The folk medical construct
Skin and soft tissue infections (SSTIs) are treated in different manners, depending on the perceived causation of the illness. Illnesses with a naturalistic (biological) causation are treated in a non-ritual context and involve the topical application of either a plant, animal, mineral, or industrial product as the therapeutic agent. This is usually carried out by the individual being treated or by the female head of household (mother or grandmother).
Illnesses of perceived spiritualistic causation are treated much differently. Some manifestations of inflammation on the skin, for example, are believed to be caused by malevolent spirits, such as mal vjntē (wind illness) or fuoco morto (dead fire illness). These cases are treated ritualistically, and a plant, animal, mineral, or industrial product is employed strictly as a ritual object in the ceremony, rather than as the therapeutic agent. Furthermore, the ritual treatment can be performed only by specific healers (most of whom are women) who are recognized in the community for their healing powers. The treatments for south Italian spiritual illnesses in Basilicata have been discussed in previous publications [19–21].
Botanical remedies
We documented the topical application of 38 plant species from 27 families, comprising 116 distinct remedies (Additional File 1). Plants are listed alphabetically by species. The vernacular and English names are also listed, as well as the author citation of each species. Detailed information regarding the cultivation status, part(s) used, preparation, application and popular use is provided. A consensus index is included and is specific to each individual remedy cited. References to similar remedies in the ethnomedical literature on mainland southern Italy are noted.
Some of the more common uses of these remedies include analgesic, vulnerary (especially for burn wounds), toothache, anti-inflammatory, anti-sting/anti-itch (for insect bites), antiseptic (for lacerations), anti-furuncle, haemostatic, suppurative, emollient, and anti-abscess. Roughly 14% of plant-based remedies are applied for the treatment of abscess and furuncle (Figure 2). Here we discuss three of the most frequently cited plant remedies: common mallow, white horehound and German chamomile.
Malva sylvestris(Malvaceae) – malva
Common mallow is a herbaceous species common throughout most of Europe, except in the most northern regions. It is one of the most important medicinal species in the southern Italian folk pharmacopoeia. Its use as a panacea is reinforced by a local saying, La malva, da ogni mal' ti salva, (the common mallow saves you from every disease). Common mallow is most often cited for its restorative properties for cold, flu, and stomach-ache and as a post-partum depurative [6, 11]. In these cases, a decoction of the aerial parts is drunk.
It is also important in topical remedies for the treatment of toothache due to dental abscess or decay, heat- and diaper- rash, bruise, furuncle, abscess, and mastitis. The application of remedies from this plant to a number of SSTIs, most of which are typically associated with bacterial infection, suggests that this plant may exhibit antibacterial properties and should be subjected to further study.
Marrubium vulgare(Lamiaceae) – maruggē
White horehound is a perennial herb native to Europe, northern Africa, and temperate Asia. Much like common mallow, white horehound is also an extremely important species in the folk pharmacopoeia of southern Italy. It, too, is considered a panacea and is associated with the following saying, A maruggē, ognē malē struggē (the white horehound destroys every disease). In previous studies on south Italian ethnopharmacology, the use of white horehound decoctions as an expectorant, hepatoprotective agent, and cure-all has been described [6, 7, 11]. The Commission E monographs approve of white horehound use for treating loss of appetite and dyspepsia [22].
A decoction of the aerial parts can be used as a rinse to treat several important SSTIs, including general dermatitis, athlete's foot, furuncle, abscess, cyst, and wart in both humans and animals. Investigation of the anti-MRSA potential of this species and its phytochemical components could be promising.
Matricaria recutita(Asteraceae) – camomilla
German chamomile is best known for its anxiolytic and sedative properties. In the Vulture-Alto Bradano, it is also commonly used as a wash for skin conditions such as rash, acne and dermatitis and also as an anti-conjunctivital eye-wash (Figure 3). Application of German chamomile decoctions for the treatment of eye inflammation and infection has been broadly reported in Italy. German chamomile has demonstrated in vitro anti-staphylococcal activity [23] and has been found to promote wound healing in vivo [24]. The German Commission E has approved the use of German chamomile in external applications for the treatment of skin and mucous membrane inflammation, bacterial skin disease, and ano-genital inflammation [22].
Zootherapy and remedies of mineral or industrial origin
The treatment of ailments with remedies made from animals and their products is known as zootherapy [25]. Since ancient times, zootherapy has been integral to the traditional pharmacopoeias of many cultures [26–28]. Despite its prevalence in traditional medical practices worldwide, the phenomenon of zootherapy has often been neglected in comparison to the literature regarding medicinal plant therapies. Animal-based remedies represent an important portion of traditional medicine practiced today in southern Italy. The sources of these remedies include human, pig, bee, chicken, and slug mucous.
Remedies of mineral and industrial origin are also important, and include sources such as copper sulphate, salt, soot, and old gas, among others. They are employed in the treatment of burn wound, furuncle, facial wrinkle, abscess, broken bone, bruise, chapped skin, conjunctivitis, bronchitis, wart, acne, stomach ulcer, callus, cradle-cap, and dermatitis.
Forty-nine remedies from 30 animal, mineral, or industrial sources are used in topical applications (Additional File 2). Remedy sources are listed alphabetically by English name. Vernacular names are also listed, along with detailed information regarding the preparation, application and popular use of the remedy. A consensus index is included and is specific to each remedy cited. References to similar remedies in the ethnomedical literature on mainland southern Italy are noted. Here, we discuss some of the most unusual of these remedies, including aged pig fat, garden slug and human breast milk.
Aged pig fat
Aged pig fat, locally known as sugna fracidē, is prepared by aging the dorsal back fat of a pig in a cool dark place, such as a cantina. It is an important component of several remedies for skin conditions. In addition to its emollient properties, it is also reported to be a useful vulnerary agent in the treatment of both animals and humans. It is also applied together with the leaves of Rubus ulmifolius to treat furuncle, and to draw the pus out of purulent abscess. A similar therapy with R. ulmifolius was reported in Campania, another area of southern Italy [29].
Garden slug
Therapies involving the slug Arion hortensis, locally known as u' marruculē or lummachē senza guscio (snail without a shell), has been briefly mentioned in previous work by our group [11]. The most popular use of this gastropod is to treat gastritis or stomach ulcer by swallowing it whole and alive. A clear mucous produced by the slug is rubbed onto the skin to treat dermatitis, inflammations, calluses, and acne (Figure 4). The mucous is thought to promote wound healing. In addition, a special ritual is incorporated in the treatment of wart. Mucous from a live slug is first rubbed onto the wart, and then the slug is hung out in the sunshine to dry out and die. It is believed that once the slug has dried up, the wart should as well. A similar remedy for wart involving mucous from an unidentified snail is mentioned in Guarrera's work in Latium, Central Italy [30]. This may, however, be a reference to the same species of garden slug.
Human breast milk
Human breast milk is a popular zootherapeutic remedy, and is applied in the treatment of conjunctivitis, chapped nipples, and cradle-cap. The topical application of breast milk to infected eyes was cited by nearly one-third of the interviewees. This remedy was also frequently cited during a previous field study by our group in the Lucanian Dolomite region of Basilicata [11]. This use of breast milk may be well-founded due to the antibacterial properties of xanthine oxidase and IgA antibodies found in the colostrum and milk [31, 32].
Ethnoveterinary remedies
Ethnoveterinary practices have been reported on in Italy in the regions of Basilicata [13], Calabria [33], Tuscany [34], Romagna [35], Marche, Abruzzo, and Latium [36, 37]. Much of this data on Italian ethnoveterinary medicine has been summarized in a useful database [38].
In Vulture-Alto Bradano, the topical application of traditional remedies to treat wounds and inflammation in livestock was particularly important in the smallest communities surveyed, primarily in the localities of Montemarcone Alto, Sant'Andrea, and Pierno. Many families in these communities are economically dependent on agropastoral activities, and the health of their animals is a central concern (Figure 5). Plant, animal, and mineral (or industrial) derived remedies for ethnoveterinary applications are indicated with the symbol '♣' in Additional Files 1 and 2. Here, we briefly discuss two important sources of ethnoveterinary treatments: copper sulphate and St. John's Wort.
Copper sulphate
Copper (II) sulphate (verderammē) is a bright blue-green mineral sold locally as a chemical fungicide for plants (Figure 6). However, it is also one of the most frequently cited traditional ethnoveterinary remedies. While it is also used for the treatment of swollen feet in humans on occasion, the burning sensation it produces is a significant detractor. It is prepared either as a ground powder, a mixture with vinegar, or a mixture with water and salt and is then applied to cracked hooves or to the chapped skin surrounding the hooves of livestock. This ethnoveterinary remedy has also been reported in the western Basilicata Dolomite mountain range [10].
Hypericum perforatum(Hypericaceae) – iperico
An oleolite made from an olive oil infusion of the aerial parts of St. John's Wort (known locally as erva pē rē cuttē or iperico) is massaged into the legs of horses and asses to treat tendonitis. This remedy has also been described in Tuscan ethnoveterinary practices [34]. In other studies, oleolite preparations of the aerial parts or flowering tops have been reported for wound healing and to restore skin damaged by burns [36, 39, 40] or for treating mastitis in milk-producing goats [29]. Oleolite preparations of a similar species, H. perfoliatum, have been reported in Sicily for use as a disinfectant and to promote healing of burn wounds [41]. The anti-staphylococcal properties of Hypericum species are well known [42–44] and are likely relevant to these traditional therapies.
Traditional knowledge: current trends and future projections
The mean number of remedies quoted by interviewees is reported by age group and gender (Figure 7). A generation gap in knowledge regarding folk remedies for SSTI's was evident. There is a statistically significant difference (p < 0.05) in knowledge of folk remedies for the skin between the youngest subset of women sampled (21–35 years old) and women 36 years and older. This may be explained by recent shifts in the socioeconomic patterns of the region. Prior to the opening of the Fiat automobile factory and all of the associated parts factories in the region, women seldom participated in the workforce. When the factories opened nearly 15 years ago, a large shift in women's socioeconomic placement occurred. Young women entered the workforce and no longer regularly participated in outdoor activities, such as upkeep of the family gardens and vineyards, thus creating a significant gap between them and nature. It also fractured the daily interaction with the older women, who are the primary keepers of TK and responsible for the oral passage to younger generations. This socioeconomic shift, undoubtedly, played a significant role in the decline of passing TK on to this youngest generation of women.
There was no significant difference between men in different age groups and men and women were roughly equivalent in oldest subsets sampled (51–70 and 71+ years old). This lack of difference in TK for men may be explained by historic emigration patterns. A large portion of men from the oldest subsets sampled emigrated to northern Italy and Switzerland in their youth for work. Later in life, these men returned to the community of their birth, but the substantial number of years away from their native environment and traditions was detrimental to their level of TK. In addition, younger men, like the young women, did not acquire much TK due to dynamic of the local economy.
Another pattern in TK levels related to the size of communities was notable. Younger men from the smaller communities (primarily the localities), who were actively involved in agriculture – either in farming crops or pastoral activities, had much higher levels of TK for skin remedies than young men from larger, less isolated communities. For example, one young shepherd from the locality of Sant'Andrea was able to describe more than 40 remedies related to the skin. Young men who either worked in factory jobs or were unemployed from a larger community, like Ripacandida, could typically only cite 4 to 7 remedies. This reflects the importance of daily interaction with the environment and its role in the acquisition and retention of TK of plant derived remedies. A qualitative analysis of the data also reflects a greater level of TK retention and transmission between generations in the smallest communities.
In summary, the likelihood of a continued decline in TK transmission across generations is great and will be most notable amongst women. Socioeconomic factors and shifts in the dynamics of women's roles in the home have perhaps the greatest influence on this paradigm. Stronger dependence on allopathic, rather than traditional medical care is expected in the coming years.
