present, the treatment of patients with TB treatment of many common as well as complex diseases for
or multidrug-resistant TB using conventional drug therapy all ages, with a minimum of adverse side effects compared to
requires 6 or 18–24 months, respectively [143]. A polypill conventional drugs. Together with the long history of their
containing amlodipine, losartan, hydrochlorothiazide, and use, plant-derived herbs and herbal products are gaining
simvastatin produces a significant effect in preventing heart popularity in the global market as registered drugs, dietary
attacks and strokes [144]. Liu Wei Di Huang Wan (Rehmannia supplements, health care products, cosmetics, and so forth.
Six Formula), which is a well-known Chinese herbal formula Medicinal plants are highly esteemed as a rich source of
used for the treatment of 137 kinds of diseases in China, new therapeutic agents for the prevention and treatment of
consists of six Chinese herbs: Radix Rehmanniae nourishes diseases. Nowadays, the public acceptance of herbal medicine
kidney Yin and essence (minute substances for supporting increases not only in Asian countries (49% in Japan, 45%
life); Fructus Corni nourishes the liver/kidney and restrains in Singapore, 70% in China, and 80% in India), but also in
the leakage of the essence; Rhizoma Dioscoreae tonifies spleen western countries [150]. The sales of herbal drugs or related
Yin and consolidates the essence; Rhizoma Alismatis pro- products are expected to increase at an annual rate of 6.4%.
motes urination to prevent buildup of significant fluids; Poria In the USA, the use of herbal products by consumers was
drains dampness from the spleen; Cortex Paeoniae clears liver less than 5% in 1991, but it increased to 50% in 2004, and
fire [145–147]. Therefore, the multitarget herbal formula can the amount of botanical remedies constitutes as much as 25%
produce a wide range of therapeutic effects. of total medications. According to a WHO report, the global
Herbal formulations evolved from thousands of years of market value of herbal products to date is US $61 billion, but it
experience in practicing herbal medicine. While therapeutic is predicted to grow to US $5 trillion by 2050 [151]. The market
interventions using multiple drugs in modern medicine are shares in Europe and the USA are 41 and 20%, respectively
based on an understanding of disease processes and drug [152].
mechanisms, the use of multicomponent herbal formulae Of the 250,000 higher plant species on earth, more than
(Fu-Fang in Chinese herbal medicine) is based on CM theory 80,000 are of medicinal value even in the genome era. In
and practical experience. Unlike using a single drug in Brazil, it is estimated that there are almost 55,000 native
orthodox medicine, raw plant or plant extracts contain an species, at least 1,200 documented medicinal plants, and
array of bioactive ingredients (a single plant contains 100– probably many more undocumented species used by various
1,000 compounds of 20–50 different structure types) that indigenous groups [153]. It can be expected that natural
can produce additive and/or synergistic actions [148]. The medicines, particularly herbal medicine, will make a growing
multi-ingredient herbal drug/formula allows for a multitarget or even a decisive contribution to human health care again. By
interaction in treating diseases. For instance, the common 2001, researchers had identified 122 compounds used in mod-
cold is a viral infectious disease of the upper respiratory ern medicine which were derived from plant/herb sources.
system, which primarily affects the nasal cavity. However, Of these, 80% have an ethnic medical use which is identical
cold symptoms typically include coughing, sore throat, runny or related to the current use of the active component(s) of
nose, headache, fever, and discomfort in the entire body. So the plant [154]. Some of these compounds include tubocu-
far, no single chemical entity can simultaneously alleviate all rarine, morphine, codeine, aspirin, atropine, pilocarpine,
clinical manifestations of common cold. Therefore a typical ephedrine, vinblastine, vincristine, taxol, podophyllotoxin,
over-the-counter cold remedy is composed of multiple drugs, camptothecin, digitoxigenin, gitoxigenin, digoxigenin, cap-
such as aspirin (A), phenacetin (P), and caffeine (C), in an saicin, allicin, curcumin, and artemisinin. Unfortunately,
APC tablet. many plant species on earth have become endangered as
One and one can add up to more than two. Therefore, the consumption of herbs and herbal products continues to
herbal treatment resembles a cocktail treatment or “magic increase world-wide.
shrapnel” (multidrugs act on multiple targets) [149]. The Traditional herbal medicine uses remedies derived from
chemical compounds residing in an herbal drug or formula- plants, animals, metals, and minerals. If herbal resources
tion work together within the body to maintain health and/or are inappropriately exploited, the extinction of many plant
Evidence-Based Complementary and Alternative Medicine 15

Diseases with
single target

Target

Component A Component C
Component B
Absorption Metabolism

Component D Component F

Alteration Herbal medicines

Alteration
Component E Component G

Distribution Elimination
Component B
Component A Component C

Target B
Target A Target C

Diseases with
multitargets

Figure 10: Pharmacodynamic synergism and pharmacokinetic synergism of herbal medicines.

species will inevitably occur, with a resulting adverse alter- and some are isolated from naturally occurring plants on
ation of the ecological environment. For example, for more the basis of their use in traditional medicine. However,
than 30 years wild Panax notoginseng has no longer been our ancestors took only certain kinds of specific natural
found in Yunnan province (the origin of the plant) in China remedies to fight or prevent a specific illness. Because modern
[155]; the acquisition of one kilogram of wild licorice will drug development is a high-risk (and therefore high-failure)
destroy 8–10 acres of grasslands [156]; digging of one Cordy- commercial endeavor and synthetic drugs have a high rate
ceps can cause direct damage to about 30 cm2 of grassland of adverse events; there is a universal trend of using herbal
[157]. To treasure and maintain the gifts from mother nature medications or related products.
(Hindu philosophy regards the Earth as a living being, i.e., Based on cultures and geographical regions, various kinds
mother nature), governments should install measures to of herbal remedies have evolved. Herbal medicines are there-
ensure the ethical exploitation of herbal resources in their fore an integral part of culture and geographical environment,
countries or societies. Therefore, it is high time to formulate and various kinds of herbal medicines have their own unique
strategies to avoid the overexploitation of herbal resources. way of understanding and treating a disease. However, the
globalization of trade and market has brought about an
integration of different kinds of herbal medicines over the
6. Concluding Remarks world. At present, herbal medications or related products in
the global market are derived from Chinese herbs, Indian
Since ancient times, disease has been a leading cause of herbs, Arabic herbs, and Western herbs. Herbal remedies
morbidity/mortality, and it is associated with a heavy eco- may also be classified into three categories, namely, modern
nomic burden among people with diseases. Despite current herbs, theoretical herbs, and empirical herbs, in accordance
advances in science and medicine, disease remains a serious with their nature/characteristics and the nature of current
threat to public health in both developed and developing usage [158]. As for the medications derived from herbs,
countries, urban and rural areas, and all ethnic groups. they no longer belong to any herbal series or category and
Ancient and modern people take medicines to fight ill- have essentially become equivalent to conventional drugs.
ness or to feel better when they are sick. Most medicines In general, most herbal remedies/formulae are considered
(conventional drugs) at present are chemically synthesized to be safe and are well tolerated because they have been
16 Evidence-Based Complementary and Alternative Medicine

Herbs have been used for a long time and are well documented with
Herbs have been their special theories/concepts and are duly accepted by country
modified in their shape, such as Chinese herbs and Indian herbs.
dosage form, methods
of preparation, or
medical indications. Herbs are historically and
freely used in local
Category 1: theoretical herbs community or region.

Category 2: modern herbs Based on property Category 3: empirical herbs

It is used based on herbalists’ clinical

experience or intuition. The herbal In the middle ages, Arabians adopted
knowledge is preserved by folk and improved the ancient medicinal
healers via oral tradition such HM classification practices of Mesopotamia, Greece,
as European and Native American herbs. Rome, Persia, and India.

Western herbology Based on region Arabic herbology

Currently, it is the most It is the oldest

influential herbal Chinese herbology Indian herbology healthcare system
remedies in the world. in the world.

Figure 11: Classification of herbal medicines (HMs) in the international market.

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