Fig. 1
(a) Fresco of the twelfth century, depicting Hippocrates and Galen. Cathedral of Anagni, near Rome. (b) The Asklepeion is an ancient medical centre placed in Kos Town. It dates from the first half of the 3rd century BC and it was built to honor the god of health and medicine, Asklepios, after the death of Hippocrates. The arrows show the remains of the Doric Temple of Asklepeion. Besides, the “abaton” the place where the sicks waited for Asklepios to appear in their dreams and heal them. (c) The square in front of the Temple where the sicks were praying
The modern pharmacology has also found that these leaves contain acetylsalicylic acid as active ingredient. The various medicaments were given in the form of ointments, powders, pills, poultices, and patches. Some substances were given by inhalation, gargling, douching, or fumigation. However, it is very unlikely that shoulder pain caused by rotator cuff tear could be affected favorably by many of these treatments, commonly used by Hippocrates and his students with the aim of inducing evacuation and vomit in the patient (Fig. 1b, c).
A general guidance for pain is reported in the “Treatise on Diseases” [8]; it consists in hot water lotions applied on the sore area, fumigation and fasting. After the acute phase, the patient would have to ingest a purge and cooked donkey milk.
In a votive relief dedicated to Amphiaraus (350 BC) (Fig. 2a), the mythological God with healing powers, an example of the presence of a shoulder disease manually treated, is shown. According to some interpretations [9], Alchino is represented in the right of the figure, entering the sanctuary. At the center, the same Alchino dreams Amphiaraus’ snake sucking the moods collected in the sick right shoulder; and finally on the left, Amphiaraus – the bearded figure – manually concludes his work of healing. A votive relief of the same period depicting a snake biting a shoulder is kept at Kos (Greece) (Fig. 2b).
Fig. 2
(a) Votive relief dedicated to Amphiaraus. (Anonymous c. 350 BC) National Archaeological Museum, Athens. (b) Votive relief with representation of “nekrodeipno” (banquet for the dead) and Cybele enthroned (Roman house, Kos)
The information about how the Etrurians treated the painful joints comes from Greek and Roman texts. Unfortunately, there are no specific references on the treatment of shoulder pain; however, as for the Egyptians, it is supposed that the principles of treatment were common to all painful joints [10]. It is well known that Etrurian medical doctors suffered a strong influence by Greeks archiatri, who settled in Sicily, Asians, and Phoenicians [10a]. In fact, in some of the tombs, knives, pliers, explorers, and cauteries were found, attesting that Etrurian priests practiced the surgeon profession according to what it had been taught them by Greek colleagues. The effect of water had a high regard.
Horace says that he was invited by Antonio Musa, medical doctor to Emperor Augustus, to the Clusinae Fontes, an ancient Etruscan thermal centre near the current Chiusi (Tuscany) [11]. The water of this spring held many healing properties, especially, the one of “chasing away rheumatism from the bones” [10b, 11].
Theophrastus, Greek philosopher and botanist of the IV-III century BC, describes the skills of the Etruscans doctors in preparing potions and drugs [12]. Pliny mentions an ancient potion based on Myriophyllum (grass lawn) and pork fat that was used to treat diseases of animal and human tendons [10c, 13]. Finally, Marcus Terentius Varro a Roman writer of the first century AC, in “De Agricoltura,” reports that on the Soratte mountain, near Rome, there was a college of Etrurians priests who owned the secrets for preparing substances able to remove pain [10c, 14]. Cato the Elder (243–146 BC), interested in medicine, treated pain with domestic remedies related, essentially, to the assumption of cabbage (used as a panacea for all the pain) and wine used as a vessel for the active substances [15].
Among the potions proposed by Cato, the one containing wine and juniper was used specifically to soothe joint pain [15].
Celsus (14 AC-37dC) in “De Re Medica” [16a] (Fig. 3a, b) does not recommend the use of cold to older people and to those who suffer scapular pain. In the Book 3 [16b], Celso provided some advice on how to manage tendon pain; the author suggests not to sweat but to drink water and get massaged. He also recommended to grease the painful part with nitro and water and submitted it to sulfur fumigations which would have been developed from sweet embers placed near the patient. To achieve an adequate benefit, the treatment would have been made to a fasting patient. Another ointment applied to the painful area was made up of equal parts of henbane seed and nettle (mixed with tallow?); water where sulfur had been previously boiled in was added. In Book 4 [16c], Celsus advised to apply heat on the painful but not swollen shoulder. In particular, during the night, heated poultices with malvavischio root boiled in wine were applied to the painful area. If the pain was particularly intense, poppy cortex mixed with wax and pork fat was boiled in wine. In Book 5 [16d], for the treatment of painful joint, the action of malagma was enhanced: potion of herbs and sprouts of sweet-smelling plants. The “Euticleo’s” one was used specifically in tendon diseases. It was composed of soot incense, resin, galbanum, ammoniac gum, and bdellium. The soothing effect of these plants on the pain had already been described by Hippocrates (De victu in acutis) and Dioscorides [2]. The “Sosagora’s” one was another malagma composed of various vegetable substances, poppy and molten lead [16]. An additional advice for the management of shoulder pain consisted of immersing into gritty bathrooms [17] and making use of suction cups [16]. The latter were applied on intact skin (to remove air) or scarified (to extract the blood) and exploited the principle of the “vacuum” created by the flame (Fig. 4).
Fig. 3
Aulus Cornelius Celsus’ Portrait (a). Front page of “De Re Medica” in eight books, 1566 (b)
Fig. 4
Drawings of bowls and cups corresponding to the description of Celsus, found at Pompeii and Herculaneum and conserved in R. Museum of Naples
Dioscorides (doctor of Greek culture-Anazarbo-Turkey – 25? AD) wrote, between 50 and 70 AD, the “De Materia Medica”: it is a herbarium written in Greek language, destined to have an important influence on the medical literature [17] (Fig. 5a). The work was in fact translated and commented in many languages up to the seventeenth century. For joint pain, Dioscorides suggested to take a decoction made from “cucumer sylvestris” [18]. He also suggested the intake of decoctions made from “ferrule galbaniflua” (Fig. 5b), formerly used as a universal remedy for the treatment of ulcers, cough, seizures, fractures, headaches, stomach aches, menstrual cramps, sore teeth, snake bites, labor pains, indigestion, and flatulence. In chronic pain, he suggested to apply to the painful area heated goat dung, contained in an oiled cloth [2].
Fig. 5
Antique miniature of Dioscorides (a) sitting on a bench. He is offering a student the mandrake. Drawing taken from “De Materia Medica” and representing the “ferrule galbaniflua” plant used by the author for the treatment of joint pain (b)
Among Roman physicians, Galen was the one who provided additional information on the genesis and the treatment of joint pain. He was born in Pergamum in 129 AC, the site where a temple and a medical school dedicated to Asclepius was located; he was able to improve his knowledge on orthopedic and trauma because it soon became the gladiator doctor of his city and because he had a passion for operative medicine which he practiced in public squares on pigs and monkeys. He moved to Rome, where he became a physician to Marcus Aurelius; he stated again the utility of bloodletting to relieve many pains (De Sanguinis Mission) [19]. Galen continued the Hippocratic concept of Nature medicatrix and argued that the doctor “is the minister of Nature” and should therefore follow primarily the criterion of “contraria contrariis,” which consisted in applying, for example, the heat if the pain was caused by cold and vice versa cold if the painful area was hot. It is said that Galen used a potion called theriaca composed of various ingredients including: alcohol, opium, viper venom, and honey. This medicine, considered for many centuries as “panacea for all the illness,” was also used for joint pain, especially in older people [20].
According to Galen (De ratione victus in acutis; De Elementis juxta sententiam Hippocratis) [19], pain was due to the philosophical “passion.” Later he came to the conclusion that the only cause of pain was the “solution of continuity” (De simpl. Medic., Chap. 2 “Subacromial Space and Rotator Cuff Anatomy”) [19].
Arabic Period
The Arabic medicine can be conventionally divided into a first period (between 750 and 900), where traditional medicine is gradually mixed with the Greek and Latin ones, and in a second one (between 900 and 1100) where many scholars detach from their teachers to take on an increasingly clear and independent personality, entirely directed toward new research and acquisitions. It is in this phase of maximum glory that personalities as Avicenna and Albucasi emerge.
In the “Canon,” the “prince of medicine” (Avicenna 936? -993?) (Fig. 6) suggested to use several herbs as a base for analgesic infusions, including juniper, chamomile, marjoram, rue, lavandula, mandrake, and opium. His concept of pain follows the celsiano one regarding inflammation. It also argues that pain itself may be the disease and not the symptom. He actually distinguished 15 forms of pain (including the articular one) which he used to treat with exercise, heat (if the joint was not swollen and hot), or cold in the form of snow or ice water. The pain adverse to treatment with herbs and decoctions was treated with cauterization.
Fig. 6
Image depicting Ibn Sina, or Avicenna, better known as “the prince of medicine.” X-XI century
The Albucasi “Practice” (Al Tesrif) (Cordoba: 912? -1002?) (Fig. 7a, b) is considered a connection between the decadent Greek medicine and the Salerno and Bologna schools. With Albucasi, medicine surgery switches from empiricism to anatomical study and experience (experimental method). In the preface to the section on “Surgery” (Book XXX), the author states that “If you ignore the anatomy, you will fall into error” [21]. Joint pain, presumably shoulder pain too, was treated with cauterization; bloodletting, and cups or suction cups. In contrast to what practiced until then, Albucasi runs cauterization in every season and not only in spring. The iron cautere is preferred by the author with respect to the gold one because the latter cools immediately and melts when it is brought to high temperature. The bloodletting was practiced by Albucasi from five upper limb veins: cephalic, median basilica, cubital, and “Salvatella” (2 branches). He used the wide knife for the voluminous vessels containing dirty blood and the small one for smaller vessels containing tenuous and bilious blood. Albucasi also suggested to run bloodletting in spring and to a fasting patient; instead he discouraged it in children younger than 14 years, in the sixties, in tired, drunk, with indigestion, vomiting, and diarrhea patients. The amount of blood to be removed should be proportionate to patient forces. The cups used by Albucasi were made from horn, glass, copper, and wood. He used them with or without scarification, as Paul of Aegina did [21].
Fig. 7
Albucasi (a), Arab physician, chemist, and scientist who lived between the tenth and eleventh century. Pages of the Kitab al-Tasrif (b), an encyclopedia of medicine and surgery written around 1000 by the author
Constantine the African, Roger of Frugardo, Rolando from Parma, Lanfranc of Milan, Guido de Chauliac, and Fabrizio “d’Acquapendente” were those who followed and put into practice Albucasi’s teachings.
Byzantine Period
With the fall of the Western Roman Empire, in 476 AD, everything that was still “civil” emigrated to Bosphorus in Istanbul, due to the barbaric invasions. Thanks to its special geographical position, Roman/Latin knowledge joins the Greek, eastern, and African ones in this place. Constantinople (Istanbul) will be the center of medical culture until its fall, due to Turks, in 1453.
Medical doctors who distinguished themselves in this period were four: Oribasius of Pergamon, Aetius of Amida, Alessandro of Tralles, and Paul of Aegina. The latter was born in a Greek island near Athens in 620 AD (Fig. 8). We know about him that he was a pupil at the school of Alexandria and based his theories on the observation of the patients, the study of symptoms and the experience.
Fig. 8
Paolo D’Aegina’s effigy, taken from a version of author’s works published in London in 1574
In Chapter XLI of Book VI of his “Memorial” [22–24], Paul describes the use of plastic cups for the treatment of painful areas. The clay cups were used, according to the author, to evacuate “moods.” The evacuation must be carried out on intact skin (if the involved area was not meaty) and with scarification (if it was meaty). The clay cups were preferred to those made of glass or horn. Paul also described the size of the cup that had to be proportionate to the area to be treated. Clay cups with long neck and large cavities were preferred to the others [22–24].
Middle Ages and Renaissance
In Italy, after the barbarian invasions, a desolate atmosphere of decadence that involved all the arts was present. However, the ancient practice of caring for the sick continued in ecclesiastical institutions and convents. Several monasteries and convents were founded, thanks to Saint Benedict of Nursia, including the one of Monte Cassino, built on the motto “the care of the sick first and foremost.” In an ancient parchment found at Monte Cassino, written by an unknown doctor, the first description of how to prepare a sedation (made of opium, mandrake and henbane juice) to get a deep sleep in case of surgery was found. “Mandrake” was one of the main ingredients for most mythological and legendary potions. The name, probably derived from the Persian (mehregiah), was assigned by Hippocrates. It was depicted in some texts on “alchemy” as a man or a child and was considered a creature belonging to both the plant and the animal kingdom such as the less known vegetable lamb of Tartary (a legendary plant whose fruits were sheep) (Fig. 9a, b).
Fig. 9
Drawing made by Ibn Butlan (1390) depicting the Mandragora (a). The root of the plant had human form. The extirpation from the soil would have caused a deadly scream. Taken from “Tacuinum Sanitatis,” Austrian National Library. The Vegetable Lamb of Tartary (b) in a picture taken from “The Vegetable Lamb of Tartary” by Lee H., London, 1887
Also in southern Italy, particularly in Salerno, some religious hospitals were born, including the one founded by the archdeacon Adelmo (820 AD) and that was built with incomes left by Matthew of Ajello (1183 AD), the grand chancellor of the emperor. The collection of these religious institutions created the preconditions for the emergence of a medical school that will be the prelude (to herald) to the establishment and the development of the university. According to the legend, the Salerno school was born from the meeting of four members, coming, respectively, from the Latin medical culture (Salernus), Jewish (Elinus), Greek (Pontus), and Arabic (Adelus) ones.
In a series of dictates concentrated in the “Regimen Sanitas Salerni” [25] (Fig. 10), which for two centuries have been the compendium of medical knowledge, medicinal herbs, such as nettle and penny royal, useful for the treatment of joint pain were described. In the therapeutic area, it was given much importance to the use of the “simple,” as the growing of medicinal plants. Many convents were equipped with an infirmary and a garden of medicinal plants, which were then stored in the “armarium pigmentatorium” which, some years later, will become the pharmacy. Therefore, these places of prayer became the site where those more learned in medicine, the heirs of Hippocrates and Galen, met the poorer ones in order to treat both body and soul. However, if the intensity of joint pain was particularly intense, a sort of mandatory pathway which initially consisted of using spices and then bloodletting was performed. In fact, Musandinus (De Cibis et potibus aegrotantium) [26] proposed this treatment for almost all diseases in patients older than 15 years.
Fig. 10
Cover of “Regimen Sanitatis Salernitanum” (Rule Health Salerno) (1050) by Luigi Cornaro, Venice, 1662
Gariopontus (? -1056) in the “Passionarius” [26] described the cauterization as a healing technique used by doctors of that time; Bruno Longoburgo in 1252 in the “Major surgery and minor surgery” gave the same description [27]. William from Saliceto in his work entitled “Cyrurgia (finished in 1268)” [28] first suggested to use the knife instead of the cautery.
Taddeo Alderotti (1215–1295), mentioned by Dante in Canto XII of “the Paradise,” contributed to spread medicine teachings at the University of Bologna. In his “Consilia,” he attributed to alcohol so high healing properties as to consider it a sort of Galenic “theriaca,” a panacea for many aches. In fact, the original theriaca was alcohol based.
In the Middle Ages, cadaver dissections were criticized and limited because of religious and popular beliefs. During the period of the “Crusades,” autopsies were only allowed to remove organs and to facilitate the transport of the dead to homeland. The continuous relics and human bones trading forced Pope Boniface VIII in 1300 to promulgate the Papal Bull “De sepolturis,” in order to prohibit manipulation of human bodies [29, 30]. This was in contrast with what Frederick II published in 1240, in an imperial decree, allowing the practice of dissection. The Popes, succeeded in that years, promulgated more bulls allowing dissection during Lent and on women, as they were considered soulless. The first official dissection in the Middle Ages was performed at the University of Bologna by Mondino de’Liucci (Sec. 1270–1326), author of “Anathomia Mundini” (Fig. 11). This book has been used to study anatomy for more than 200 years [31] even though it had no illustrative tables or figures. Guido da Vigevano (1280–1349), a Mondino pupil, continued the practice of cadaver dissections and his manuscript “Anathomia,” published in 1345, is the first example of a text with anatomical illustrations. Guido da Vigevano’s drawings, based on empirical observations [32], represented a guide to the anatomists of the Renaissance, a period in which the association between science and art reached the highest degree, especially in 1543, thanks to the work “de Humani Corporis Fabrica” of Andreas Vesalius [33]. Guido da Vigevano also wrote “Anatomy designated for figures” (1345), which included illustrations. In the second section of the book, he describes the veins used for bloodletting, a practice still used for persistent joint pain [30, 34].
