Headaches in the medieval Medical School of Salerno

Abstract

Premise

Headaches are a serious public health concern of our days, affecting about 50% of the world’s adult population. However, such a plague is not limited to the modern era, since ancient archaeological, written, religious and cultural evidences testify to countless attempts to face such disorders from medical, neurosurgical, psychological and sociological perspectives.

Background

Substantially, the Hippocratic and Galenic theories about headache physiopathology remained predominant up to the 17th century, when the vascular theory of migraine was introduced by Thomas Willis and then evolved into the actual neurovascular hypothesis. The medieval Medical School of Salerno, in southern Italy, where the Greco-Roman medical doctrine was deeply affected by the medio-oriental influence, gave particular attention to both prevention and treatment of headaches.

Conclusion

The texts of the School, a milestone in the literature of medicine, translated into different languages and widespread throughout Europe for centuries, provide numerous useful recipes and ingredients with an actually proven pharmacological efficacy.

History of headaches

Headaches (migraine, cluster headache, tension-type headache) are painful and disabling disorders of the nervous system with an estimated prevalence of about 50% in the world’s adult population. According to the World Health Organization, it is a serious public health concern of our days. However, headaches are not a plague limited to the modern era, since ancient archaeological, written, religious and cultural evidences testify to countless attempts to face such disorders from medical, psychological and sociological perspectives (1,2). Several skulls dated to the Mesolithic (10,000 BC) and Neolithic Ages with evidence of trepanation and post-operative healing have been found in various archaeological sites (3). Apart from ritual reasons connected to the belief that the brain’s resident evil spirits could be released, the medical hypotheses at the basis of this neurosurgical procedure include decompression in the case of head injuries and haemorrhages, but also nervous systems disorders like chronic headaches and epilepsy, even if this has yet to be proven.

The religious beliefs were deeply rooted in ancient times. Babylonian cuneiform tablets dated to 4000 BC describe an incantation to send headache caused by the evil spirit Ti’u to heaven (4) and give a proof of the typical migraine symptomatology “flashing like lighting” (5). On the other hand, a rational empirical therapeutic procedure involving the binding of the head to reduce painful pulsations is also described. The religious component was also strong in ancient Egyptian medicine and even the Egyptian Gods Ra and Horus suffered from headaches, whereas in the Greek mythology Zeus had severe headache that led to Athena’s birth from his head. Egyptians had a rich pharmacopeia and proposed several remedies of vegetal, animal or mineral origin to mitigate headache, as described in the Ebers, Hearst, Berlin and Edwin-Smith papyri (2000–1350 BC), as well as trepanation procedures and methods able to relieve pressure and cool, such as binding a clay crocodile holding grain in its mouth to the head of the patient with linen, while reciting an incantation, as described in the Chester Beatty V Papyrus (6,7).

Such procedures mainly had an apotropaic function, aimed at magically transferring the pain into the clay figure. However, some authors attributed a potential unintentional capacity of this method to relieve headache by collapsing blood vessels (7). Greek medicine made substantial attempts to explain headache physiopathology thanks to the Hippocratic theory of the four humours. In the texts of the Hippocratic corpus, it is highlighted that wine can cause headache and that local application of heat can alleviate muscular tensions associated to headache. Inducing vomiting or bleeding to expel bad humours and restore their balance was an efficacious remedy to alleviate head pain, or applying cooling mixtures of vinegar and rose oil, according to Hippocrates (460–377 BC), Aretaeus of Cappadocia (30–90 AD) and Aulus Cornelius Celsus (25–50 AD). Hippocrates was the first to describe the ocular symptoms of migraine aura, whereas Aretaeus attempted a first primitive classification distinguishing three types of headache, cephalalgia, cephalea and heterocrania, characterised by nausea, photophobia and visual symptoms (8). Galen (129–199 AD) introduced the term hemicrania, ascribing its causes to a choleric complexion and accumulation of yellow bile (9,10) and, beyond the induction of vomiting, suggests the application of electric torpedo fish to the patient’s forehead, although the therapeutic application of torpedo fish (in Greek “Narce” (Νάρκη) fish, hence the term narcosis) was already known by Hippocrates and by the Roman physician Scribonius Largus (1–50 AD) (11–13). In his Compositiones medicinae, he clearly stated that “Headache even if it is chronic and unbearable is taken away and remedied forever by a live black torpedo placed under the spot that is in pain, until the pain ceases. As soon as the numbness has been felt the remedy should be removed lest the ability to feel be taken from the part. Moreover, several torpedoes of the same kind should be prepared because the numbness, that is the proof of the cure, can be felt after two or three applications” (13). Such techniques can be considered the forerunner of Transcutaneous Electrical Nerve Stimulation (TENS), low voltage electrical current delivered across the skin, a non-invasive neurostimulation technique to stimulate peripheral nerves for pain relief in migraine and other conditions (14,15). Galen believed that the meninges, pericranium and blood vessels were possible locations of headache. Substantially, the Hippocratic and Galenic theories about headache physiopathology remained predominant through the Middle Ages up to the 17th century, when the vascular theory of migraine was introduced by Thomas Willis (1621–1675 AD) and then evolved into the actual neurovascular hypothesis (16).

The medieval Medical School of Salerno

In the Middle Ages, attention was given to natural remedies and electuaries to alleviate headaches. In this period, before the creation of the first Universities in Europe, in southern Italy there was a city overlooking the Mediterranean Sea, Salerno, where a Medical School (900–1200 AD) rose and prospered that became famous all over Europe and the Mediterranean coasts and that can be considered the forerunner of medical universities. According to the legend, the illustrious Medical School of Salerno was founded by four physicians: The Greek Pontus, the Arab Adale, the Jewish Rabbi Helinus and the Latin Salernus, who blended together their different medical cultures (17). Indeed, the Greco-Roman natural derivation of the School is deeply influenced by medio-oriental knowledge, thanks to the direct contacts through the commercial routes between the Salerno harbour and the African coasts, the availability of oriental medicinal herbs and products and, later, the translation of the main medical Arabic texts into Latin by Constantine the African, who lived in Salerno before withdrawing to Monte Cassino Abbey. The School, which was famous throughout Europe for its very practical approach and skilled physicians, also produced a huge amount of original medical texts written by its doctors and “magistri”, among whom there were also women, the most famous of whom was Trotula De Ruggiero (18–20).

The Regimen Sanitatis Salerni

The most famous text of the School was the Regimen Sanitatis Salerni, collectively written around the 11th to 13th centuries by several doctors of the school, which remained a milestone in the literature of medicine for centuries and was translated into numerous languages: English, French, German, Dutch, Czech and Polish (21–23). Its success can be attributed to the fact that it was not a specialist medical textbook, but a very practical guide rich with advice and recipes useful not only to practitioners but also to common people. Indeed, since it was a poem written in rhyme in Leonine verse, its medical recommendations were easy to remember and assimilated into popular culture. Several precepts were devoted to headache, with a particular insight into the natural remedies to counteract or even prevent it. Indeed, the Medical School of Salerno gave a particular importance to preventive medicine and to a correct diet and lifestyle, as attested by the incipit of Regimen, which can be considered a real manifesto of the School: ‘Si tibi deficiant medici, medici tibi fiant haec tria, mens laeta, requies, moderata diaeta” (if you lack physicians, let these three things be your medicine: Good humor, quiet [avoiding or reducing stress] and moderate diet) (24).

The physiopathology at the basis of the School precepts is of clear Greco-Roman derivation, based on the Hippocratic-Galenic four humours theory. However, the originality of the School is in a very practical approach, given by the great hands-on experience of its physicians and an almost infinite number of remedies, enhanced by the availability of typical herbs of the Mediterranean area and imported from the medio-oriental pharmacopeia. Indeed, Salerno was also famous for the first known botanical garden of the West, the Minerva Garden, established by the School physician Matteo Silvatico in the 14th century (22).

Numerous references to headaches and their treatment are present in the Regimen, with the terms “capitis dolor”, “emicranea” and “cephalea”. Emphasis is given to the prevention of headache, highlighting that excessive afternoon rest as well as exposure to sun or too much wine can cause headache due to the accumulation of bad humours. In these cases, it is suggested that the forehead and temples should be rubbed with cooked Black nightshade, which was extensively used in the Middle Ages and before by ancient Greeks, thanks to its analgesic, sedative and narcotic properties. A lot of natural herbal remedies and complex antidotes and electuaries – very popular in those times – composed of dozens of ingredients including herbs, spices, seeds, animal derivatives, minerals, and gums are listed in the Regimen for their ability to counter headache, restoring the balance of the humours (Table 1). Analysing the therapeutic effectiveness of the remedies proposed from a scientific point of view, we can find numerous ingredients that are still used in traditional medicine and that have proven beneficial properties. Black nightshade has been traditionally used worldwide for its anti-inflammatory, anti-nociceptive and anti-pyretic properties, among others, due to its high content of glycoalkaloids (25). Celery, a traditional Italian food plant that also spread to Arabic regions, with its high content of glycosides, flavones, and phenolic compounds, has reported antioxidant, anti-spastic, sedative and hepatoprotective activities (26). Cloves, a spice employed for centuries as a food preservative and as a medicinal plant for its antioxidant and antimicrobial activities, is one of the major vegetal sources of phenolic compounds such as flavonoids (eugenol) and phenolic acids (gallic, caffeic and salicylic acids). The main compound responsible for antinociceptive activity is eugenol, thanks to the activation of calcium and chloride channels in ganglionar cells (27). The common viola has been extensively used in traditional medicine to treat cough, fever, headache, insomnia, epilepsy and other conditions, mainly for its sedative, analgesic and anti-inflammatory properties, due to its high amounts of bioactive phytochemicals (terpenes, flavonoids and alkaloids) (28). Similar effects have been ascribed to Rosa canina, which has shown moderate effectiveness in clinical studies in patients with osteoarthritis (29). The pain-killing efficacy of coffee is well known and the habit of drinking coffee for headache relief is very widespread. A lot of commercial pain relievers contain caffeine as an adjuvant among the active substances, since it plays a proven role in pain modulation through a direct action on the adenosine receptors, which are involved in nociception (30).

Table 1.

Ingredients and original recipes active against headache extracted from the Regimen Sanitatis Salerni (22). Note: The table has been compiled and comments provided by the authors.

Name/text name	Recipe	Latin verses (22)	Effect
Beverages
Coffae/coffaeum		Impedit atque facit somnos, capitisque doloris tollere coffaeum novit	It gives sleep to some and unrest to others; it relieves headache
Herbal remedies
Black nightshade (Solanum nigrum)/Morella		Si dolor est capitis ex potu, lympha bibatur, Ex potu nimio nam febris acuta creatur; Si vertex capitis vel frons aestu tribulentur, Tempora fronsque simul moderate saepe fricentur, Morella cocta nec non calidaque laventur; Istud enim credunt capitis prodesse dolori	Cooked warm black nightshade rubbed on the temples alleviates pain
Celery (A.graveolans)/Apium		Humores apium subito totius adjuvat corporis et capitis	Celery humours relieve head and body
Clove (Syzygium aromaticum)/Gariophilus		Gariophilus suptus mane caput bene purgat, et fervorem capitis inflicti deprimit idem, humores siccat et auget cordis amorem, Alleviat caput cerebro praestatque levamen. Addet et somnum, confortat utique caput	Clove relieves headache through astringent properties
Rose (R. caninae)/Rosa		Gengivas, colicam, capitis juvat ipsa dolentes	Rose is useful for headache, abdominal cramping and gums
Violet (Viola)/Viola		Crapula discutitur, capitis dolor atque gravedo, purpureant dicum violam curare caducos	Violet dispels headache
Wilde thistle (Dipsacus fullonum)/Virga pastoris		Virgula pastoris tenet omnia fraena cruoris, Est medela foris ficus, capitisque doloris	Wild thistle is active against headache
Betony (Stachys officinalis)/ Betonica		Succus betonicae Baptistae nocte legetur, Hunc bibe mane, sic emicranea saepe fugatur.	Betony juice is efficacious against hemicrania
Antidotes and electuaries
Aurea Alexandrina		Aurea quae da tur capitis dolor alleviatur … Aurea quando datur, caput a languore levatur	It relieves headache
Adrianum	Electuary, contains opium, herbs (e.g. henbane), seeds, spices, gums, honey	Delirium capitis … si laedat, sanum faciens fugat haec Adrianum	It relieves headache
Athanasia	Electuary, contains spices, herbs, gums, powdered mummy, Armenian bole, hematite, honey	capitisque dolorem Athanasia juvat	It relieves headache
Arrogon	Ointment containing animal fats, beeswax, gums, laurel-berry, oil, herbs	capitisque dolorem Arrogon ista fugat	It relieves headache
Blanca	Electuary containing gums, spices, herbs, minerals, castor, ambergris, lion’s flesh, honey	Antiquum capitis oculi sanatque dolorem, cephaleam	It is efficacious against headache, ocular ache and cephalea
Diacastoreum	Electuary containing castor (substance obtained from perineal sacs of beaver)	Nervi defectus, cephalea nocens, yeronoxa, Enfraxis splenis hepatisque, repietio renum, Vertigo capitis, somnusque lethargicus, haec sunt Quae dyacastoreum depellens liberat aegrum	It is active against nervous pathologies, headache, vertigo, lethargic sleep
Diaolibanum	Electuary containing olibanum (Boswellia)	Constringit fluxum diaolibanum lacrimarum, Et capitis vitium depellitur hujus ad usum, Ac diautibanum cerebro dut regere sanum.	It relieves headache
Euperiston (Theodoricon euperiston ‘well-proven God-given’)	Electuary containing various gums, spices, herbs, honey	Menstrua, rheuma, calor nocuus … oculi cerebri dolor, algor, vertigo capitis … Sanguinis ut cesset euperiston tibi praebet. Euperiston amat quae propter menstrua clamat	It is active against menstrual ache, rheumatisms, headache, ocular ache, vertigo
Mitridatum	Panacea or antidote against poison, containing gums, spices, herbs, wine, honey	Mitridatum vitium capitis quod procreat algor Extinguit	It relieves headache
Pigra Galieni	Cinnamon, mastyke, aloes, casia roots	Frigiditas capitis, matricis, nausea ventris, Errores stomachi pigra fugavit Galieni. Pigra caput purgat, vitiis stomachique repugnant	It is active against head and gastric affections
Sal sacerdotale	Powder containing salt, spices, crushed herbs (cinnamon, cumin, ginger, pepper, oregano)	Sale Sacerdotis capitis dolor et malus oris Cedit odor, caligo cadit tenebras oculorum inducens, tusses fugiunt et anhelitus altus	It relieves headache and earache. It soothes cough
Triasandali	Powder containing Indian sandalwood (Santalum album), red sandalwood (Pterocarpus santalinus), roses, rhubarb, liquorice, portulaca, gums, seeds,	Capitisque dolorem	It relieves headache
Unguentum marciaton	Unguentum containing beeswax, olive oil, butter, animal fats, gums, 50 herbs (e.g. poppy, betony, rosemary, mints), henbane	Thoracis, capitis, stomachi dolor, algor … haec sunt quae marciaton juvat usus	It is active against head, thoracic and gastric affections
Pillulae sine quibus esse nolo		Mundat visus quibus est nomen sine quibus auribus, yliacae, veteri prosunt cephaleae	It alleviates headache

Many of the herbal ingredients and spices (cinnamon, cumin, ginger, pepper, oregano) composing the electuaries have well-known analgesic and anti-inflammatory properties that could ameliorate patients’ symptomatology and alleviate headaches. Among these, aloe and Boswellia are among the top herbal supplements still used today in numerous pathological conditions and their bioactive components, such as boswellic acids, are subject to active research work as candidate drugs (31–33). Some preparations contain medicinal plants rich in narcotic compounds, such as poppy or henbane, which could be primarily responsible for the beneficial effects observed by the physicians of the School. Indeed, narcotics were widely used in the Salerno’s pharmacopeia and in general in the Middle Ages, both in western and eastern medicine. Other ingredients of mineral or animal origin appear very strange to our eyes, but were very common in medieval recipes, such as castor, a substance obtained from the perineal sacs of the beaver, which is listed among the components of Diacastoreum and Blanca, or lion’s flesh (Blanca). Among the minerals, Armenian bole, ambergris, and hematite were used both for their medicinal, chemical-physical and superstitious properties, such as those ascribed to mummy powder, an ingredient of Athanasia.

Conclusions

Through the analysis of the Regimen it is possible to draw a clear picture of headaches in the eyes of a medieval physician in Europe, which persisted up to the 17th century. The magical religious component of ancient populations is absent in early medieval medicine, but the knowledge about the etiopathogenesis of the disease had not advanced from the Hippocratic-Galenic theory. On the contrary, particular attention was given by the Medical School of Salerno to prevention and therapeutics, with the description of numerous useful recipes made with local ingredients and new ones imported from the Mideast, with proven pharmacological effects due to the significant content of bioactive phytochemicals, which explains their use in traditional and natural medicine up to our days.

Article highlights

Headaches are not an affliction of the modern era: Collected archaeological, written, religious and cultural evidences prove innumerable attempts from the dawn of time to deal with such disorders from multiple perspectives.

The medieval Medical School of Salerno in Italy blended a medical culture of Greek-Latin origin to Jewish and Arabic medical knowledge.

The School of Salerno, through its precepts and medical practice, paid special attention to both disease prevention and therapeutics. The recipes carefully described in its texts use natural remedies rich in bioactive phytochemicals with well-known analgesic and anti-inflammatory properties.