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East, Persia, and India (Fig. 3.1). Important
principles here were the influences of light,
air, nutrition, exercise, rest, regulated sleep,
the balance of the body humors, and a balanced mind on human well-being.
“Let your food be your medicine and
your medicine be your food.” This statement
is attributed to the Greek physician Hippocrates of Kos (460–377 ). However, there
were also some older natural healing
methods that advocated this maxim, such as
TCM and Ayurveda, the traditional Indian
system of medicine. Ayurveda can be traced
back at least 5000 years, and here, too, nu
trition and aromatic herbs play a very important role in health. Like most traditional
systems of medicine, it has been developed
and refined over thousands of years based
on observation and experience. Ayurvedic
therapies have been practiced for thousands
of years, long before there were placebocontrolled experiments.
In Ayurveda, as in the other Asian traditional medical systems, foods, medicinal
herbs, and other substances (including min
eral and animal substances) are also considered as potential “remedies”. In contrast
to modern pharmacy, Ayurveda thus basically makes no distinction between food and
medicine, both are considered as dravya
(“substance”). If a “substance” (and this includes also food) is to be used for Ayurveda,
it must be able to be evaluated according to
the special Ayurvedic principles. In contrast
to Western medicine, in Ayurveda and also
in other traditional Eastern medical systems
(e.g. TCM, TPM/TIM), a specific herbal mixture is developed for the individual person
that best suits his or her “type”. The classification according to the three doshas is generally reflected in the individual diet and the
other Ayurvedic applications. Furthermore,
food is usually cooked so that the body can
better absorb the individual active plant
components; raw vegetables are rarely consumed. The individual herbal raw materials
such as cloves (S. aromaticum), turmeric
(Curcuma longa), ginger (Zingiber officinale),
cardamom (Elettaria cardamomum), coriander (C. sativum), cumin (C. cyminum), nutmeg (Myristica fragrans), pepper (P. nigrum
and Piper longum), saffron (C. sativus), and
cinnamon (C. verum) are very often attributed a spiritual effect on body and mind. In
Europe, long pepper (P. longum), as the first
introduced species of the genus Piper, has
been more or less neglected. This pepper
species originates from India and is still
widely cultivated there today as a holy medicinal plant in the context of Ayurvedic medicine. In contrast to black pepper (P. nigrum),
which is mainly used in Europe today, long
pepper’s aroma shows sweet, minty, and
sometimes even chocolate-like aspects in
addition to the pungency (mainly caused by
the alkaloid piperine) that has also given
this plant species the popular name “chocolate pepper” (Zaveri etal., 2010).
It is not surprising that the list of medicinal and aromatic plants species used in
Ayurvedic medicine corresponds very well
with that mentioned by Avicenna in his
book Canon of Medicine. In ancient times,
there was already an extensive commercial
trade between India, China, Arabia, and Persia. The so-called “Silk Road”, which already
existed during Roman times, not only supported the trade with various goods but also
contributed significantly to the exchange of
medical knowledge and ideas between these
countries.
Even today, Ayurveda still represents an
important medical system in India, Pakistan, Nepal, and Sri Lanka, which in the past
has also partly influenced the medical systems in Tibet, Myanmar, and Malaysia. Another famous Eastern health system is TCM,
which has also been established in Korea
and Japan and spread south to Thailand,
Laos, and Vietnam, where it is complemented by both Ayurveda and Unani, the
ITM system used mainly in South Asian
countries with significant Muslim populations. ITM has its roots in the Hippocratic
theory of the humors adopted from ancient
Greece. The common basic concept of all
these medical systems is that there exists an
underlying life energy called prone in Sanskrit, chi in China, and ki in Japan. In general, the aim is to combine physical, mental,
and spiritual aspects and in this way to prevent diseases and strengthen the body’s defences. In Ayurvedic medicine, illness is
generally attributed to mental or physical
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imbalances. The individual therapy approach is generally based on the three Ayurvedic doshas, which determine the mental
balance and are assigned to the five elements: space, water, earth, air, and fire. In this
context, Vā ta , consisting of air and space, is
considered the life energy; kampha, related
to earth and water, on the other hand, is responsible for the structure of the body, its
growth, and flexibility. The dosha pitta, assigned to fire and water, is made responsible
for all biochemical processes in the human
body.
In a similar way, TPM/TIM too is based
on the concept of the four humors: phlegm
(balgham), blood (dam), yellow bile (safrā’),
and black bile (saudā’). This concept mainly
refers to the theories developed by Rhazes
and Avicenna.
Kampo medicine is the original traditional system of medicine in Japan. Here,
no distinction is made between Western and
Kampo medicine, and both systems are
therefore subject to the same legal regulations today. Accordingly, the application for
marketing authorization of ethical Kampo
medicinal products follows the general notification for medicinal products. In addition,
applications for marketing authorization of
ethical Kampo medicinal products should
follow the Kampo-specific notification
“Handling of ethical Kampo medicinal products”. In general, the safety, efficacy, and
quality of Kampo medicinal products are
comprehensively ensured by the Japanese
Pharmacopoeia, Good Manufacturing Practice, Good Agricultural and Collection Practice, Certificate of Marketing Authorization,
Marketing Authorization Standard, and
Pharmacovigilance.
Temperament is a key concept for
understanding the fundamentals of traditional medicine, on the basis of which
people are classified as healthy and sick.
This principle plays an important role in determining ways to maintain health and also
in treating diseases.
Increasingly, conventional medicine
today is also placing more emphasis on
treating the patient as an individual rather
than the disease in general. Accordingly, numerous studies have already been conducted
to gain more knowledge regarding the relationship between temperament and proteomes in the human body (Jafari etal., 2014;
Shirbeigi etal., 2017). Today, TPM/TIM is
considered a rich and valuable source in the
field of medical history to the point that in a
period of history, it has been used as an important educational reference even at various universities in European countries
(Aciduman etal., 2009).
In Western medicine, too, “personalized
medicine” has been gaining more attention
again for several years. In line with the present spirit (zeitgeist) of increasing personal
individualization, the challenge here is to
achieve a maximum therapeutic efficacy for
each patient while minimizing any possible
side effects. In this context, especially
high-throughput technologies and modern
imaging techniques are used to gain a better
understanding of the molecular processes
involved in the development of various
diseases.
Even before the collapse of advanced
civilization in the Mediterranean region in
the period from the 6th to the 8th century
, Benedict of Nursia founded the first
monastery of the Benedictine order on
Monte Casino in southern Italy, which was
later named after him. Benedictus founded
the abbey of Montecassino in a temple of
Apollo around the year 529. This abbey is
still considered the original monastery of
the Benedictine order (in Latin: Ordo Sancti
Benedicti, OSB) which also provided the
framework for monastic medicine. The
monks and nuns drew on the medical know
ledge of the ancient physicians and adopted
the four-fluid doctrine, the so-called “humoral pathology”, as a basis. The basic rule
for monastic life was given by the Latin
motto ora et labora (“pray and work”), with
the care of body and soul always in the fore
ground. The Benedictine monks mainly
healed sick people, and in this context felt
responsible not only for the members of the
order, but for anyone who came to them
with a health problem.
This idea of placing mercy and charity
above all other duties was considered revolutionary at that time, because in GrecoRoman culture weak and sick people were
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regarded responsible for their own fate.
Apart from Benedict, his friar Cassiodorus
( 490–580) was particularly committed to
the development of monastic medicine. This
work was not only focused on the study of
the books handed down by Hippocrates, Dioscorides, and Galen, but also placed particular emphasis on the study of medicinal
herbs and the development of new plant
mixtures that could be used for various healing purposes. Apart from the ancient books
cited above, the monks referred mainly to
the natural history book with the Latin
name Naturalis historia written by Plinius
and thus they created a medicinal compendium that was considered a standard work at
that time.
Ancient civilizations contributed much
to the development of phytotherapy by
identifying and describing numerous species of medicinal plants. This knowledge of
herbal raw materials thus formed the basis
of medieval medicine. The revival of herbal
medicine can be observed since the 6th century , when monasteries were established
where gardens were planted to grow medicinal plants. Monastic schools were also
founded, and monks expanded their knowledge by studying and copying ancient books
and prepared medicines of natural origin according to secret recipes, which were used to
cure the sick. Although the Middle Ages is
often regarded as a dark age, many achievements of phytotherapy from this period
have passed into history and are still used by
people today.
The monks and nuns in the monasteries
copied and interpreted the writings of Greek
and Roman philosophers and physicians and
were thus able to store and preserve the knowledge passed down from antiquity in Europe.
Monastery herb gardens typically followed
the rules set down around 840 by Walahfrid Strabo, Benedictine monk, poet, and botanist. In his book, Liber de cultura hortorum, he
described 24 medicinal plants, their characteristics, and individual application. The book
became one of the most important botany
books of the Early Middle Ages.
After the decline of the Imperium Roma-
num (Roman Empire) medical development
in Europe gained new impetus with the
Lorsch Pharmacopoeia (Lorscher Arzneibuch)
in the middle of the 11th century .
In the High Middle Ages (11th and 12th
centuries ), the first important writings
of monastic medicine were created, such as
the translations of the book Constantinus Af-
ricanus in Salerno. Furthermore, the Benedictine nun Hildegard of Bingen (
1098–1179) described 300 plant species including their individual medicinal applications. Unfortunately, her Book of Secrets in
Nature and Creatures (Liber subtilitatum diversarum naturarum creaturarum) was lost
after her death. About 150 years later, several manuscripts were retrieved and attempts were made to reassemble Hildegard’s
original work, which was divided into two
treatises, Physica and Causae et curae (Causes
and Cures). The textbooks are mainly attributed to Hildegard, although some sections
may have been influenced by later revisions.
Until the 19th century , the humoral
pathology developed in antiquity according
to Hippocrates and the numerous writings
of Galen remained predominant in medicinal treatments in both the Orient and Occident. Accordingly, the balance of the four
humors (eucrasia) was considered an important prerequisite for health. Hildegard of
Bingen was also influenced by the ancient
teachings of humoral therapies, according to
which mismanagement of the humors leads
to disorders of body and mind. Therefore, a
central message of Hildegard of Bingen’s
medicine is the belief in the power of nature;
a power that strives for balance.
The knowledge from the Near Eastern
roots of monastic medicine and comprehensive visionary insights, shaped, among other
things, the so-called “Hildegard medicine”
that is still well known and appreciated in
Europe of today. Hildegard of Bingen and
the medicine of her time were practiced
within the monastic community. Like most
medieval medical cures, her practices were
mainly guided by the principles described in
the Bible. Today, monastic medicine is increasingly gaining influence in modern
medicine and it is generally accepted that
Hildegard of Bingen’s work was significantly
influenced by the following four works
(Baader, 1979):
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• Physiologus, a book on natural history
written in Egypt in the 2nd century .
is book of an unknown author was
available in several translations, including Latin, around 700.
• De materia medica by the Greek phys-
ician Dioscorides with descriptions of
about 500 medicinal plants recognized
for medical treatment (Fig. 3.9).
With regard to the cultivation of medi-
•
cinal plants, she beneted predominantly from the already mentioned Benedictine monk Walahfrid Strabo, whose
famous work Hortulus (Garden) has
Fig. 3.9. Page from the Vienna Dioscorides codex (Codex medicus Graecus of the Austrian National
Library, 6th century), an illustrated version of De materia medica (1st century AD), page 29v). (Public
Domain, https://commons.wikimedia.org/w/index.php?curid=43449887.)
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served as an important basis for horticulture for centuries.
• e herbal medicine traditions recog-
nized in the Middle Ages were generally
known as “Macer Floridus” from the
11th century and coincided with the
development of Circa instans simplicibus
medicinis (From the Simple Medicines),
which was developed by Matthew Platearius, the medieval physician of the
Salerno Medical School.
After the Ottoman Empire’s advance
into the Iberian Peninsula, Christianity
benefited from Islam’s extensive knowledge
of the natural sciences and medicine. In this
context, the Toledo school of translators
around Gerhard of Cremona ( 1134–
1187), who translated numerous Arabic
writings into Latin, was of particular
importance.
From around 1280 onward, the first
German pharmacopoeia, written by Ortolf
von Würzburg, a highly respected wound
physician with an academic education, was
used regionally until the end of the 16th
century. It is characterized by a high level of
expertise and can be described as a pioneering act, as it was customary until then to
write medical textbooks in Latin. He addressed his textbook to fully trained practitioners, primarily wound physicians, and
imparted to them profound knowledge
about diagnosis, prognosis, and therapy. Ortolf drew primarily on Salerno sources for
his work, which was primarily based on 12th
and 13th century sources, and he also used
medical literature from Parma, Toledo, and
Paris. Among the most important sources is
the Compendium medicinae (Compendium of
Medicine) written by Gilbertus Anglicus.
In these books, mentioned above, first
influences of Oriental medicine can already
be found, which at that time could already
look back on a longer tradition. In the 14th
and 15th centuries , increasingly comprehensive herbal encyclopedias were published, which claimed to collect and
disseminate the entire phytotherapeutic
knowledge available in Europe at that time
(Fuchs, 2001). These herbal records describing
the use of medicinal plants thus represent in
a certain way the basis of today’s “European
Pharmacopoeia”.
Especially in the Middle Ages, Galen’s
teachings were favored over others and established the basis of medical knowledge at
European universities until the 19th century (Schipperges and Durling, 1989). Furthermore, special attention should be also
paid to the physician Ibn But lan (11th cen-
tury ), who worked at the court in Baghdad and, as a Christian doctor, wrote many
medical works. In his book entitled Taqwīm
as (Tabular Overview of Health, in-Sihhah
Latin: Tacuina sanitatis in medicina), he
teaches several health rules that are presented in the form of a synoptic table work.
This clear reference work for questions of a
healthy lifestyle at that time attracted special attention in several European cities such
as Vienna, Paris, and Rome. Later a Viennese edition of the Tacuina was produced in
the 14th century , probably in Lombardy
(Herr, 1988).
In the middle of the 15th century a
so-called Paris Tacuinum sanitatis evolved,
including also several illustrations from
Circa instans (Goehl, 2015) which were presented in the tradition of the synoptic table
work, created by Ibn Butlan. These manuscripts, however, were not written for specialists but more for the upper middle classes
and nobility in Europe. Accordingly, the content of this book is essentially based on ancient and medieval humoral pathology and
explains which foods and human states of
mind (anger, joy, etc.) represent the four
elements “dry”, “moist”, “cold”, and “warm”
and for which people and in which regions
they could be useful. The concept of humoral
pathology assumes that the function of the
human body is regulated by the four humors
(blood, phlegm, yellow bile, and black bile)
and only secondarily by its organs. It was assumed that humors correspond to the four
elements “cold–warm” and “dry–humid”.
Applying a specific selection of medicines
and food raw materials, the doctors tried to
restore the patient’s health as best as possible by establishing a balance with special
regard to the human body fluids and primary elements (Table 3.1). Garlic, for example, is described in this context as “warm”
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pathology, developed by Ortolf on the basis of the four elements and several primary qualities. (According
to Riha, 2017.)
Primary elements Warm/humid Warm/dry Cold/humid Cold/dry
Elements Air Fire Water Soil
Body fluids Blood Yellow bile Mucus Black bile
Temperaments Sanguine type Choleric type Phlegmatic type Melancholiac
Colors Red Yellow White Black
Taste Sweet Bitter Salty Sour
Time of day Morning Noon Night Evening
Gender Man Woman
Age Youth Adulthood Childhood Senility
Organs, tissue Heart, liver,
muscles
Gall bladder Brain, stomach/gut, kidneys/
urinary bladder, fat
Spleen, bones,
tendons
and “dry”. In addition, the book states that
garlic “produces pungent juices and is useful
against scorpion and snake bites, as well as
against worms”. Therefore, “garlic is especially recommended for weakened natures
and in cold regions”.
In the Middle Ages the manuscripts of
Circa instans were widely circulated throughout Europe and were also translated into
German and served as a model for later authors such as Adam Lonitzer ( 1528–
1568) when writing their pharmaceutical
textbooks. Furthermore, it can be clearly
seen that the chapter division refers to
Dioscorides and the descriptions of the
humoral pathology are based on Galen’s
theories (Goehl, 2015).
The wound physician Ortolf von Baierland (born in the first half of the 13th century) wrote a medical textbook around
1280 that was used regionally until the end
of the 16th century.
Ortolf also focused on the model of
medieval humoral pathology. He refers to
this model particularly in the diagnosis and
subsequent therapy. When examining his
patients, Ortolf also oriented himself to certain “leading symptoms”, which he assigned
to the respective primary qualities (cold–
warm and dry–damp, respectively) (Riha,
2017).
Philippus Aureolus Theophrastus Bombastus von Hohenheim, who called himself
“Paracelsus” ( 1493–1541), occupied a
special position. Until today, the myth of
Paracelsus is very widespread, especially in
German-speaking countries. Especially, his
well-known sentence “all things are poison
and nothing is without poison; it is the dose
alone that makes a thing not poison” remains unforgotten. Paracelsus created his
own system of healing various diseases,
which was based on alchemical medicine on
the one hand and on empirical knowledge
on the other. For example, he treated syphilis, which was widespread in the 16th century, with mercury and guaiac wood. During
his lifetime, Paracelsus was known only to a
few contemporaries, as hardly any of his
writings were printed.
Herbal Medicinal Products as a
Source for Modern Evidence-Based
Medical Systems
Nowadays, more attention is again being
paid to research related to plants used in
traditional medicine, as they can be produced comparatively cheaply and usually
show no undesirable side effects. Spices and
herbs such as garlic, mustard, cinnamon,
cumin, cloves, thyme, basil, pepper, ginger,
and rosemary have been used since ancient
times as food additives, flavorings, and natural preservatives. A number of spices also
exhibit antimicrobial activity against numerous bacteria and fungi. Therefore, an
increasing consumption of herbal medicines
is observed worldwide, as they represent often
a suitable alternative to the use of synthetic
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drugs in the treatment of a number of health
problems, including heart disease, diabetes,
hypertension, and even certain types of
cancer.
The use of herbs to treat various diseases is almost universal, particularly in
nonindustrialized societies (DaSilva et al.,
2002). According to estimates of the WHO,
about 80% of the population in some Asian
and African countries currently apply
herbal medicines in order to heal certain
diseases. In the USA about 25% of modern
medicines available on the market are derived from herbal plants and widely used in
modern medicine. About 80% of the 120
active ingredients currently isolated from
higher plants show a positive correlation
between their modern therapeutic and
traditional use (Fabricant and Farnsworth,
2001). It is estimated that at least 7000 active medicinal ingredients in the modern
pharmacopoeia are derived from plants.
Significant variations in plant properties
with different soil conditions have been observed for many medicinal and aromatic
plants (Carrubba and Scalenghe, 2012).
The growing interest in medicinal plants
can be also seen, among other things, in the
significant increase in plant monographs in
the European Pharmacopoeia (at present
clearly more than 100).
Today, in the context of clinical research, evidence-based medicine (EBM) is
generally considered the standard in the
Western world. However, a few phytopharmaceuticals do not correspond to these specifications, which is not surprising due to
the individual underlying philosophy.
However, despite the enormous scientific
successes of “modern medicine”, it should
not be overlooked that many cultures on
this earth gained extensive experience with
medicinal plants over thousands of years
and usually the doctors could successfully
treat their patients. The isolation of individual active substances from the individual
medicinal plants must also be viewed critically, since solvent extraction or steam distillation already may cause significant changes
in the plant metabolite profile. The selection
of the respective extraction solvent (e.g.,
n-hexane, ethanol, water, supercritical carbon dioxide) already generates a selection
according to the different polarities. However, since the efficacy of herbal drugs often
involves the complex interaction of individual constituents, the isolated extraction of
individual chemical groups (e.g., terpene hydrocarbons, alkaloids, fats, sugars, amino
acids) may sometimes reduce their pharmacologic efficacy.
On the other hand, however, the use of
single active ingredients and active ingredient complexes isolated from the plant matrix has resulted in phytopharmaceuticals
with high and reliable pharmaceutical efficacy. Undoubtedly, the very high number of
plant secondary plant metabolites represents a “treasure trove” for the development
of future drugs. Searching for new valuable
plant substances and active ingredient complexes, the so-called “omics” techniques
available today (genomics, transcriptomics,
proteomics, metabolomics) and intelligent
biostatistical methods in particular will play
a very important role.
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