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Alberto Gobbi
João Espregueira-Mendes
John G. Lane
Mustafa Karahan
Editors

Bio-orthopaedics
A New Approach
Bio-orthopaedics
Alberto Gobbi • João Espregueira-Mendes
John G. Lane • Mustafa Karahan
Editors

Bio-orthopaedics
A New Approach
Editors
Alberto Gobbi John G. Lane
O.A.S.I. Bioresearch Foundation NPO Musculoskeletal and Joint Research
Milan Foundation
Italy San Diego
California
João Espregueira-Mendes USA
Clínica do Dragão, Espregueira-Mendes
Sports Centre – FIFA Medical Centre of Mustafa Karahan
Excellence Department of Orthopedics
Porto Acibadem University
Portugal Istanbul
Turkey

ISBN 978-3-662-54180-7    ISBN 978-3-662-54181-4 (eBook)

DOI 10.1007/978-3-662-54181-4

Library of Congress Control Number: 2017941285

© ISAKOS 2017
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer-Verlag GmbH Germany
The registered company address is: Heidelberger Platz 3, 14197 Berlin, Germany
This book is dedicated to my Father; he taught me that when
somebody leaves, it is because someone else will arrive. To my
Mother, still smiling in her eighties at every sunrise with the
excitement of a child. To Emanuela, she keeps telling me that I
never have time but, I know, one day, I will find the right words
and then, it will be simple…
To my children, they just grew up too fast! I learned from them
that if you live pursuing your “personal legend,” trying to make
your dreams come true, life will be a bumpy ride; however, the
only thing that will make it impossible is the fear of failure.
God bless all the friends who have shared my journey.
—Alberto Gobbi

I dedicate this book to my team and my family.

—Prof. Espregueira-Mendes

I want to dedicate this book to my parents for their unwavering

support and the work ethic they provided me. To my family and
especially my wife for their support and understanding of my
many hours of work.
—John G. Lane

We all continuously learn and teach as a condition for our

profession with an unsatisfied thirst for knowledge. I dedicate
my share of the work in this book to my first teacher, not only at
home but in school, my mother, Guzide Karahan, who installed
an endless energy in me.
—Mustafa Karahan
Foreword

Healing is a matter of time, but it is also a matter of opportunity.

—Hippocrates
Healing cannot be imposed, but may have to be encouraged.
—Girdlestone 1932

The ability of injured tissues to heal is the fundamental basis on which the
practice of surgery is predicated. As noted by Girdlestone and Hippocrates,
tissue healing is not guaranteed and is governed by a variety of local and
systemic factors. While advances in cellular and molecular biology over the
last two decades have significantly improved our understanding of the basic
biological processes involved in tissue healing, the ability to ensure, opti-
mize, or enhance this repair process in all tissues has not progressed at the
same rate.
Classically, the orthopedic surgeon’s control over tissue healing was often
limited to optimizing the biomechanical environment (i.e., reattaching a ten-
don, replacing a ligament, stabilizing a broken bone) and limiting additional
tissue damage. Mother Nature and the patient were then left to do the rest.
Confounding systemic factors such as diabetes, smoking, hypercholester-
emia, and age, as well as local factors (poor vascularity, tissue degeneration,
cell death, etc.) can hamper this healing response and lead to poor clinical
outcomes. Over the past several years, the orthopedic community has begun
to explore ways to enhance the biologic response of connective tissues in an
effort to optimize the repair process and improve clinical outcomes. These
advances have come in the form of cell-based therapies, cytokine-­based ther-
apies, and scaffold-based therapies. This text, Bio-Orthopaedics: A New
Approach, provides an excellent snapshot of the current status of these thera-
pies in orthopedics.
Professor Alberto Gobbi has been a key figure in the evolution and clinical
application of biologics in orthopedics and sports medicine. As the editor of
Bio-Orthopaedics: A New Approach, Prof. Gobbi has gathered together a
stellar collection of clinicians and basic scientists to share their insight, expe-
rience, and expertise in the scientific rationale and clinical application of a
variety of innovative modalities designed to optimize connective tissue heal-
ing. The importance of a strong scientific foundation on which to predicate
the rationale of bio-orthopedics is skillfully put forth in the early chapters of
this text. This is followed by a balanced and comprehensive review of clinical

vii
viii Foreword

issues related to various musculoskeletal conditions. These tissue-themed

chapters provide an excellent sequel to the accompanying Emerging
Orthobiologic Approaches chapters for each of the musculoskeletal tissues
(muscle, tendon, ligament, bone, menisci, cartilage). While this text is not
intended to be the final word on the clinical validity of a specific biologic
therapy, this text does provide an important and practical state-of-the-art ref-
erence for medical students, residents, and clinicians on the potential role of
biologics in orthopedic applications. In addition, this text provides a valuable
benchmark for future clinical studies.
The field of bio-orthopedics is constantly evolving, and I am confident that
the information presented in Bio-Orthopaedics: A New Approach will con-
tribute significantly to the continued evolution of biologic therapies in ortho-
pedics. I commend Prof. Gobbi and the coeditors Prof. Espregueira-Mendes,
Prof. John Lane, and Mustafa Karahan, M.D., and the many talented authors
for their excellent contributions.

Steven Paul Arnoczky, D.V.M.

Acknowledgments

I would like to thank Jane Elizabeth Hayward for helping me in the process
of selection, editing, and keeping up the pressure on me, the co-editors, and
all the contributors of this book.
—Alberto Gobbi

I would like to thank all my research and development team which provided
a valuable help in the development of this book, to my co-editors which
supervised and organized the book contents, and to all the book’s contribu-
tors. With them, this book became a useful source of knowledge.
—Prof. Espregueira-Mendes

The guiding influence and direction of my mentor Prof. David Amiel and the
meticulous work of Frances Shepherd.
—John G. Lane

I had help from many of my students, residents, and fellows throughout the
preparation of the book. I especially want to thank Assoc. Prof. Sarper Gursu
and Dr. Ersin Erçin for their invaluable help.
—Mustafa Karahan

ix
Introductory Commentary

Dr. Alberto Gobbi is a pioneer in the development of new techniques and

research into the use of cell-based therapies in degenerative disease. He is one
of the first Italian surgeons to be elected honorary member of the American
Academy of Orthopedic Surgeons and the Arthroscopy Association of North
America.
He is both founder and director of O.A.S.I. Bioresearch Foundation NPO
based in Milan.
By deciding to dedicate his time and energy to act as chief editor and com-
pile this book, he has provided a dramatic departure from descriptions of the
current and traditional standard of care for orthopedic practices. By providing
authors the opportunity to discuss bio-orthopedics in each of the chapters, the
emphasis involves understanding the biologic basis of tissue repair and regen-
eration. Although the biology of skeletal tissues has long been the focus of
traditional orthopedics, most of the clinical solutions have involved mechani-
cal and structural solutions to the patients’ problems. In this new era, the bio
is how the host repairs/regenerates the defective tissue using the tissues’
intrinsic capability to do so, utilizing not only screws, nails, and hammers as
part of the orthopedic approach. The emphasis of these chapters is how to
manage the body’s own regenerative capabilities to provide solutions for the
injured or defective tissue. This could be accomplished by using biological
materials that release informational molecules or by adding starter cells to
manage the injury site. These starter cells or the host-intrinsic cells that
respond to the released informational molecules are not stem cells, but rather
are secretory cells capable of providing site-specific bioactive molecules that
both initiate the regenerative process and sustain the subsequent complex
series of formative events [1].
To back up for a moment, in the late 1980s, I suggested that mesenchymal
stem cells (MSCs) could be isolated from adult human bone marrow, put into
culture, and expanded and could be a new technology for reconstructive
orthopedics because, in cell culture, we could drive these cells into a bone,
cartilage, muscle, marrow stroma, and the other mesenchymal phenotypes
[2]. Indeed, I started a company, Osiris Therapeutics, as a bio-orthopedic sup-
plier of these multipotent progenitors (MSCs) for tissue-engineered recon-
struction of skeletal tissues. The basis for these suggestions was the dogma of
the day which stated that such reparative cells were derived from the “Stroma”
of bone marrow. In the subsequent years, MSCs were isolated and expanded
from a huge array of vascularized human tissues. In 2008, Crisan et al. [3]

xi
xii Introductory Commentary

clearly documented that MSCs were derived from perivascular cells, peri-
cytes, which brought together a huge array of information that clearly indi-
cated that the in situ MSCs were derived from perivascular cells and did not
function as a multipotent progenitor in vivo. In fact, the detail that MSCs did
not arise from stroma (i.e., connective tissue) opened up new logics and
explanations for both the immunomodulatory and trophic capabilities of
these cells once they were reintroduced to injury sites [4]. These new facts
also caused an explosion of clinical trials that exploited these MSC properties
for use in a large spectrum of non-orthopedic clinical problems ranging from
GVHD, ALS, MS, diabetes, kidney transplantation, etc. We have recently
reviewed all of the new cellular and molecular information related to MSCs
and summarized much of it in a poster for Nature Protocols [5]. It follows
that some of the released molecules form biologic products that both release
the MSCs from their perivascular anchorages and stimulate and sustain their
control over regenerative activities.
Bone marrow has been used since the days of Aristotle to provide a boost
to bone reconstructions. The assumption is that there are osteo-progenitors
that add value and participate in bone formative and natural regenerative
events. There are such osteo-progenitors in bone marrow (see poster, [5]), but
it may be that the therapeutic capacity of marrow in skeletal reconstructive
events is due to the array of secreted molecules from both MSCs [6] and
hematopoietic progenitors in marrow since it has long been known that both
cell types have strong paracrine functionalities.
These paracrine capabilities and the actions of multiple secreted bioactive
molecules bring into focus the modern view of skeletal reconstruction events
with emphasis on both cells and the multitude of informational molecules
that are synthesized and organized at local regenerative tissue sites. These
bioactive factors are in, on, and outside of cells and in, on, and bound to the
extracellular matrix and released upon injury and trauma and as a natural
function of local microenvironment that these cells experience. Indeed, these
complex events described above are the bio of the bio-orthopedics and are the
basis of many of the chapters in this book. The bio is not new, but it is now a
key component in the practice of modern orthopedics. This book contains the
emphasis on bio-orthopedics and its central and timely discussion as a basis
for the new standard of care in orthopedics. The use of biologics in a variety
of injured skeletal tissues has been slow to start, but now appears to be the
time when these new materials and logics will be implemented. This book
has many chapters which focus on the new logics of biologic (BIO)
orthopedics.

Arnold I. Caplan, Ph.D.

Department of Biology
Skeletal Research Center
Case Western Reserve University
10900 Euclid Avenue, Cleveland
OH 44106-7080, USA
Introductory Commentary xiii

References

1. Caplan AI. Adult mesenchymal stem cells: when, where, and how. Stem
Cells Int. 2015;2015:628767.
2. Caplan AI. Mesenchymal stem cells. J Orthop Res. 1991;9:641–50.
3. Crisan M, Yap S, Casteilla L, et al. A perivascular origin for mesenchymal
stem cells in multiple human organs. Cell Stem Cell. 2008;3:301–13.
4. Caplan AI. Why are MSCs therapeutic? New data: new insight. J Pathol.
2009;217:318–24.
5. Somoza RA, Correa D, Caplan AI. Roles for mesenchymal stem cells as
medicinal signaling cells. Nat Protoc 2015; 11.
6. Meirelles Lda S, Fontes AM, Covas DT, et al. Mechanisms involved in the
therapeutic properties of mesenchymal stem cells. Cytokine Growth
Factor Rev. 2009;20:419–27.
Contents

Part I Overview

1 The Optimization of Natural Healing���������������������������������������������� 3

Christopher Rogers and Alberto Gobbi
2 Overview of Orthobiology and Biomechanics ������������������������������ 25
Jorge Chahla, Mark Cinque, Robert F. LaPrade,
and Bert Mandelbaum
3 Education and Understanding Orthobiologics:
Then and Now���������������������������������������������������������������������������������� 41
Steven Sampson and Hunter Vincent
4 Orthobiologics: Regulation in Different Parts
of the World�������������������������������������������������������������������������������������� 47
Jason A. Grieshober, Eyitayo Fakunle,
and Ralph A. Gambardella
5 Tissue Engineering and New Biomaterials������������������������������������ 65
Mustafa Karahan and Rustu Nuran
6 Physiology and Homeostasis of Musculoskeletal Structures,
Injury Response, Healing Process, and Regenerative
Medicine Approaches���������������������������������������������������������������������� 71
Kaitlyn E. Whitney, Ioanna Bolia, Jorge Chahla,
Hajime Utsunomiya, Thos A. Evans, Matthew Provencher,
Peter J. Millett, Robert F. LaPrade, Marc J. Philippon,
and Johnny Huard
7 Host Environment: Scaffolds and Signaling
(Tissue Engineering) Articular Cartilage Regeneration:
Cells, Scaffolds, and Growth Factors �������������������������������������������� 87
Livia Roseti and Brunella Grigolo
8 Current State for Clinical Use of Stem Cells
and Platelet-Rich Plasma�������������������������������������������������������������� 105
Volker Musahl, Conor I. Murphy, Thomas P. Pfeiffer,
Jeremy M. Burnham, and Gregory V. Gasbarro

xv
xvi Contents

9 Xenografts: Biologic Combination Devices �������������������������������� 125

Kevin R. Stone
10 Orthopedic Sports Disorders: Genetic
and Molecular Aspects������������������������������������������������������������������ 135
Moises Cohen, Diego Costa Astur and João Victor Novaretti
11 Cell-Free Scaffolds for the Treatment of Chondral
and Osteochondral Lesions ���������������������������������������������������������� 139
F. Perdisa, A. Sessa, G. Filardo, M. Marcacci, and E. Kon
12 Understanding Scaffolds, Stem Cells, and Growth
Factors�������������������������������������������������������������������������������������������� 151
R. Cugat, P. Alvarez-Diaz, D. Barastegui,
M. Garcia-­Balletbo, P. Laiz, R. Seijas, and G. Steinbacher
13 Cell Culture Approaches for Articular Cartilage:
Repair and Regeneration�������������������������������������������������������������� 161
Eyitayo S. Fakunle and John G. Lane
14 Gene Therapy �������������������������������������������������������������������������������� 173
Henning Madry, Patrick Orth, Jagadeesh K. Venkatesan,
Ke Tao, Lars Goebel, and Magali Cucchiarini
15 The Use of a Large Animal Model and Robotic Technology
to Validate New Biotherapies for ACL Healing�������������������������� 185
Jonquil R. Mau, Huizhi Wang, and Savio L-Y. Woo
16 Use of Stem Cells in Orthopaedics ���������������������������������������������� 197
Konrad Slynarski, Hieronymus P. Stevens, Joris A. van Dongen,
Filip Baszczeski, and Lukasz Lipinski
17 Stem Cells in Joint Repair������������������������������������������������������������ 205
Celeste Scotti, Kota Koizumi, and Norimasa Nakamura

Part II Muscle

18 Shoulder Muscle Architecture, Physiology,

and Plasticity���������������������������������������������������������������������������������� 215
Samuel R. Ward and Richard L. Lieber
19 Emerging Biological Approaches to Muscle Injuries ���������������� 227
Anne D. van der Made, Gustaaf Reurink, Johannes L. Tol,
Mario Marotta, Gil Rodas, and Gino M. Kerkhoffs
20 The Use of PRP in Athletes with Muscular Lesions
or Classification of PRP Preparations ���������������������������������������� 239
G. Zanon, A. Combi, F. Benazzo, and M. Bargagliotti

Part III Tendon

21 Basic Science of Tendons �������������������������������������������������������������� 249

Rocco Aicale, Domiziano Tarantino,
and Nicola Maffulli
Contents xvii

22 Emerging Orthobiologic Approaches to Tendon

Injuries�������������������������������������������������������������������������������������������� 275
Gian Luigi Canata, Valentina Casale, Angelo De Carli,
Giacomo Zanon, Francesco Benazzo, Maria Concetta Rivellino,
Alberto Vascellari, and Francesco Oliva

Part IV Ligaments

23 Ligament Histology, Composition, Anatomy, Injury,

and Healing Mechanisms�������������������������������������������������������������� 291
John G. Lane and David Amiel
24 Emerging Orthobiologic Approaches to Ligament
Injury���������������������������������������������������������������������������������������������� 313
Alberto Gobbi and Graeme P. Whyte
25 Biological Augmentation in Acute ACL Repair�������������������������� 325
Alberto Gobbi and Graeme P. Whyte

Part V Menisci

26 Current Concepts in Natural History of Meniscal

Injury and Future Options in Meniscus Healing:
Orthobiologics�������������������������������������������������������������������������������� 339
Theofylaktos Kyriakidis, René Verdonk,
and Peter Verdonk
27 Meniscus Scaffolds: Past, Present, and Future �������������������������� 355
Sarper Gursu and Mustafa Karahan
28 Meniscus Restoration�������������������������������������������������������������������� 363
Camila Cohen Kaleka, Pedro Debieux,
Diego da Costa Astur, Gustavo Gonçalves Arliani,
and Moisés Cohen
29 Meniscus Scaffolds: 30 Years of Experience�������������������������������� 375
William G. Rodkey and Shu-Tung Li
30 Clinical Use of the Meniscal Scaffold ������������������������������������������ 389
P. Bulgheroni, E. Bulgheroni, and M. Campagnolo
31 Scaffolds for Meniscus Regeneration ������������������������������������������ 399
A. Sessa, F. Perdisa, E. Kon, M. Marcacci,
and G. Filardo
32 Building the Basis for Patient-­Specific Meniscal
Scaffolds������������������������������������������������������������������������������������������ 411
Ibrahim Fatih Cengiz, Hélder Pereira, Marios Pitikakis,
João Espregueira-Mendes, Joaquim Miguel Oliveira,
and Rui Luís Reis
33 3D-Printed Artificial Meniscus ���������������������������������������������������� 419
Yusuke Nakagawa, Lisa A. Fortier, Jeremy J. Mao,
Ichiro Sekiya, and Scott A. Rodeo
xviii Contents

Part VI Bone

34 Bone Anatomy and the Biologic Healing Process

of a Fracture ���������������������������������������������������������������������������������� 437
Ersin Ercin, Onder Murat Hurmeydan,
and Mustafa Karahan
35 Clinical Orthobiologic Approach to Failure or
Delay in Bone Healing ������������������������������������������������������������������ 449
Fabio Valerio Sciarretta
36 Avascular Necrosis of the Hip ������������������������������������������������������ 461
Mahmut Nedim Doral, Gazi Huri, Nadir Suleyman Cetinkaya,
and Egemen Turhan
37 Emerging Orthobiologic Approach to Fractures������������������������ 473
Marcin E. Domzalski and Patrycja Szkutnik
38 Subchondral Bone: Healthy Soil for the Healthy
Cartilage������������������������������������������������������������������������������������������ 479
Deepak Goyal, Anjali Goyal, and Nobuo Adachi

Part VII Cartilage

39 Osteochondritis Dissecans: Pathoanatomy, Classification,

and Advances in Biologic Surgical Treatment���������������������������� 489
Alberto Gobbi and Graeme P. Whyte
40 Clinical Orthobiological Approach to Acute Cartilage
Injury: Pros and Cons ������������������������������������������������������������������ 503
Tomoyuki Nakasa, Nobuo Adachi, and Mitsuo Ochi
41 Biologic Knee Arthroplasty for Cartilage Injury
and Early Osteoarthritis���������������������������������������������������������������� 517
Graeme P. Whyte and Alberto Gobbi
42 Bilayer Collagen Membrane in Articular Cartilage
Defect Repair���������������������������������������������������������������������������������� 527
Francesco Allegra, Enrico Bonacci, Gennaro Campopiano,
and Giovanni Corsini
43 Scaffold-Free Stem Cell-Based Tissue Engineering to
Repair Cartilage and Its Potential Application to Other
Musculoskeletal Tissues.���������������������������������������������������������������� 537
Kazunori Shimomura, Wataru Ando, Hiromichi Fujie,
David A. Hart, Hideki Yoshikawa, and Norimasa Nakamura
44 Clinical Applications of Adipose Tissue-Derived
Stem Cells �������������������������������������������������������������������������������������� 553
Alberto Gobbi, Laura de Girolamo, Graeme P. Whyte,
and Fabio Valerio Sciarretta
Contents xix

45 Orthokine���������������������������������������������������������������������������������������� 561
Ron Arbel
46 Joint Congruence Restoration in Osteochondral Defects:
The Use of Mesenchymal Stem Cells with the “Sandwich”
Technique���������������������������������������������������������������������������������������� 571
Boguslaw Sadlik and Mariusz Puszkarz
47 Biological Reconstruction in Patients with Osteochondral
Defects: Postoperative Management and MRI
Monitoring�������������������������������������������������������������������������������������� 587
Boguslaw Sadlik, Mariusz Puszkarz, and Adrian Blasiak
48 The Role of Biological Treatments in Spine Disorders�������������� 599
José Fábio Santos Duarte Lana, Edilson Silva Machado,
Renato Bender Castro, João Lopo Madureira Junior,
Paulo David Fortis Gusmão, Nivaldo Evangelista Teles,
Luiz Felipe Chaves Carvalho, João Paulo Bezerra Leite,
Bruno Tavares Rabello, and Ozório de Almeida Lira Neto
49 Cell Culture Methods�������������������������������������������������������������������� 619
Alain da Silva Morais, F. Raquel Maia, Rui L. Reis,
and Joaquim M. Oliveira
50 Evolving Perspectives in Orthobiologic Approaches
to Articular Cartilage Regeneration�������������������������������������������� 637
Lorenzo Brambilla, Celeste Scotti, Alberto Gobbi,
and Giuseppe M. Peretti
51 Comprehensive Approach to Patellofemoral Chondral
Lesion Treatments�������������������������������������������������������������������������� 651
Luiz Felipe Morlin Ambra, Andreas H. Gomoll,
Eildar Abyar, and Jack Farr
52 Partial Anterior Cruciate Ligament Lesions: A Biological
Approach to Repair ���������������������������������������������������������������������� 665
Graeme P. Whyte, Alberto Gobbi, and Dawid Szwedowski
53 Osteochondral Repair Using a Hybrid Implant
Composed of Stem Cells and Biomaterial ���������������������������������� 671
Kazunori Shimomura, Hiromichi Fujie, David A. Hart,
Hideki Yoshikawa, and Norimasa Nakamura

Index�������������������������������������������������������������������������������������������������������� 683
 Part I
Overview
 The Optimization of Natural
Healing
1
Christopher Rogers and Alberto Gobbi

Contents
1.1 Introduction
1.1 Introduction 3
1.2 The Phases of Tissue Healing 4 The doctor of the future will give no medicine, but
1.2.1 Hemostasis Phase 4 will interest his patients in the care of the human
1.2.2 Inflammation Phase 5 frame, in a proper diet, and in the cause and pre-
1.2.3 Proliferation Phase 5 vention of disease.
1.2.4 Remodeling Phase 5 —Thomas Edison (1847–1931)
1.3 Impaired Tissue Healing 6
Since Edison’s day, a mountain of scientific
1.4  actors That Contribute to Impaired
F evidence has been created that supports this asser-
Healing 7
tion. The benefits of a healthy diet, regular physi-
1.4.1 Obesity 7
1.4.2 Drugs 7 cal activity, and avoidance of substances known
to promote disease have essentially become com-
1.5 Factors That Improve Natural Healing 9
1.5.1 Sleep 9 mon knowledge. When it comes to using “natu-
1.5.2 Circadian Rhythms 10 ral” remedies for the treatment of musculoskeletal
1.5.3 Nutrition 11 conditions, there seems to be no shortage of rec-
1.5.4 Dietary Supplements 13 ommendations; however, many of these remedies
1.5.5 Physical Activity 15
1.5.6 Cognitive Control/Biofeedback 17 remain incompletely evaluated in the medical lit-
erature. These treatments do not always assure
Conclusion  17
safety or efficacy, simply because they are “natu-
References  17 ral.” Regenerative medicine physicians rely upon
the peer-reviewed medical literature for guidance
to maximize clinical outcomes.
Recent estimates conclude that the average
adult human is composed of 37.2 trillion cells [1]
and, perhaps, as many bacteria [2]. The word cell
derives from the Latin word cella, meaning “small
C. Rogers, M.D. room.” In 1665, Robert Hooke discovered and
San Diego Orthobiologics Medical Group, 6125 Paseo named them for their resemblance to monastery
Del Norte, Suite 100, Carlsbad, 92011 CA, USA
cells inhabited by Christian monks [3]. In these
A. Gobbi, M.D. (*) “small rooms,” all of the amazing properties of life
Orthopedic Arthroscopic Surgery International
are found. The cell serves such vital functions as
(O.A.S.I.) Bioresearch Foundation, Gobbi Onlus,
Milan, Italy energy production, protein synthesis, and the repair
e-mail: gobbi@cartilagedoctor.it of all the tissues of the musculoskeletal system.

© ISAKOS 2017 3
A. Gobbi et al. (eds.), Bio-orthopaedics, DOI 10.1007/978-3-662-54181-4_1
4 C. Rogers and A. Gobbi
The human body is in a continual state of
renewal. In the average adult, more than 1.1 mil-
lion new platelets and 2.4 million erythrocytes
are produced every second [4, 5]. Bone and mus-
cle cells turnover at a much slower rate, but will
be completely replaced several times throughout
an individual’s life span [6]. The viability of
these cells, and therefore our health, is influenced
by the activities we do daily and the environment
in which we do those activities. Behaviors that
optimize health will naturally lead to optimal
healing. Optimizing healing is therefore nothing
more than the facilitation of optimizing one’s
overall health.
In the clinical context, healing can manifest in
three forms: “healing better,” “feeling better,” and
“dealing better.” Healing in the truest sense
implies that injured, degenerated, or diseased tis-
sue is repaired and normal function is restored.
However, very little effort extended in current
medical practice achieves this high standard. Up
until recently, complete tissue healing either
occurs naturally or not at all. Corticosteroid injec-
tions for the treatment of chronic inflammation,
analgesics for unresolving pain, and even surgical
repair of damaged tendons or joints often provide
only temporary relief and rarely restore normal
tissue function [7–9]. Yet, these treatment options
have remained the standard of care in orthopedics
for decades. For many patients, simply achieving
relief of their symptoms is sufficient. They simply
wish to feel better. They understand the limita-
tions of medical care and are often content with a
quick fix to alleviate symptoms.
In cases where all efforts have failed to alleviate
symptoms, patients are offered pain management
which may include supportive counseling, behav-
ioral modification, and education. There is no
doubt that these efforts have enabled patients to
better cope with their otherwise unmanageable
condition. Oftentimes, simply educating the
patient and taking time to listen to their concerns
will result in a therapeutic benefit. Empowering
the patient to control emotional responses and
enhancing cognitive awareness and the impact that
the environment has on their symptoms can allow
these benefits to be maintained over long periods
of time [10].
Regenerative medicine is the clinical transla-
tion of cellular biology and tissue engineering to
replace, rejuvenate, or regenerate human cells,
tissues, and organs in order to restore normal
function. This emerging field of medicine is
changing the face of orthopedics at an ever-­
accelerating rate. Our expanding knowledge of
cellular biology, human genetics, and tissue engi-
neering and the clinical translation of this new
understanding will likely continue to evolve for
the foreseeable future. As clinicians and scien-
tists, we and our patients will have an increasing
number of treatment options to consider as we
strive to eliminate musculoskeletal pain and dys-
function. With cellular-based therapy, patients
may finally be relieved of having to deal better or
merely feel better and will be enabled to actually
heal better. Regenerative medicine holds great
promise and has already begun to deliver on that
promise.
1.2 The Phases of Tissue Healing
Healing is the process whereby tissues repair them-
selves in response to disease or trauma. Tissue
healing is a dynamic process involving the coordi-
nated actions of both resident and migratory cells
within the extracellular matrix leading to the repair
of injured tissues. The healing process is not only
complex but also fragile, and it is susceptible to
interruption or failure leading to chronic nonheal-
ing tissue that may cause pain or loss of function.
Factors contributing to incomplete healing include
diabetes, arterial disease, infection, and metabolic
deficiencies [10]. The tissue healing process can be
divided into four distinct phases: hemostasis,
inflammation, proliferation, and remodeling.
1.2.1 Hemostasis Phase
In the hemostasis phase, platelets in the blood
become activated and adhere to the injured site
within minutes following injury. Injured vessels
constrict and the coagulation cascade is activated
limiting blood loss. Platelets release cytokines to
promote clotting by the activation of fibrin, which
1 The Optimization of Natural Healing
forms a fibrous mesh binding platelets to each
other. This forms a hemostatic clot that seals the
injured blood vessel and prevents further bleed-
ing [11, 12]. The fibrin clot formed by fibrin,
fibronectin, vitronectin, von Willebrand factor,
and thrombospondin provides the provisional
matrix for cellular migration [13].
Platelets contain alpha granules which release
platelet-derived growth factor (PDGF), insulin-­like
growth factor-1 (IGF-1), and transforming growth
factor-β (TGF-β). These proteins attract and activate
fibroblasts, macrophages, and endothelial cells. The
platelets also contain dense bodies that release vaso-
active amines such as serotonin that increase micro-
vascular permeability leading to tissue edema.
1.2.2 Inflammation Phase
In the inflammation phase, bacteria, damaged and
dead cells, and their debris are removed via the
process of leukocyte phagocytosis. The activation
of complement leads to granulocyte or polymor-
phonuclear leukocyte infiltrates within 24–48 h.
The polymorphonuclear leukocytes adhere to the
endothelial cells in blood vessels by margination
and exit the vessel wall by diapedesis. Bacteria in
the wound are killed by the release of degrading
enzymes and oxygen-derived free radical species,
before being phagocytosed. Macrophages also
contribute to the phagocytosis of cellular debris.
Monocytes are attracted to the wound by a vari-
ety of chemoattractants, including complement,
immunoglobulin G fragments, collagen and elas-
tin breakdown products, and the cytokines: leukot-
riene B4, platelet factor IV, PDGF, and TGF-β
[10]. Monocytes undergo a phenotypic change and
become tissue macrophages which release cyto-
kines and growth factors recruiting fibroblasts and
endothelial cells. They release collagenase to
debride tissue and further stimulate inflammation
with the production of other growth factors
(TGF-α, heparin-binding epidermal growth factor,
and basic fibroblast growth factor). After 72 h,
lymphocytes are attracted to the injury by interleu-
kin-1 (IL-1), IgG, and complement products. They
may play a role in collagen and extracellular
matrix remodeling [14].
5
1.2.3 Proliferation Phase
The proliferation phase starts about 3 days after an
injury. It is the phase when angiogenesis, collagen
deposition, granulation tissue formation, epithelial-
ization, and wound contraction occur [15]. Vascular
endothelial cells form new blood vessels with the
stimulation of vascular endothelial growth factor
(VEGF) [16]. TFG-β and PDGF, secreted by plate-
lets, attract macrophages and granulocytes promot-
ing early angiogenesis. The macrophages also
release angiogenic substances, TNF-α and bFGF. A
microvascular network organizes in the fibrin clot
to form granulation tissue, which is composed of
proliferating fibroblasts, capillaries, tissue macro-
phages in a matrix of collagen, glycosaminogly-
cans, and glycoproteins (fibronectin and tenascin).
Fibroblasts and myofibroblasts appear
between 2 and 4 days after injury. Fibroblasts are
attracted by PDGF and TGF-β. They proliferate
and produce extracellular matrix proteins such as
fibronectin, hyaluronan (HA), collagen, and pro-
teoglycan [10, 16]. Type I and III collagen, syn-
thesized by the fibroblasts, provides strength and
integrity to connective tissue. The extracellular
matrix (ECM) supports further ingrowth of cells.
Cells that are no longer producing extracellular
matrix undergo apoptosis and are removed [10].
1.2.4 Remodeling Phase
In the remodeling phase, the matrix matures, and
collagen bundles increase in diameter and are orga-
nized along the lines of tissue tension. Collagen
synthesis and the breakdown of the extracellular
matrix continue until day 21 when steady state is
reached. Matrix metalloproteinases (MMPs) are
produced by fibroblasts, granulocytes, and macro-
phages to degrade collagen. Tissue inhibitors of
metalloproteinase (TIMP) activity increase as
remodeling continues. Early collagen deposition is
highly disorganized but becomes more organized
with wound contraction. The remodeling phase
continues over a prolonged period of time leading
eventually to a reduced capillary growth, blood
flow and metabolic activity reduction, and an acel-
lular, avascular healed wound.
6 C. Rogers and A. Gobbi

1.3 Impaired Tissue Healing Macrophage activation is suppressed in chronic

wounds leading to an impaired inflammatory
Incomplete healing may occur when any phase of response [23]. Polymorphonuclear (PMN) cells
the healing process is disrupted. Most chronic produce more reactive oxygen species in chronic
injuries do not progress beyond the inflammatory wounds [24]. The production of catabolic factors
or proliferative phase. This leads to chronic involved in both cartilage degradation and noci-
inflammation or incomplete tissue healing caus- ceptive stimulation includes IL-1, IL-6, TNF-α,
ing pain and loss of function (Fig. 1.1). PGE2, FGF-2, and PKCδ [25].
Altered protease activity is a biomarker of Fibroblasts in chronic ulcers may not be capa-
incomplete healing. In the phases of normal wound ble of responding to growth factors such as PDGF
healing, the production and activity of proteases and TGF [26], and fibroblasts isolated from
are tightly regulated, but this regulation appears to chronic wounds demonstrate reduced motility or
be disrupted in chronic injuries. Levels of various migration [27].
MMPs and serine proteases are markedly increased Free radicals are short-lived, reactive chemi-
in fluids from chronic wounds. Levels of MMP-1 cals containing one or more unpaired electrons.
(collagenase), MMP-2 (gelatinase A), and MMP-9 They are classified as reactive oxygen species
(gelatinase B) have been shown to be elevated in (ROS), reactive nitrogen species (RNS), or reac-
fluid derived from pressure ulcers [17]. During tive chlorine species (RCS). In low levels, they
granulation tissue formation in chronic ulcers, lev- influence cell differentiation and migration, neu-
els of MMPs have been shown to be decreased, rotransmitters, leukocyte adhesion, thrombosis,
while levels of their inhibitors, TIMPs, have been angiogenesis, and vascular tone. But excess pro-
found to be increased [18]. This may explain the duction can induce cellular damage by oxidizing
mechanism of impaired cellular responses and cell components and molecules such as lipids,
extracellular matrix reorganization observed in proteins, or DNA [28].
chronic wounds. Free radical production results endogenously
Similarly, anabolic and catabolic imbalance in from reactions of organic compounds with oxygen
chondrocyte, subchondral bone, and extracellular or neutrophils stimulated by exposure to microbes.
matrix is seen in osteoarthritis (OA). Degradation They are produced in the body during phagocyto-
and destruction of collagen II caused by MMP-­ sis, in prostaglandin synthesis, and in the cyto-
13 are considered a key factor in the development chrome P450 system, respiratory chain reactions,
of OA [19]. Indeed, biomarkers indicative of type and aerobic respiration in the mitochondria [29].
II collagen (Col II) synthesis such as carboxy The superoxide (O2−) radical is one of the main
peptide of Col II procollagen (CP-II), or cleaved reactive oxygen species in the cell deployed by the
products C2C and CTX-II, are increasingly being immune system to kill invading microorganisms,
expressed in ratios of each other and show great but is also implicated in cellular damage and aging.
promise in detecting early osteoarthritis [20]. The superoxide dismutase enzyme catalyzes the
Elevated levels of the pro-inflammatory cyto- reaction of the superoxide (O2−) radical to form
kines TNF-α, interleukin-1 β (IL-1β), and TGF-­ either molecular oxygen (O2) or hydrogen perox-
β1 are found in chronic wounds [21]. Levels of ide (H2O2) efficiently reducing oxidative stress.
these cytokines decrease as the wound heals [22]. Modern industrialized society produces numerous

Fig. 1.1 The phases of tissue healing (https://en.wikipedia.org/wiki/File:Wound_healing_phases.png#References)

1 The Optimization of Natural Healing
exogenous sources of free radicals which include
ionizing radiation, lead, pesticides, cadmium, alco-
hol, cigarette smoke, ultraviolet light, asbestos,
automobile exhaust, microwave radiation, and air
pollution from fires or volcanic activity [30, 31].
Oxygen-derived free radical reactions have been
associated with several diseases including
Alzheimer’s disease, Parkinson’s disease, multiple
sclerosis, amyotrophic lateral sclerosis, atheroscle-
rosis, hypertension, ischemic heart disease,
asthma, chronic obstructive pulmonary disease,
rheumatoid arthritis, renal failure, and lung, breast,
and hematologic cancers [32, 33].
1.4 Factors That Contribute
to Impaired Healing
1.4.1 Obesity
Excess body weight is the primary modifiable
factor influencing the development of knee osteo-
arthritis [34, 35]. Knee pain from osteoarthritis
correlates strongly with body mass index (BMI)
in studies performed all over the world [36–44].
Knee osteoarthritis occurs about seven times
more frequently in obese individuals than in non-
obese individuals [45]. Garver et al. found that
individuals in the highest BMI class had signifi-
cantly more pain and poorer function than those
with lower BMIs, even after controlling for
radiographic osteoarthritis severity [46].
Increasing low-level activity, especially
among inactive individuals, alleviates knee pain
and reduces the risk of disability from knee
osteoarthritis [34]. Randomized controlled trials
show that exercise is safe and effective for over-
weight and obese adults with osteoarthritis [47].
Messier et al. [48] studied the effects of knee
pain and body weight reduction by diet, with or
without exercise in 399 older adults (>55 years)
with knee osteoarthritis and body mass index of
27–41. After 18 months, lean weight loss was
11.4% for the diet/exercise group, 9.5% for the
diet-alone group, and 2% for the exercise group.
Pain levels and IL-6 serum concentrations were
lower in the diet/exercise group when compared
with the diet-alone or exercise-alone groups. The
diet/exercise group also had better physical health-
7
related quality of life scores and better function
scores. Regardless of which etiological factors
have the greatest effect on knee osteoarthritis, a
reduction in excess body weight is the primary
risk factor that can be modified to reduce knee
osteoarthritis pain [34, 48].
1.4.2 Drugs
More than one billion people worldwide smoke
tobacco products. Smoking is the leading cause
of preventable death and causes 480,000 deaths
each year in the United States alone [49]. The US
Department of Health and Human Services
reports that cigarettes contain at least 250 chemi-
cals known to be harmful in humans, including
hydrogen cyanide, carbon monoxide, and ammo-
nia. Among the known harmful chemicals, at
least 69 can cause cancer [49, 50].
Nicotine, present in all tobacco products, is
addictive and reduces cutaneous blood flow by
vasoconstriction, stimulates release of proteases
that may accelerate tissue destruction, suppresses
the immune response, and leads to an increased
risk of infection [51]. Almost every clinical study
on the effects of smoking in patients undergoing
orthopedic surgery for cartilage or ligament inju-
ries demonstrates negative outcomes in patients
who smoke [52]. In patients undergoing rotator
cuff repair, there is decreased tendon repair quality,
decreased biomechanics, poorer clinical outcomes,
and impaired healing of small to medium tears as
assessed by magnetic resonance imaging in
patients who smoke [53]. In cases of fracture heal-
ing, smoking tobacco is a contributory factor in
delayed unions and prolonged healing times [54].
Smoking cessation is the single most effective
intervention to improve healing. Heart rate, blood
pressure, carbon monoxide levels, oxygenation, and
blood circulation can normalize within a few weeks
of quitting. Smoking cessation restores the tissue
microenvironment rapidly and the inflammatory
cellular functions within 4 weeks, but the prolifera-
tive response remains impaired [51]. Smoking ces-
sation just 4 weeks prior to surgery can significantly
reduce complication rates [55]. Long-term effects
of quitting include decreased risk of cancer, heart
disease, and pulmonary disease [56]. Assistance for
8 C. Rogers and A. Gobbi
patients who choose to quit smoking can be found
at the National Cancer Institute’s quit line,
1-800-QUIT-NOW (www.smokefree.gov).
Alcohol is one of the most widely used drugs
in the world. The Substance Abuse and Mental
Health Services Administration reported rates of
alcoholism are as high as 10% in the North
American population. Alcohol is a central ner-
vous system depressant with wide-ranging and
detrimental systemic effects [57]. Increased insu-
lin resistance and higher serum sugar levels with
alcohol consumption impair healing [58].
Chronic alcohol abuse is associated with a
high risk of malnutrition which results in
decreased inflammatory and immune responses
to tissue injury, decreased fibroblast migration,
angiogenesis, and decreased type I collagen pro-
duction [59]. Alcohol also reduces bone quality
and delays fracture repairs [60, 61].
Glucocorticosteroids, including prednisone and
dexamethasone, have been used to treat inflamma-
tion in rheumatoid and osteoarthritis since 1951.
However, long-term use can delay healing by
interfering with inflammation, fibroblast prolifera-
tion, collagen synthesis and degradation, deposi-
tion of connective tissue ground substances,
angiogenesis, wound contraction, and re-epitheli-
alization [62]. Subcutaneous injection of dexa-
methasone strongly interferes with both the
synthesis and degradation of type I collagen and
type III collagen [63]. Animal studies show a 30%
reduction in wound tensile strength with perioper-
ative corticosteroids at 15–40 mg/kg/day [64].
Local administration of glucocorticoid has sig-
nificant negative effects on tendon cells in vitro,
including reduced cell viability, cell proliferation,
and collagen synthesis. The mechanical properties
of tendon are also significantly reduced [65].
Corticosteroid injections inhibit collagen tendon
repair and are a predictor of future tendon tear [66].
Long-term use or high-dose intra-articular
administration of glucocorticosteroids may also
induce apoptosis in chondrocytes impairing carti-
lage homeostasis [67]. Increased chondrocyte
autophagy has been described as an adaptive
response to protect chondrocytes from short-term
glucocorticosteroid exposure, whereas prolonged
exposure decreases autophagy and increases apop-
tosis in vitro [67]. Yet, in vitro dexamethasone has
failed to induce chondrotoxicity in low-­dose
exposures [68].
Clinical trials in humans do not demonstrate
adverse effects in patients receiving a single-dose
steroid injection following surgery [69]. And a
review of the human literature found that high-­
dose corticosteroid administration for less than 10
days has no clinically important effect on wound
healing, but in patients taking chronic corticoste-
roids for at least 30 days before surgery, wound
complication rates are increased up to five times
[64]. Further studies are required to determine the
effects of a single-dose steroid injection versus
prolonged steroid use on healing in patients receiv-
ing regenerative medicine therapies.
Nonsteroidal anti-inflammatory drugs
(NSAIDs) are commonly used for their analgesic
and anti-inflammatory effects. Cyclooxygenases
(COX-1 and COX-2) catalyze the conversion of
arachidonic acid to prostaglandins which plays a
significant role in normal bone healing, osteo-
clastic activity, bone formation, and angiogenesis
[70]. These drugs have been hypothesized to
affect the healing process of bone fractures and
orthopedic surgical sites. Nonsteroidal anti-­
inflammatory drugs (NSAIDs) have been shown
to have a depressant effect on wound healing
while simultaneously decreasing the granulocytic
inflammatory reaction [71]. NSAIDs have an
antiproliferative effect on blood vessels and skin,
thereby delaying wound healing rates [72].
The role of NSAIDs in orthopedics remains
controversial because of unclear effects on heal-
ing [73]. Delayed fracture healing and spinal
fusion inhibition have been described in associa-
tion with traditional NSAID use [74–77]. Several
experimental models of bone, ligament, and ten-
don repair have assessed the effects of these
drugs in animals with variable outcomes [78].
Celecoxib, a COX-2-specific NSAID, and indo-
methacin significantly inhibit tendon-to-bone
healing in a rat model [79]. However, in a recent
review of the literature, the short-term use of low-­
dose NSAIDs and COX-2 inhibitors did not
appear to have a detrimental effect following soft
tissue injuries [73]. Most studies on the effects of
NSAIDs on healing have been completed in ani-
mal models making it difficult to translate these
results to the clinical setting.
1 The Optimization of Natural Healing
1.5  actors That Improve Natural
F Melatonin is a neurohormone secreted by the
Healing
1.5.1 Sleep
Perhaps no activity influences optimal health
more profoundly than sleep. In the United
States, the average sleep duration has decreased
steadily from 9 h per night in 1910 to 6.8 h per
night [80]. Only 56% of people surveyed
believe they get enough sleep each night [80].
The situation is far worse for patients suffering
with orthopedic injuries. More than 70% of
patients with lower back pain suffer from sleep
disturbance when measured both subjectively
and objectively [81]. Sasaki et al. measured the
prevalence of sleep disturbance in patients
with knee osteoarthritis finding a prevalence of
3.6%, 6.9%, 19.4%, 32.7%, and 75.0% in
Kellgren–Lawrence grades 0, 1, 2, 3, and 4,
respectively [82].
Sleep disruption is known to cause a range of
adverse physiological and psychological effects.
Poor sleep is associated with decreased cognitive
performance, altered carbohydrate metabolism,
and impaired endocrine function [83]. Decreased
carbohydrate tolerance and increased sympa-
thetic tone are also associated with sleep depriva-
tion [83]. Over the long term, these effects can
lead to serious health conditions such as depres-
sion, obesity, type 2 diabetes, hypertension, and
coronary artery disease [84, 85].
Sleep deprivation leads to an imbalance
between catabolic and anabolic hormone activity
[86–88]. In humans, reduced sleep and obstruc-
tive sleep apnea adversely impact metabolic and
hormonal pathways [83, 89, 90]. Poor sleep also
enhances catabolic processes and is associated
with increased evening cortisol levels [91, 92].
Chronic insomnia is associated with higher
hypothalamic pituitary axis (HPA) activity lead-
ing to elevated cortisol and adrenocorticotropic
hormone (ACTH) levels [83, 89, 93, 94]. Sleep
and exercise may interact with each other by
endocrine and inflammatory pathways associ-
ated with sarcopenia [95]. Exercise training in
older adults possibly interacts with sleep by
reducing inflammatory biomarkers, such as IL-6
and TNF-α [96].
9
pineal gland, and it is well known for inducing
and regulating sleep. Exposure to light sup-
presses melatonin synthesis. The primary use of
melatonin as a supplement is to normalize abnor-
mal sleep patterns. Exogenous melatonin is one
of the most frequently used nonprescription sleep
aids due to its role in the internal timing of bio-
logical rhythms, including promotion and regula-
tion of sleep [97]. Melatonin may reduce the time
it takes for people to fall asleep and resets the
body’s sleep–wake cycle [98]. Melatonin also
increases total sleep time in individuals suffering
from sleep restriction or altered sleep schedules
and relieves daytime fatigue associated with jet
lag [99].
The National Sleep Foundation recommended
dose of melatonin is 0.3–5.0 mg taken 60 min
before bedtime. This supplement should only be
taken as needed for occasional insomnia. Start
with the lowest dose possible because synthetic
melatonin is not regulated by the FDA and listed
doses may not be accurate. Potential side effects
include daytime drowsiness, depressed mood,
irritability, abdominal pain, dizziness, and
headache.
Although melatonin has important effects on
sleep physiology, it may also play a role in the
protection against trauma-induced cartilage
degeneration. Hong et al. investigated the
effects of melatonin combined with treadmill
exercise on cartilage damage [100]. Intra-
articular injection of collagenase in rats caused
cartilage fibrillation and abnormal chondro-
cytes clustering and downregulated TGF-β1
mRNA levels. However, these changes were
rarely seen in the melatonin alone or melatonin
combined with exercise subjects. Collagenase
injection caused significant serum TNF-α and
IL-6 level upregulation. Melatonin, with or
without exercise, significantly decreased the
expression of catabolic mediators and cellular
death markers with lower mineralization indi-
cating that melatonin with exercise may have
both preventive and synergistic effects in reduc-
ing cartilage degeneration.
Magnesium is an essential mineral that plays
a key role in the regulation of central nervous
system excitability. Magnesium deficiency is
10 C. Rogers and A. Gobbi

associated with poor quality sleep, increased 4. Take a hot bath less than 3 h before bedtime.
sleep latency, predominance of light slow-wave The core body temperature drops after a hot
sleep, diminution of deep slow-wave sleep, and bath and signals that it is time to sleep.
a reduction in rapid eye movement (REM) 5. After a hot bath, spend 10 min stretching or
sleep [101]. Shorter sleep time is associated massaging muscles to minimize the likeli-
with higher levels of the inflammatory markers hood of pain that triggers awakenings.
interleukin 6 (IL-6) and C-reactive protein 6. Avoid watching TV or using a computer at
[102]. The highest elevations are found in least an hour before going to bed. These
patients with sleep apnea and high body mass devices emit blue light reducing the produc-
index (BMI) [103]. Magnesium supplementa- tion of melatonin and can disrupt circadian
tion has demonstrated improved sleep quality rhythms, affecting cell cycle regulation and
in adults older than 51 years of age [104]. metabolism. In addition, modern television
The NIH recommended daily allowance rarely offers content conducive to a good
(RDA) of magnesium is 420 and 320 mg for men night’s sleep.
and women older than 50 years of age, respec- 7. Install low-wattage yellow, orange, or red
tively. It is estimated that 38% of adults have light bulbs for a light source to navigate at
daily magnesium intakes less than the recom- night. These wavelengths do not impair mel-
mended allowance [105]. Magnesium deficiency atonin production to the same degree as blue
is considered when serum magnesium concen- light.
trations are lower than 0.75 mmol/L. Patients 8. Sleep in complete darkness, cover the win-
with malabsorption (Crohn’s, celiac disease, his- dows with drapes, or wear an eye mask.
tory of intestine surgery), type 2 diabetes, Light controls melatonin production in the
chronic alcoholism, and renal disease or those pineal gland, and even a small amount of
taking diuretics are at increased risk of magne- light from a clock radio can interfere with
sium deficiency. Green leafy vegetables, nuts, sleep.
legumes, and whole grains are rich sources of 9. Maintain bedroom temperature to less than
magnesium. Dietary supplementation with mag- 70 °F (21 °C). The optimal room tempera-
nesium glycinate 300 mg is preferred to other ture for sleep is between 60 and 68 °F
forms of supplemental magnesium due to (15.5–20 °C).
increased bioavailability and reduced risk of 10. Move all electronics away from the bed at
side effects. Magnesium overdose can result in night. Electromagnetic fields found in elec-
diarrhea, hypotension, lethargy, confusion, and tronic devices such as a computer or router
cardiac rhythm abnormalities. can disrupt the pineal gland and its melato-
Sleep hygiene education is a safe and cost-­ nin production.
effective method for managing sleep disturbance. 11. Avoid using loud alarm clocks and, if possi-
Patients suffering from sleep disturbance should ble, do not use them at all.
be given the following advices: 12. If you find that your mind is racing, consider
writing your ideas down on a notepad or
1. Get 10–15 min of morning sunlight each day. even spend a few minutes attending to the
The circadian system needs bright light to issue of concern.
reset itself. More sunlight exposure is
required as you age.
2. Get a daily dose of bright sun exposure during 1.5.2 Circadian Rhythms
the day to optimize melatonin production.
3. Avoid drinking caffeinated beverages several These are essentially endogenous physiological
hours before bedtime. Some people do not oscillations occurring at 24-h interval. These
metabolize caffeine properly and should rhythms are maintained by circadian clocks
avoid caffeine altogether. which are located in every functional cell type,
1 The Optimization of Natural Healing
including the immune system. The immune sys-
tem and its regulation play a vital role in tissue
healing, and disorders of immune system have a
direct effect on efficacy of tissue healing. Most
immune cells through their expression of circa-
dian clock genes display profound impacts on
cellular functions, including a daily rhythm in the
synthesis and release of cytokines, chemokines,
and cytolytic factors [106].
Alteration of circadian rhythms through clock
gene mutation in many animal studies has shown
altered immune response states [106]. A rat model
study has shown that rats with circadian rhythm
disorder showed poor collagen synthesis and
impaired effect of interleukin (IL)-1, IL-6, trans-
forming growth factor α, and stress hormones on
fibroblasts [107]. A recent molecular level study
has also shown that cardiac neutrophil oscilla-
tions have a direct effect on myocardial infarct
size and healing [108]. Melatonin, a key hormone
promoting circadian rhythm, has shown to have a
direct effect on skin wound healing in a mouse
model. This mouse model study found transplan-
tation of umbilical cord blood (UCB)-MSCs pre-
treated with melatonin-enhanced wound closure,
granulation, and re-­ epithelialization at mouse
skin wound sites [109].
In the present era, circadian rhythm disorder
influences healing in people who travel great dis-
tances across the globe and in athletes or workers
who are subjected to work night shifts. Further
research in the area of human chronobiology can
help in better understanding of the role of circa-
dian rhythm and its influence on tissue healing in
humans.
1.5.3 Nutrition
The development of various chronic and degen-
erative diseases, such as cancer [110], heart dis-
ease [111], and neuronal degeneration [112, 113],
may be attributed to oxidative stress. Oxidative
stress has also been implicated in the process of
aging [114] and in the pathogenesis of osteoar-
thritis [115]. Oxidative stress induces telomere
genomic instability, replicative senescence, and
dysfunction of chondrocytes in human osteoar-
11
thritic cartilage. [115]. In tissue cultures of carti-
lage explants, nitrotyrosine staining, chondrocyte
telomere length, and glycosaminoglycans (GAG)
remaining in the cartilage tissue were decreased
in cartilage exposed to reactive oxygen species
(ROS). However, in cartilage treated with the
anti-oxidative, ascorbic acid, a tendency to main-
tain chondrocyte telomere length and proteogly-
can was seen in the cartilage explants, suggesting
that oxidative stress induces chondrocyte telo-
mere instability and catabolic changes in carti-
lage matrix structure and composition [115].
Increased reactive oxygen species (ROS)
inhibit mesenchymal stem cell (MSC) prolifera-
tion, increase senescence, enhance adipogenic
differentiation, reduce osteogenic differentiation,
and inhibit MSC immunomodulation [116, 117].
Furthermore, oxidative stress reduces their
ex vivo expansion capabilities [117]. MSCs may
have low innate antioxidant activity and are more
sensitive to oxidative stress compared to more
differentiated cell types [118, 119].
Antioxidants are substances capable of scav-
enging free radicals and preventing cellular dam-
age. Increased consumption of whole foods such
as fruits and vegetables containing natural anti-
oxidants may offer health benefits [120, 121].
Nonenzymatic antioxidants are classified as
metabolic or nutrient antioxidants. Metabolic
antioxidants are produced by endogenous cellu-
lar metabolism and include coenzyme Q10, mel-
atonin, uric acid, bilirubin, l-arginine, transferrin,
and glutathione.
Nutrient antioxidants are provided in the diet
and include selenium, manganese, zinc, flavo-
noids, vitamins E and C, and omega-3 and
omega-6 fatty acids. The oxygen radical
­absorbance capacity (ORAC) assay measures the
degree of inhibition of peroxy-radical-induced
oxidation by nutrient antioxidants. A review of
the antioxidant activity in 326 selected foods
reveals high activity in many fruits, vegetables,
herbs, and spices [122]. Foods with higher ORAC
values include blueberries, raspberries, strawber-
ries, cranberries, blackberries, apples, pears, cit-
rus fruits, gooseberries, figs, onions, broccoli,
artichokes, eggplant, asparagus, garlic, thyme,
oregano, basil, peppermint, black pepper, ginger,
12
cinnamon, curry powder, cumin, paprika, pea-
nuts, almonds, pecans, walnuts, pistachios,
beans, and peas.
Nutritional deficiencies have been long recog-
nized as an indicator of poor health. Patients with
decreased albumin or zinc levels demonstrate
delayed healing and greater incidence of compli-
cations following orthopedic surgery. Greene
reported that patients with albumin level less than
3.5 g/dL showed a sevenfold increase in the risk
of major wound complications following hip or
knee arthroplasty [123]. Low albumin levels may
be due to kidney or liver disease, poor nutrient
absorption, or low protein diets.
Decreased protein intake can negatively
impact healing due to decreased collagen produc-
tion, angiogenesis, and fibroblast proliferation.
The essential amino acids histidine, isoleucine,
leucine, lysine, methionine, phenylalanine, tyro-
sine, threonine, tryptophan, and valine are not
produced in the body and are only supplied by
the diet. They serve as enzymes, hormones, cyto-
kines, growth factors, and components of anti-
bodies. Inadequate protein intake impedes both
tissue maintenance and healing. Insufficient pro-
tein intake can be assessed utilizing serum albu-
min, pre-albumin, or total lymphocyte count. The
recommended daily allowance for protein in
healthy adults more than 20 years of age is 80 mg
per kg of body weight. Malnourished patients
may require up to 1.5 g per kg of body weight
[59]. Excellent sources of digestible protein
include eggs, milk, cheese, meat, fish, rice,
wheat, oatmeal, peanut butter, and beans.
Zorrilla demonstrated that patients with zinc
levels less than 95 μg/dL had almost 12-fold
increased risk for wound complications in
patients undergoing hip hemiarthroplasty for
fracture [124]. The daily recommended dose for
zinc is 11 and 8 mg/day in men and women older
than 50 years, respectively. Good sources of zinc
include meats, seafood, milk, cheese, nuts,
legumes, and whole grains.
The active form of vitamin D, 1,25-dihydroxy-
vitamin D3, is essential for normal bone growth,
maintenance, and repair. It is probably essential
for the health of most nonskeletal tissues as well
as the vitamin D receptor has been identified on
C. Rogers and A. Gobbi
almost every cell in the body. Vitamin D supple-
mentation also significantly inhibits human mes-
enchymal stem cell (MSC) apoptosis and delays
the development of replicative senescence in
long-term cultures [125].
The optimal serum level is controversial and
has been reported from 25 to 80 ng/mL with defi-
ciency defined as less than 30 ng/mL [126]. By
this standard, nearly 90% of healthy US adults
are vitamin D deficient [127]. The prevalence of
vitamin D insufficiency has been measured in
52.3% of sports medicine patients and 66.1% of
trauma patients [128].
After total hip arthroplasty, patients with vita-
min D deficiency have lower postoperative Harris
hip scores [129]. Up to 83% of chronic lower
back patients have abnormally low vitamin D
levels, and clinical improvement is seen with
vitamin D supplementation [130]. Vitamin D
insufficiency also plays a critical role in children
undergoing hematopoietic stem cell transplanta-
tion for malignancy. Hansson et al. demonstrated
a more rapid increase in neutrophil granulocyte
levels, decreased rejection, and increased sur-
vival rates in children who were vitamin D suffi-
cient [131].
Vitamin D is synthesized from 7-dehydro­
cholesterol in the skin through exposure to sun-
light. Many individuals do not get enough sunlight
exposure, and those living in colder climates are
at even greater risk for vitamin D deficiency.
Therefore, vitamin D supplementation is recom-
mended for most adults. Singh et al. studied the
effect of vitamin D supplementation on serum
vitamin D levels. They noted serum concentra-
tions are influenced by age, body mass index
(BMI), and serum albumin ­concentration [132].
They recommend 5000 IU/day for 3 months to
correct vitamin D deficiency. After 3 months,
they advise repeating the vitamin D serum con-
centration test. Once the deficiency has been cor-
rected, a maintenance dose of 2000 IU/day is
recommended.
Vitamin C (l-ascorbic acid) is an essential
water-soluble vitamin required for the biosynthe-
sis of collagen, protein metabolism, and wound
healing. It is also an important antioxidant shown
to regenerate antioxidants in the body, including
1 The Optimization of Natural Healing
vitamin E (alpha-tocopherol) [133]. Good
sources of vitamin C include citrus fruits, toma-
toes, potatoes, peppers, broccoli, strawberries,
Brussel sprouts, and cantaloupe. When neces-
sary, vitamin C supplementation of 1 g/day is
recommended. At doses above 1 g/day, absorp-
tion falls to less than 50%, and unmetabolized
ascorbic acid is excreted in the urine [133]. Each
vitamin and mineral has a specific role to play in
health, and once sufficient amounts of that nutri-
ent to perform those roles are obtained, there is
no benefit to consume more.
Manganese, vitamin B6 (pyridoxine), and
vitamin E (alpha-tocopherol) are also linked to
good tendon health; however, deficiency of these
nutrients in well-nourished individuals is exceed-
ingly rare. These essential nutrients are found in
seafoods, nuts, whole wheat, seeds, tofu, chicken,
turkey, and green leafy vegetables.
1.5.4 Dietary Supplements
The term “nutraceutical” was derived from the
words “nutrition” and “pharmaceutical” and is
defined as a food that offers health benefits [134].
The term, however, is not recognized by the US
Food and Drug Administration (FDA) which uses
the term “dietary supplement” instead. The FDA
states that supplements are not intended to treat,
diagnose, prevent, or cure diseases. Therefore,
companies that produce them cannot make health
claims.
Despite strong evidence of the health benefits
of consuming a diet rich in whole fruits, vegeta-
bles, whole grains, and lean protein, there is little
evidence for the multitude of dietary supplements
offered to patients with orthopedic injuries.
Despite this fact, approximately 62.5% of adults
with arthritis reported taking at least one dietary
supplement. Glucosamine and chondroitin sul-
fate are the most common supplements used by
patients with osteoarthritis [135].
Eriksen et al. performed a systematic review
and stratified meta-analysis of randomized
placebo-­controlled trials on the efficacy of glu-
cosamine in the treatment of painful arthritis
[136]. Glucosamine was shown to moderately
13
reduce pain although a high level of between trial
inconsistency was observed. The single most
important explanation was product brand. Twelve
trials using the Rottapharm/Madaus product
resulted in significant pain reduction although a
sensitivity analysis showed less promising
results.
A large National Institutes of Health (NIH)
study compared glucosamine hydrochloride,
chondroitin, both supplements together, cele-
coxib, or a placebo in patients with mild knee
osteoarthritis. Those who received the celecoxib
had better short-term pain relief at 6 months than
those who received the placebo. Those who
received glucosamine and chondroitin supple-
ments did not receive significant improvement in
knee pain or function, although the investigators
saw evidence of improvement in a small subgroup
of patients with moderate-to-severe pain who
took glucosamine and chondroitin together [137,
138]. The American College of Rheumatology
indicates that there is insufficient evidence of effi-
cacy and does not recommend glucosamine or
chondroitin sulfate for patients with hand, hip, or
knee osteoarthritis [139].
Fusini et al. performed a critical review of nutra-
ceutical supplements in the management of tendi-
nopathy [140]. They concluded that results were
encouraging but were unable to confirm a benefit
from glucosamine, chondroitin sulfate, vitamin C,
type I collagen, arginine alpha-­ketoglutarate, bro-
melain, curcumin, boswellic acid, or methylsulfo-
nyl-methane (MSM). Numerous supplements have
been proposed to reduce chronic inflammation
associated with joint diseases such as osteoarthritis
and rheumatoid arthritis. In a review by Ghasemian
et al., ginger, rosemary, borage, Boswellia serrata,
and urtica dioica (stinging nettle) have demon-
strated preclinical or clinical evidence of efficacy
and safety [141].
Osteoarthritis is a multifactorial process that
includes articular cartilage catabolism, synovial
tissue inflammation, and subchondral bone resorp-
tion. These pathological changes are associated
with an excessive production of pro-­inflammatory
molecules such as interleukin 1-β (IL-β) and tumor
necrosis factor alpha (TNF-α). A review of current
nutraceuticals in the management of osteoarthritis
14
summarized the biologic effects of several nutra-
ceuticals consumed by patients [142].
Pomegranate juice (Punica granatum) has
strong antioxidant properties due to their high
content of hydrolyzable tannin and anthocyanins,
a polyphenolic compound that exhibits antioxi-
dant and anti-inflammatory capabilities. In osteo-
arthritic chondrocytes, pomegranate fruit extract
(PFE) has been shown to suppress COX-2
enzyme activity and IL-1β-induced prostaglandin
E2 (PGE2) and nitric oxide (NO) production
[143]. Interleukin 1-β (IL-1β)-induced expres-
sion of matrix metalloproteinase (MMP)-1,
MMP-3, and MMP-13 has been reduced by PFE
in osteoarthritic chondrocytes as well [144].
Clinical studies of PFE efficacy in treating OA
inflammation have not yet been performed.
Green tea (Camellia sinensis) contains cate-
chins which have demonstrated anticancer, anti-­
inflammatory, antibacterial, and neuroprotective
effects [142]. In particular, epigallocatechin-­3-­
gallate (EGCG) decreases reactive oxygen spe-
cies (ROS)-mediated cytotoxicity in human
chondrocytes [145]. Several inflammatory medi-
ators of inflammatory joint disease are inhibited
by EGCG as well including IL-1β, TNF-α, IL-6,
nitric oxide, and PGE2 in human chondrocytes
[146, 147]. Encouraging evidence from in vitro
and animal studies demonstrates the potential
anti-inflammatory and antiarthritic effects of
green tea; however, controlled clinical trials have
not yet been completed.
Frankincense oil is an aromatic resin obtained
from trees of the genus Boswellia. Boswellia ser-
rata (B. serrata) in vitro has been reported to
inhibit leukotriene biosynthesis [148], collagen
IV and elastin hydrolysis [149], IL-1β-induced
cartilage matrix breakdown, and nuclear factor
kappa β (NFKB) in human chondrocytes [150].
Pain reduction, swelling, and disability have been
demonstrated in human clinical trials using a her-
bomineral formulation containing B. serrata
[151, 152], B. serrata extract with Aflapin or
Laxin [153], or B. serrata 1000 mg daily [154]
when compared with placebo.
Bromelain is derived from the pineapple
plant stems and immature fruit. Bromelain influ-
ences inflammation by decreasing PGE2 and
C. Rogers and A. Gobbi
thromboxane A2 and modulation of immune cell
surface adhesion molecules [155]. Phlogenzym
(which contains 90 mg bromelain, trypsin, and
rutin) is compared favorably to diclofenac 100–
150 mg by reducing pain 80% in patients with
knee osteoarthritis during a 4-week trial [156].
No serious adverse events were reported.
Phlogenzym (which contains 540 mg bromelain)
showed significantly better pain relief in patients
with moderate-to-severe knee osteoarthritis than
diclofenac 100–150 mg during a 12-week trial
[157]. Again, no serious adverse events were
noted. Although bromelain has demonstrated
clinical efficacy, the optimum dosage remains
unclear.
Cat’s claw (Uncaria tomentosa and Uncaria
guianensis) is a vine found near the Amazon
River with anti-inflammatory properties. U.
tomentosa inhibits COX-1 and COX-2, TNF-α,
PGE2, nitric oxide production, and lipopolysac-
charide (LPS)-induced iNOS gene expression
[158, 159]. Pain with daily activities due to
Kellgren–Lawrence grade 2–3 knee osteoarthritis
was significantly reduced in a 4-week placebo-­
controlled trial of cat’s claw bark extract; how-
ever, night pain was not improved [160].
Devil’s claw (Harpagophytum procumbens) is
a desert plant found in southern Africa which
claims benefits for digestion and joint and lower
back pain. A dose-dependent analgesic and anti-­
inflammatory effect have been demonstrated in
rats [161]. Devil’s claw inhibits PGE2 produc-
tion, TNF-α, IL-1β, IL-6, MMPs, and nitric oxide
[162–164]. Significant pain relief has been
achieved with harpagoside 360 mg daily [165],
harpagoside 57 mg daily [166], and harpagoside
100 mg daily [167] when compared to placebo in
patients with osteoarthritis or nonspecific lower
back pain.
Turmeric (Curcuma longa) comes from the
C. longa root and contains curcuminoids (cur-
cumin, demethoxycurcumin, bis-demethoxycur-
cumin) which are natural polyphenols with strong
antioxidant capacity. A randomized double-blind
placebo-controlled trial investigated the ability of
curcuminoids to reduce systemic oxidative bur-
den in patients suffering from knee osteoarthritis
[168]. Forty mild-to-moderate knee osteoarthritis
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The theatre was a large barn-like structure; and it was filled with an
audience who sat in its boxes, or small, square divisions marked off
by narrow boards, where they arranged themselves for the most part
as they were assorted by domestic or friendly ties. Although they
obviously kept fully aware of what was going on upon the stage, and
at times seemed to look and to listen intently, or to break forth into
irrepressible applause, the most exciting scenes did not appear
greatly to interrupt their incessant smoking and indulgence in various
kinds of cheap drinks and eatables. Incessant tea-drinking went on
as a matter of course.
The principal play on this occasion celebrated the daring and
unflinching loyalty of a confidential servant to his Samurai master.
The purposes of the master were by no means wholly honourable as
judged by our Western standards of morals; and the means
contrived by the servant for carrying out these purposes were
distinctly less so. Especially was this true of the heartless and base
way in which the servant, in furtherance of his master’s interests,
treated the daughter of his master’s enemy, who had trusted him
with her love and her honour. I am sure that for this sort of behaviour
the rascal would have been hissed off the stage of even the lowest
of the Bowery theatres. But when he was detected and caught by the
father of the girl, the servant who was so despicably base toward
others, remained still so splendidly loyal to his master, that the
climax of the entire drama was reached and successfully passed in a
way to astonish and disgust the average audience in Western and
Christian lands. For he cheerfully bares his neck and, kneeling,
stretches it out to catch fully the blow of the father’s sword,—
protesting that he esteems it an honour and a joy to die in this
honourable manner for his lord and master. So impressed, however,
is the would-be executioner with the rascal’s splendid exhibition of
the noblest of all the virtues, that he raises the betrayer of his
daughter from his knees, pardons him, praises him unstintedly for his
honourable excellence, makes peace with the servant’s master, and
gladly bestows upon the servant his own beloved daughter in
honourable marriage.
As I have already said, it was undoubtedly the influence of such
dramas which helped to keep alive the extreme and distorted views
of the supreme excellence of loyalty as a virtue, in the narrower
significance of the terms, that went far toward securing the
remarkable character for self-sacrificing courage and endurance of
the Japanese private soldier during the late war with Russia. It would
not be fair, however, to infer from this, or other similar experiences,
the inferiority of the Japanese as a race in either ethical maxims or
moral practice. For, has not an extravagant and perverted
conception of the Christian virtue of “love” served in Occidental lands
to obscure and overshadow the even more fundamental virtues of
courage, endurance, and a certain necessary and divine sternness
of justice? And, with all its restrictions and deficiencies, the
Japanese Bushidō has hitherto resisted the temptations to avarice
and a selfish indulgence in luxury, on the whole, rather better than
anything which these Western nations have been able to make
effective in its stead. But when Japan gets as far away from the
Knightly spirit of Feudalism as we have for a long time been, its
moral doctrines and practices of the older period are likely to
undergo changes equally notable with those which have taken place
in Europe since feudal times prevailed there.
It was not until my second visit, in 1899, that I enjoyed the
opportunity of seeing Japan’s then most celebrated actor, Ichikawa
Danjuro. “Danjuro” is the name of a family that has been eminent in
the line of histrionic ability for nine or ten generations. Ichikawa, of
that name, was especially remarkable for combining the several
kinds of excellence demanded of the actor by Japanese dramatic art.
He had very uncommon histrionic power; even down to his old age
he was able almost equally well to take all kinds of parts, including
those of women and boys; and he had “marvellous agility as a
dancer.” As respects his ideals and characteristic style—making due
allowance for the wide differences in language and in the traditions
and requirements of the stage in the two countries—Danjuro has
been called “The Irving of Japan,” not altogether unaptly.
On this occasion I had not my usual good fortune of being in the
company of an intelligent and ready interpreter, who could follow
faithfully and sympathetically, but critically, every detail of the
scenery and the wording of the plays, as well as of the performance
of the actors. But the two of the three plays in which Danjuro took
part, between the rising of the curtain at eleven o’clock and our
departure from the theatre at about four in the afternoon, were quite
sufficient to impress me with the high quality of his acting. I need
scarcely say that he gave me that impression of reserve power and
of naturalness which only the greatest of artists can make. But,
indeed, reserve, and the suggestiveness which goes with it and is so
greatly intensified by it, is a chief characteristic of all the best works
of every kind of Oriental art.
It was a still different exhibition of Japanese histrionic skill which I
witnessed on the afternoon and evening of October 15, 1906. In the
most fashionable theatre of Tokyo a Japanese paraphrase of
Sardou’s “La Patrie” was being given by native actors. It was in
every way a most ambitious and even daring attempt to adopt
outright rather than to adapt, foreign dramatic models, in all their
elaborate details. How far would it be—indeed, how far could it be—
successful? I could see and judge for myself; since I was to have the
best of interpreters. The advertised time for the rising of the curtain
was five o’clock; but the actual time was a full half-hour later. The
entire performance lasted for somewhat more than five hours. The
scenery and stage settings were excellent. The scene of the meeting
of the Prince of Orange and the Count of Flanders in the woods by
moonlight was as artistically charming and beautiful a picture as
could be set upon the stage anywhere in the world. Much of the
acting, considering the difficulty of translating the motifs and the
language, was fairly creditable; but the Japanese have yet a great
deal to learn before they can acquire the best Western and modern
style of the dramatic art. Indeed, why should they try? The stilted
stage-manners of their own actors in the past, and the extravagance
of posturing and gesturing for the expression of strong emotions, still
hamper them greatly in this effort. Why then should they spend time
and money on the attempt at this reproduction of foreign models,
rather than in the reproduction and development of the best of their
own dramatic art? Certainly, artistic success in such an endeavour,
even if it could easily be attained, could not have the same influence
upon the conservation of the national virtues which have
distinguished their past that might reasonably be hoped for by a
more strictly conservative course. As a piece of acting the attempt to
reproduce the French play was a failure. The performance of the
drama was followed by a very clever farce called “The Modern
Othello,” which was written by a business man of Tokyo, a friend of
our host on this occasion.
For witnessing the latest developments of the highest-class dramatic
art of Japan, it was a rare opportunity which was afforded by a series
of performances lasting through an entire fortnight in November of
1906. The occasion was a “Memorial,” or “Actor’s Benefit,”
commemorative of the life-work of Kan-ya Morita, who, in a manner
similar to the late John Augustin Daly, had devoted himself to the
improvement and elevation of the theatre. All the best actors in
Tokyo, including the two sons of Morita, took part in these
performances, which consisted of selected portions of the very best
style of the dramas of Old Japan. I cannot, therefore, give a more
graphic picture of what this art actually is, and what it effects by way
of influence upon the audience, than to recite with some detail our
experiences as members of a theatre party for one of these all-day
performances.
A former pupil of mine and his wife were the hosts, and the other
guests, besides my wife and myself, were Minister and Madam U
——, and Professor and Mrs. U——. Since we were the only
foreigners among the members of the party, our hostess came to
conduct us to the tea-house, through which, according to the
established custom, all the arrangements for tickets, reserved seats,
cushions, hibachis, refreshments, and attendance, had been made.
There we met the husband, who had come from his place of
business; and after having tea together, we left our wraps and shoes
at the tea-house, and, being provided with sandals, we shuffled in
them across the street into the theatre. Four of the best boxes in the
gallery, from which a better view of the stage can be obtained than
from the floor, had been thrown into one by removing the partitions of
boards; and every possible provision had been made for the comfort
of the foreigners, who find it much more difficult than do those to the
manner born to sit all day upon the floor with their legs curled up
beneath them. The native audience—and only a very few foreigners
were present—was obviously of the highest class, and was in
general thoroughly acquainted with the myths, traditions, and
histories, which were to be given dramatic representation. As the
event abundantly showed, they were prepared to respond freely with
the appropriate expressions of sentiment. It is an interesting fact that
Japanese gentlemen and ladies, whom no amount of personal grief
or loss could move to tears or other expressions of suffering in
public, are not ashamed to be seen at the theatre weeping copiously
over the misfortunes and sorrows of the mythical divinities, or the
heroes of their own nation’s past history.
The curtain rose at about eleven o’clock; and the first play was a
scene from an old Chinese novel, and bore the name “zakwan-ji.” It
represented three strong men who, meeting in the night, begin to
fight with one another. Snow falls, while the battle grows more fierce.
Two of the men are defeated; and the victor, in his arrogance, then
attacks the door of a shrine near by. But the spirit of the enshrined
hero appears and engages the victor of the other men in combat. Of
course, the mere mortal is easily overcome by his supernatural foe;
but when he yields, all parties speedily become friends. The acting
was very spirited and impressionistic; but no words were spoken by
the actors. The story was, however, sung by a “chorus” consisting of
a single very fat man, who sat in a box above the stage; but the
language was so archaic that even our learned friend, the professor,
could not understand much of it.
The second play was a version of the celebrated story of the Giant
Benkei and the warrior Yoshitsune. It differed materially from the
version given by Captain Brinkley in his admirable work on Japan. In
this scene, when Yoshitsune and Benkei have arrived at the “barrier,”
disguised as travelling priests, and are discussing the best means of
procedure, three country children appear with baskets and rakes to
gather pine leaves. On seeing the priests, the children warn them
that yesterday and the day before two parties of priests have been
killed by the soldiers at the barrier, on suspicion of their being
Yoshitsune and his followers in disguise. Benkei then comes forward
and asks of the boys the road the travellers ought to take. In very
graceful dances and songs the children give a poetical description of
this road. Benkei then takes an affectionate leave of his master, and
goes up to the gate to ask for passports of its guardian. It is agreed
that the signal for danger shall be one sound of Benkei’s horn; but
that if the horn is sounded three times, it shall mean “good news.”
Soon the horn is sounded once, and Yoshitsune rushes to the
rescue of his faithful attendant. At this point the stage revolves, and
the next scene presents the guardian of the gate seated in his
house, while in the foreground Benkei is being tortured to make him
confess. Yoshitsune attempts to rescue Benkei, but the latter
prevents his master from disclosing his identity. The guardian,
however, suspects the truth; but since he is secretly in favour of
Yoshitsune, he releases Benkei, and after some hesitation grants the
coveted passports and sends the whole party on their way.
The third play, like the first, was also Chinese; it was, however, much
more elaborate. A Tartar General, while in Japan, has married a
beautiful Japanese girl, and has taken her back with him to live in
China. After a great battle the General returns to his home, and an
old woman among the captives is introduced upon the stage to plead
for the release of her son, a Captain in the Japanese army, who had
also been taken captive. The old woman proves to be the step-
mother of the young wife and the Japanese Captain is her brother.
When the wife recognises her mother, she is much overcome, and
joins in pleading for the life of both the captives. The husband
becomes very angry and threatens to kill both mother and daughter;
but the mother, although her arms are bound, throws herself before
him and saves her daughter. The daughter then goes to her room,
and according to a prearranged signal with her brother, opens a vein
and pours the blood into a small stream that runs below. The brother,
who is in waiting on a bridge over the stream, sees the signal and
hurries to the rescue of his sister. He reaches the palace and
compels the men on guard to carry his sword within; it requires eight
men to accomplish this stupendous task, so exceedingly strong is
the swordsman! He overcomes the Tartar General and gets himself
crowned Emperor; but he comes out of the palace in time to see his
sister die of her self-inflicted wound. The aged mother, thinking it
would be dishonourable to allow her step-daughter to make the only
great sacrifice, stabs herself and dies to the sound of doleful music
long drawn-out.
During the intermission which followed this impressive but crudely
conceived and childish tragedy, we enjoyed an excellent Japanese
luncheon in the tea-house near by.
When the curtain rose for the next performance, it disclosed a row of
ten or twelve actors clothed in sombre Japanese dress, all on their
knees, who proceeded to deliver short speeches eulogistic of the
deceased actor in whose memory this series of plays was being
performed. The next play represented Tametomo, one of the twenty-
three sons of a famous Minamoto warrior, who with his concubine,
three sons, his confidential servant, and some other followers, had
been banished to an island off the coast of Japan. The astrologers
had prophesied that he and his oldest son would die; but that his
second son would become the head of a large and powerful family.
Not wishing his future heir to grow up on the barren island, he
manages to get a letter to a powerful friend on the mainland, who
promises that if the boy is sent to him, he will treat him as his own
son and educate him for the important position which he is destined
to fill in the world. But the father does not wish to disclose his plan to
the rest of the family. He therefore bids the two older boys make a
very large and strong kite; and when it is finished and brought with
great pride to show to the father, he praises the workmanship of
both, but calls the younger of the two into the house and presents
him with a flute. The child is much pleased with the gift and at once
runs away to show it to his brother, but stumbles and falls at the foot
of the steps and breaks the flute. This is considered a very ill omen,
and Tametomo pretends to be very angry and threatens to kill his
son. The mother, the old servant, and the other children plead for the
life of the boy; and at last the father says that he will spare his son,
but since he can no longer remain with the rest of the family, he will
bind him to the kite and send him to the mainland. A handkerchief is
then tied over the boy’s mouth and he is bound to the huge kite and
carried by several men to the seashore. Then follows a highly
emotional scene, in which the mother and brothers bewail the fate of
the boy and rebuke the hard-hearted father. The wind is strong, and
all watch the kite eagerly; while the father reveals his true motive for
sending away his son, and the youngest of the brothers, a babe of
four years old, engages in prayer to the gods for the saving of his
brother. The servant announces that the kite has reached the shore;
and soon the signal fire is seen to tell that the boy is safe. Tametomo
then assures his wife that the lives of the family are in danger from
the enemy, whose boats are seen approaching the island. At this the
wife bids farewell to her husband and takes the two children away to
kill them, with herself, before they fall into the hands of the enemy.
Tametomo shoots an arrow at one of the boats, which kills its man;
but the others press forward, and just as they are about to disembark
on the island the curtain falls.
On this lengthy and diversified programme there follows next a
selection of some of the most celebrated of dramatic dances. The
first of these was “The Red and White Lion Dance.” Two dancers
with lion masks and huge red and white manes trailing behind them
on the floor, went through a wild dance to represent the fury of these
beasts. The platforms on which they rested were decorated with red
and white tree-peonies; for lions and peonies are always associated
ideas in the minds of the Japanese. Another graceful dance
followed, in which the dancers, instead of wearing large masks,
carried small lion heads with trailing hair, over the right hand. The
masks of these dancers had small bells, which, as they danced,
tinkled and blended their sound with the music of the chorus. Then
came a comic dance, in which two priests of rival sects exhibited
their skill,—one of them beating a small drum, while his rival
emphasised his chant by striking a metal gong.
The seventh number on the programme was very tragic, and drew
tears and sobbing from the larger part of the audience, so intensely
inspired was it with the “Bushidō,” and so pathetically did it set forth
this spirit. Tokishime, a daughter of the Hōjō Shōgun, is betrothed to
Miura-no-Suké. The young woman goes to stay with the aged
mother of her lover, while he is away in battle. The mother is very ill,
and the son, after being wounded, returns home to see his mother
once more before she dies. The mother from her room hears her
son’s return and denounces his disloyal act in leaving the field of
battle even to bid her farewell; she also sternly forbids him to enter
her room to speak to her. The young man, much overcome, turns to
leave, when his fiancée discovers that his helmet is filled with
precious incense, in preparation for death. She implores him to
return to his home for the night only, pleading that so short a time
can make no difference. When they reach the house, a messenger
from her father in Kamakura presents her with a short sword and
with her father’s orders to use it in killing her lover’s mother, who is
the suspected cause of the son’s treachery. Then ensues one of
those struggles which, among all morally developed peoples, and in
all eras of the world’s history, furnish the essentials of the highest
forms of human tragedy. Such was the moral conflict which
Sophocles set forth in so moving form in his immortal tragedy of
“Antigone.” The poor girl suffers all the tortures of a fierce contention
between loyalty and the duty of obedience to her father and her love
for her betrothed husband; who, when he learns of the message,
demands in turn that the girl go and kill her own father. The daughter,
knowing her father to be a tyrant and the enemy of his country, at
last decides in favour of her lover, and resolves to go to Kamakura
and commit the awful crime of fratricide. After which she will expiate
it by suicide.
The closing performance of the entire day was a spectacle rather
than a play. It represented the ancient myth of the Sun-goddess, who
became angry and shut herself up in a cave, leaving the whole world
in darkness and in sorrow. All the lesser gods and their priests
assembled before the closed mouth of the cave and sang enticing
songs and danced, in the hope of inducing the enraged goddess to
come forth. But all their efforts were in vain. At last, by means of the
magic mirror and a most extraordinarily beautiful dance, as the cock
crows, the cave is opened by the power of the strong god, Tajikara-
o-no-miko-to; and the goddess once more sheds her light upon the
world.
At the close of this entire day of rarely instructive entertainment it
remained only to pick at a delicious supper of fried eels and rice
before retiring,—well spent indeed, but the better informed as to the
national spirit which framed the dramatic art of the Old Japan. It is in
the hope that the reader’s impressions may in some respect
resemble my own that I have described with so much detail this
experience at a Japanese theatre of the highest class.
 CHAPTER VIII
THE NO, OR JAPANESE MIRACLE-PLAY

The comparison of the Japanese dramatic performance which bears

the name of “Nō” to the miracle-plays of Mediæval Europe is by no
means appropriate throughout. Both, indeed, dealt in the manner of
a childish faith, and with complete freedom, in affairs belonging to
the realm of the invisible, the supernatural, the miraculous; and both
availed themselves of dramatic devices for impressing religious
truths and religious superstitions upon the minds of the audience.
Both also undertook to relieve a protracted seriousness, which might
easily become oppressive, by introducing into these performances a
saving element of the comic. But in some of its prominent external
features, the Japanese drama resembled that of ancient Greece
more closely than the plays of Mediæval Europe; while its literary
merit, and the histrionic skill displayed upon its stage, were on the
whole greatly superior to the Occidental product. In the “Nō,” too, the
comic element was kept separate from the religious, and thus was
never allowed to disturb or degrade the ethical impressions and
teachings of the main dramatic performances.
In the just previous chapter the account of the probable origin of this
form of dramatic art in Japan has been briefly given: and a few
words as to its later developments will serve to make the following
description of some of the performances which I have had the good
fortune to witness, in the company of the best of interpreters, more
interesting and more intelligible. It has already been pointed out that
the Nō was at first performed by Shintō priests in the shrines, and so
the acting, or “dancing,” and the music are of a religious or
ceremonial origin and style. But the texts of the drama called by this
name came from the hands of the Buddhist priests, who were the
sources of nearly all the literature of the earlier periods.
The popularity which these ceremonial entertainments attained at
the court of the Tokugawa Shōguns received a heavy blow at the
time of the Restoration. With all their many faults, the Tokugawas
were active and influential patrons of art and of the Buddhist religion.
After their overthrow, important material and military interests were
so absorbing, and the zeal for making all things new was so
excessive, that there was no small danger of every distinctive form of
native art suffering a quick and final extinction instead of an
intelligent and sympathetic development. Besides, the philosophical
and religious ideas of Buddhism, as well as of every form of belief in
the reality and value of the invisible and spiritual, were at the time in
a deplorable condition of neglect or open contempt. About the
fifteenth year of the Era of Meiji, however, an attempt was made to
revive these religious dramatic performances. And since this
movement has been more and more patronised by the nobility,
including even some of the Imperial family, and by the intellectual
classes, the equipment, the acting, and the intelligent appreciation of
the audiences, have so improved, that it is doubtful whether the “Nō,”
during its entire historical development, has ever been so well
performed as it is at the present time. According to a pamphlet
prepared by a native expert, it is the supreme regard given by the
suggestion of spiritual ideals to a trained and sympathetic
imagination, which furnishes its controlling artistic principles to this
form of the Japanese drama.
“The Nō performance,” says the authority whom I am quoting, “is a
very simple kind of dance, whose chief feature is its exclusive
connection with ideal beauty, wholly regardless of any decorations
on the stage. The old pine-tree we see painted on the back wall of
the stage is only meant to suggest to us the time when performances
were given on a grass plot under a pine-tree. Sometimes such rudely
made things are placed on the stage, but they may be said to
represent almost anything, as a mound, a mountain, a house, etc.;
their chief aim is accomplished if they can be of any service in calling
up even faintly the original to the imagination of the audience. The
movements of the performer, in most cases, are likewise simple and
entirely dependent upon the flourishes of a folding fan in his hand,
for the expression of their natural beauty. Any emotion of the part
played is not studiously expressed by external motions and
appearances, but carelessly left to the susceptibility of the audience.
In short, the Nō performance has to do, first of all, with the interest of
a scene, and then with human passion.”
The last sentences in this quoted description are liable to serious
misunderstanding; for what the author really means is unfortunately
expressed through lack of an accurate knowledge of the value of
English words. That anything about this style of dramatic
performance is “carelessly left” to the audience, is distinctly contrary
to the impression made upon the foreign critical observer of the
Japanese Nō. The truth which the writer probably intended to
express is the truth of fact; both the ideas and the emotions which
are designed for dramatic representation are suggested rather than
declaimed or proclaimed by natural gestures; and this is, for the
most part, so subtly done and so carefully adapted to conventional
rules, that only the most highly instructed of the audience can know
surely and perfectly what ideas and emotions it is intended to
express.

“IN ONE CORNER OF THE STAGE SITS THE CHORUS”

The regular complement of performers in the Japanese Nō is three
in number: these are a principal (Shité), and his assistant (Waki);
and a third, who may be attached to, and act under, either of the
other two (a so-called Tsuré). In one corner of the stage sits the
chorus (Jiutai), whose duties and privileges are singularly like those
of the chorus in the ancient Greek drama. They sing, or chant, a
considerable portion of the drama, sometimes taking their theme
from the scene and sometimes from the action of the play.
Sometimes, also, they give voice to the unuttered thoughts or fears,
or premonitions of the performer on the stage; and sometimes they
even interpret more fully the ideas and intentions of the writer of the
drama. They may give advice or warning, may express sympathy
and bewail the woes or follies of some one of the actors; or they may
point a moral motif or impress a religious truth. At the rear-centre of
the stage sits the orchestra, which is regularly composed of four
instruments,—a sort of snare-drum at one end and a flute at the
other; while in between, seated on low stools, are two players on
drums of different sizes, but both shaped like an hour-glass. As to
the function of this rather slender, and for the most part lugubrious
orchestra, let me quote again from the same expert native authority.
“Though closely related to one another and so all learned by every
one of the players, the four instruments are specially played by four
respective specialists, each of whom strictly adheres to his own
assigned duty, and is not allowed in the least to interfere with the
others. Now this music is intended to give assistance to the Shité in
his performance, by keeping time with the harmonious flow of his
song, which is usually made up of double notes, one passage being
divided into eight parts. The rule, however, may undergo a little
modification according to circumstances. In short, the essential
feature of the music is to give an immense interest to the audience,
by nicely keeping time with the flow of the Shité’s words, and thus
giving life and harmony to them.” More briefly said: The instrumental
part of the Japanese performance of Nō punctuates the tempo,
emphasises the rhythm of the actor’s chant or recitative, and helps to
define and increase the emotional values of the entire performance.
One or two attendants, dressed in ordinary costume and supposed
to be invisible, whose office is to attend upon the principal actor,
place a seat for him, arrange his costume, and handle the simple
stage properties, complete the personnel of the Nō as performed at
the present time.
It was customary in the period of the Tokugawa Shōgunate, and still
continues to be, that a complete Nō performance should last through
an entire long day, and should consist of not fewer than five
numbers, each of a different kind. As has already been said, these
serious pieces were separated by Kyogen, or comediettas of a
burlesque character. The shorter performances, to which tickets may
be obtained for a moderate fee, have doubtless been visited by
some of my readers. But I doubt whether any of them has ever spent
an entire day in attending the regular monthly performances of the
rival schools, as they are given for the entertainment and instruction
of their patrons among the nobility and literati. It is, perhaps, more
doubtful whether they have had the patience to hold out to the end of
the day; and altogether unlikely that they have had the benefit of any
such an interpretation as that afforded us by the companionship of
my friend, Professor U——. For this reason, as well as for the
intrinsic interest of the subject, I shall venture to describe with some
detail the dramas which I saw performed during two all-day sessions
of the actors and patrons of the Nō, in November, 1906.
The first of these performances was at the house of an actor of note
who, although ill-health had compelled him to retire from the stage,
had built in his own yard a theatre of the most approved conventional
pattern, and who conducted there a school for this kind of the
dramatic art. The enterprise was supported by a society, who paid
the expenses by making yearly subscriptions for their boxes. Two of
the boxes had been kindly surrendered to us for the day by one of
these patrons.
Although we reached the theatre, after early rising, a hasty
breakfast, and a long jinrikisha ride, before nine o’clock, the
performance had been going on for a full hour before our arrival. The
first play for the day which we witnessed bore the title of “Taira-no-
Michimori”; it is one of the most justly celebrated of all the extant Nō
dramas, both for its lofty ethical and religious teaching and also for
its excellent artistic qualities. The scene is supposed to be near
Kobé, on the seashore. A very sketchy representation of a
fisherman’s boat was placed at the left of the stage. The chorus of
ten men came solemnly in, knelt in two rows on the right of the
stage, and laid their closed fans on the floor in front of them. The
four musicians and two assistants then placed themselves at the
rear-centre of the stage. In addition to the use of their instruments,
as already described, they emphasised the performance by the
frequent, monotonous emission of a cry which sounds like—“Yo-hé,
yo-hé, yo-hé.”
This play opens with the appearance of two characters, who
announce themselves as wandering priests, and who proclaim the
wonderful results which their intercessory prayers have already
achieved. They then relate the fact of the battle on this very spot, in
which the hero of the play, Taira-no-Michimori, was slain. So great
was the grief of his wife that, when she heard of the death of her
husband, she threw herself over the sides of the boat in which she
was seated at the time, and was drowned. Since then, the ghosts of
the unhappy pair have been condemned to wander to and fro, in the
guise of simple fisher-folk. When the priests have finished, they seat
themselves at the right-hand corner of the stage; and the chorus
take up the story of the battle and its sequent events. First, they
describe in poetic language the beauty of the moonlight upon the
sea and its shore. But as they enter upon the tale of so great and
hopeless a disaster, the chorus and the orchestra become more
excited, until—to quote the statement of my learned interpreter—
they cease to utter intelligible words, and “the Hayaskikata simply
howl.”
But now the ghosts themselves appear at the end of the long raised
way on the left, by which they must reach the stage; and with that
strange, slow and stately, gliding motion which is characteristic of so
much of the acting in this kind of drama, they make their way to the
skeleton boat, step softly into it, and stand there perfectly
motionless. (It is explained to us that, in Nō “ladies are much
respected” and so the wife stands in the boat, in front of her
husband,—a thing which she would by no means have done in the
real life of the period.)
Standing motionless and speechless in the boat, with their white
death-masks fixed upon the audience, the wretched ghosts hear the
church-bells ringing the summons to evening prayer, and catch the
evening song which is being chanted by the priests within the temple
walls. As though to enhance their wretchedness by contrasting with it
the delights of earth, the chorus begins again to praise the beauty of
the Autumn moonlight scene. The persuasive sounds of the intoning
of the Buddhist scriptures, and the prayers of the priests imploring
mercy upon the faithful dead, are next heard; and at this, the chorus
take up their fans from the floor and begin to extol the saving power
of both scriptures and priestly intercession. And now the ghostly
forms fall upon their knees, and the woman, as though to propitiate
Heaven, magnifies the courage and fidelity of the hero and recites
his death-song in the recent battle. At this the chorus break out into
loud lamentations that the entire family of so famous a hero has
perished and that no soul is left alive to pray for the souls departed.
After a period of kneeling, with their hands covering their faces in an
attitude of hopeless mourning, the ghosts rise and slowly move off
the stage; and the first act of the drama comes to an end.
Between the acts, a man appears and recites in the popular
language what has already been told by the chorus and the actors in
the more archaic language of the drama itself. The priests ask for a
detailed narrative of the character and life of the two noble dead; and
in response to this request, the reciter seats himself at the centre of
the stage and narrates at length the story of the love of Itichi-no-Tami
(the hero’s personal name) for his wife Koshaisho; of his knightly
character; and of her great devotion to her husband. When the
priests confess themselves puzzled by the sudden disappearance of
the fisherman and his wife, the reciter explains that their prayers
have prevailed, and that the ghosts of Itichi-no-Tami and Koshaisho
will now be permitted to resume their proper shape.
During this popular explanation, the audience, who, being for the
most part composed of learned persons, might be supposed not to
stand in need of it, engaged freely in conversation, and availed
themselves of the opportunity to take their luncheons; while through
the window at the end of the “bridge” the ghosts might be seen
changing their costumes and their wigs, with the assistance of
several “green-room” dressers.
In the second act of the drama, the ghost of the hero appears in his
proper form, gorgeously dressed as a prince, and is joined by his
wife upon the stage. He performs a very elaborate dance, and
recalls his parting from his wife, the different events of the battle, his
wounding and defeat, and the wretched conditions that followed.
These recollections work him into a state of fury; the passion for
revenge lays hold of, and so powerfully masters him, that all which
has already been done for his salvation is in danger of being lost.
And now begins a terrible spiritual conflict between the forces for
good and the forces for evil, over a human soul. The priests pray
ever more fervently, and rub their beads ever more vigorously, in
their efforts to exorcise the evil spirits. The beating of the drums and
the “yo-hés” become more frequent and louder. But at last the
prayers of the priests prevail; the soul of the doughty warrior is
reduced to a state of penitence and submission; and Itichi-no-Tami
and Koshaisho enter Paradise together.
No intelligent and sympathetic witness of this dramatic performance
could easily fail to be impressed with the belief that its influence, in
its own days, must have been powerful, and on the whole salutary.
For in spite of its appeal to superstitious fears, it taught the
significant moral truth that knightly courage and loyalty in battle—
important virtues as they are (and nowhere, so far as I am aware, is
there any teaching in the Nō performances which depreciates them)
—are not the only important virtues; nor do they alone fit the human
soul for a happy exit from this life or for a happy reception into the
life eternal. And as to the doctrine of the efficacy of prayers for the
dead: Has not this doctrine been made orthodox by the Roman-
Catholic Church; and is it not taught by the Church of England
prayer-book and believed by not a few in other Protestant churches?
The next of the Nō performances which we saw the same day was
less interesting and less pronouncedly a matter of religious dogma. It
bore the title of Hana-ga-Tami, or “The Flower Token.” This drama
tells the story of a royal personage who lived one thousand years
ago in the country near Nara. For his mistress he had a lovely and
devoted country maiden. Although he had not expected ever to
become Emperor, the reigning monarch dying suddenly, the young
man is selected for the succession, and is summoned in great haste
from his home to ascend the vacant throne. So great, indeed, was
his haste that he could not say farewell to his lady-love, who had
gone on a visit to her parents; but he leaves a letter and a flower for
her as a token of his undiminished affection. Overcome by gratitude
for his goodness and by loneliness in her abandoned condition, the
girl at last decides to follow him to Nara,—at that time the Capital of
the country. She takes with her only one maid and the precious
flower-token. After many frights—for travelling at that time was very
dangerous—by following the birds migrating southward, she at last
reaches Nara. Being poor, and without retinue, she cannot secure
entrance to the Palace; but she manages to intercept a royal
procession. When one of the Imperial followers reprimands her and
attempts to strike from her hand the flower-token, to which she is
trying to call the Emperor’s attention, she becomes indignant and
performs a dance that wins for itself the title of the “mad dance.” In
the procession the part of the Emperor is taken by a young boy;
since to have such a part performed by an adult man would be too
realistic to be consistent with the Imperial dignity. The attention of the
Emperor being attracted by this strange performance, he expresses
a wish to see the “unknown” in her “mad dance.” But when she
appears, dressed in bridal robes of white and red, and tells the story
of her life in a long song accompanied by expressive movements,
and finally sends her love to His Majesty, who “is like the moon,” so
far above a poor girl like her, and like the reflection of the “moon in
the water,” so unobtainable; the Emperor recognises her by the
flower-token and gives orders to admit her to the Palace. She then
exhibits her joy in another song and dance, which ends with the fan
“full-open,” to denote happiness complete and unalloyed and
admitting of “no more beyond.”
The last of this day’s Nō performances dealt again with the power of
the prayer of the minister of religion to exorcise evil spirits. Two
itinerant Buddhist priests find themselves at nightfall in the midst of a
dense forest. They send a servant to discover a place for them,
where they may spend the night. The servant returns to tell them of a
near-by hut, in which an old woman lives alone. They go to the hut,
boasting by the way that their prayers can even bring down a bird on
the wing; but when they reach the hut and ask for shelter, its
occupant at first declines to receive them, on the ground that her
dwelling is too poor and small to shelter them. At last they persuade
her; whereupon she comes out of the bamboo cage, which
represents her hut, and opens an imaginary gate for them. The
priests show much interest in her spinning-wheel. But she appears
sadly disturbed in mind at their presence; and finally announces that,
as the night is so cold, she will go out and gather a supply of
firewood. With an air of mystery she requires from them a promise
not to enter her sleeping-room while she is absent; and having
obtained their promise, she takes her leave.
The aged servant of the priests, however, becomes suspicious of
something wrong, and begs permission of his masters to enter the
forbidden room, since he has himself taken no part in their promise;
but as a point of honour they refuse his earnest request. The
servant, in spite of their refusal, feigns sleep for a time, and then
when his masters have fallen into a sound slumber, he steals away
to the bedroom of the old woman. On the first two or three attempts,
he makes so much noise as to waken the priests; but finally he
succeeds in entering the room which, to his horror, he finds filled with
human bones,—all carefully classified! He then rushes to his
masters and wakens them with the information that their hostess is
really a cannibal witch, and that they must escape for their lives. This
advice he at once puts into practice by making good his own escape.
But the flight of the priests is only symbolised by their standing
perfectly motionless in one corner of the stage, while the chorus
eloquently recites these blood-curdling experiences.
When the witch, in her demon-like form, overtakes the ministers of
the Buddhist religion, the two spiritual forces represented by the
actors then on the stage enter into the same kind of conflict as that
which has already been described. The demon rages furiously; the
priests pray fervently, and rub their rosaries with ever-increasing
vigour; for the contest is over a human soul. But at the last the evil