Informacije

Trepination Timeline


  • 6500 pne

    Prvi dokazi o kirurškom zahvatu trepinacije pronađeni u Francuskoj.

  • 5000 pne

    Dokazi o hirurškom postupku trepinacije pronađeni u Kini.

  • 950 pne - 1400 pne

    Dokazi o hirurškom postupku trepinacije pronađeni u Mezoamerici.


Subungualni hematom

A subungualni hematom je skup krvi (hematom) ispod nokta ili nokta (crni nokat). Može biti izuzetno bolno za ozljedu svoje veličine, iako u suprotnom nije ozbiljno zdravstveno stanje.

Subungualni hematom
Druga imenaPrst trkača, teniski prst, skijaški prst
Subungvalni hematom nožnog prsta
SpecijalitetInterna medicina, Podiatrija
SimptomiPromjena boje nokta, bol
Faktori rizikaLoše nošenje nogu, pretreniranost, posebno planinarenje i trčanje
LiječenjeObično nezasluženo, drenaža krvi ili uklanjanje noktiju u teškim slučajevima
PrognozaObično se sami rješavaju dok nokat raste


Mentalni poremećaji

Trenutno sam istoričar i psiholog na Univerzitetu u Novom Meksiku (UNM). S obzirom na to, planiram kombinirati dvije discipline u grafikonu mentalnih poremećaja onako kako su medicinski shvaćeni i povijesno zabilježeni. Prvi povijesni zapisi o mentalnim poremećajima datiraju 10.000 godina, međutim, prvenstveno ću se usredotočiti od 400. godine prije Krista do danas. Budući da nikako ne mogu uključiti svaku snimljenu epizodu, navest ću najznačajnije primjere koji su bili i jesu široko prihvaćeni. Akademske vrijednosti unutar ovih djela imaju za cilj sažeti i educirati čitatelje o mentalnim poremećajima kroz većinu dokumentirane povijesti, kao i zašto je važno da se ova područja i dalje istražuju i razvijaju. Ovaj će esej dati sažetu historiografiju mentalnog poremećaji koji uključuju uočene uzroke, kao i tretmani, jer oba napreduju kroz dokumentiranu povijest.

Čini se pomalo jebeno, ovaj čin 'TREPHINATION -a' Tokom ovog perioda, ako nešto nije u redu s glavom neke osobe, oni su samo izbušili rupu i pustili 'LOŠE'. [izvor]

Dokumentovana istorija mentalnih poremećaja datira iz posljednjih “10.000 godina, a vremenski okvir je evidentan kroz dokaze o Trephination širom Evrope “(Pitsios, 239). Sa više od „200 lobanja pronađenih od Skandinavije do Balkana“ (Pitsios, 239). Ova drevna tehnika bila je prva kirurška operacija i služila je u brojne svrhe. Njegova evolucija kroz periode napredovanja tehničkih sredstava, znanja i terapijskih potreba kako je vrijeme prolazilo. „Hipokrat je prvi put klasificirao vrste lomova lobanje i definirao uvjete i okolnosti za izvođenje trepanacije“ (Pitsios, 239). Historiografski izazov u crtanju o čemu su pisali historičari mentalni poremećaji je da nisu do kraja 19. i početka 20. stoljeća. S obzirom na to, ja sam svoje historiografske podatke izveo iz teorija i modela ponašanja koji su se tada prakticirali.

„Godine 400. p.n.e. Hipokrat sugerirao da su mentalni poremećaji uzrokovani i biološkim i psihološkim svojstvima ”(Barlow, 30). Hipokrat, poznat i kao Hipokrat II, bio je grčki ljekar, koji se smatra jednom od najistaknutijih ličnosti u istoriji medicine, kao i „ocem zapadne medicine“ (Barlow, 14). Očigledno je da se za to vrijeme s vremena na vrijeme mislilo da se mentalni poremećaji liječe bušenjem rupa kroz određene dijelove lubanje, omogućavajući oslobađanje pritiska zajedno sa svim lošim duhovima. Međutim, tijekom “18. i 19. stoljeća, operacije trepinacije bile su odbačene kao terapijska kirurška metoda, zbog visoke smrtnosti koja je tada dosegla 100%” (Pitsios, 240). Način na koji su se mentalni poremećaji percipirali u ovom razdoblju može nam se sada činiti varvarskim i brutalnim, ali u to vrijeme ova metoda je bila najnapredniji kirurški tretman i služila je kao platforma iz koje su odskočila psihološka istraživanja.

Godine 200. n. Galen, rimski liječnik usvojio je i ugradio Hipokratove ideje koje su stvorile dugotrajnu školu mišljenja u cijelom području psihopatologije. Predložio je da su normalno i abnormalno ponašanje povezane s četiri tjelesne tekućine ili humorom. Ove tekućine/humore trebalo je održavati na određenim razinama kako bi ljudi mogli funkcionirati "normalno". Četiri humora uključuju kolerik (žuta žuč, vatra), melanholičan (crna žuč, zemlja), sangvinik (krv, zrak) i flegmatik (flegma, voda). Ova biološka tradicija će se nastaviti do 19. stoljeća. Putevi kojima su oni ovog vremena percipirali mentalne poremećaje bili su primitivni, ali su napredovali. Napredak u razmišljanju, praksi i znanju doveo je do toga da su ljudi ovog doba nadogradili određene aspekte, ali i oslobodili druge. S uvjerenjem da su mentalni poremećaji čisto uzrokovani fiziološkim aspektima, mislioci ovog razdoblja počivali bi na biološkoj tradiciji koja se prakticirala u posljednjih nekoliko stotina godina.

Zlo ili neshvaćeno? Smatralo se da su pojedinci u ovom razdoblju opsjednuti natprirodnim, a ne mentalno oboljelim [izvor]

Čini se da je dokumentirana istorija mentalnih poremećaja uzela pauzu od devet stotina godina, jer se vremenski okvir nije ponovo pojavio sve do 1300-ih. Zbog nedostatka usredotočenosti povjesničara, većina informacija u ovim radovima potječe od onih iz medicinskog i psihološkog područja, jer su oni jedini ljudi koji su dokumentirali ovu temu. Za mentalne poremećaje u ovom periodu krivi su demoni i vještice. Praznovjerje bila je rasprostranjena, a egzorcizmi su se izvodili kako bi se žrtve oslobodile ‘zlih duhova’. U „kasnom srednjem vijeku, mentalna bolest nije prepoznata kao takva. Umjesto toga, mentalno poremećeni optuženi su za čarobnjaštvo ”(Spanos, 417). Krajem 14. stoljeća, nadležne vjerske sile počele su podržavati ova praznovjerja zbog njihove sve veće popularnosti među evropskim društvom.

Na tom mjestu u to vrijeme mentalni poremećaji nisu bili izravno dokumentirani kao takvi, međutim, posredno povezani, o knjigama vještice su objavljeni. „Malleus Maleficarum, ili na latinskom, Čekićev čekić“, napisao je Heinrich Kramer1486. ​​Glavna svrha knjige bila je osporiti sve argumente protiv postojanja vještica i uputiti suce kako da identificiraju, ispitaju i osude vještice. Stoljeće kasnije, 1580. Jean Bodin objavit će ‘O demonskoj maniji vještica, ili u Frecnh, De la démonomanie des sorciers’. Dakle, u ovom trenutku u istoriji mišljenja o mentalnim poremećajima je da oni nisu krivi za nenormalno/devijantno ponašanje, već bi vještica bila krivac.

Vjerovalo se da su vještice i demoni posjedovali one čije je bizarno ponašanje pokazalo mentalno oboljelo, a zapravo se smatralo đavolskim djelom. Tretmani za ove mentalni poremećaji oslanjao se samo na religiju kako bi izliječio pojedince. Uz „egzorcizam, u različitim vjerskim ritualima izvedeni su pokušaji da se žrtva oslobodi zlih duhova. Obrijati uzorak križa u kosi na glavi žrtve i pričvrstiti oboljele na zid blizu pročelja crkve kako bi mogli imati koristi od slušanja mise ”(Barlow, 10). Ova sujevjerja su se nastavila kroz sljedećih nekoliko stoljeća. Kao što je uzročnost zla i ludila bila kriva za čarobnjaštvo i čarobnjaštvo u 15. stoljeću. Ta se „uzročnost“ čak prosula i preko Atlantika, što je „evidentno u Salemu, suđenjima protiv vještica u Massachusettsu u kasnom 17. stoljeću, što je rezultiralo vješanjem brojnih žena“ (Barlow, 10). Zbog činjenice da bi većina optuženih za posjedovanje ovih ovlasti i posjeda otvoreno priznala da su “izvršili nemoguća djela poput letenja zrakom, bili su u zabludi, a vjerovatno su mnogi bili shizofreni” (Spanos, 417).

Tretman posjedovanja koji nije bio povezan s religijom bio je još čudniji, posebno na prvi pogled. Jedan od načina liječenja bio je „suspendiranje opsjednute osobe nad jamu punu otrovnih zmija kako bi zle duhove prestrašila iz njihovih tijela“ (Barlow, 11). Čudno, ponekad je ova taktika/liječenje zaista stupila na snagu. „Pojedinci čudnog ponašanja iznenada bi došli k sebi i doživjeli olakšanje od simptoma, čak i privremeno“ (Barlow, 11). Druge metode liječenja sastojale su se od “uranjanja osobe u ledeno hladnu vodu” kao elementa šoka (Barlow, 11). U 1500 -im Paracelsus, švicarski liječnik i astrolog bio je pionir u nekoliko aspekata medicinske revolucije renesanse. On sugerira da nisu đavo ili zli duhovi ti koji utječu na psihološko funkcioniranje ljudi, već Mjesec i zvijezde. Od 1400-1800 liječeni su i oni za koje se mislilo da imaju mentalne poremećaje puštanje krvi i pijavice za oslobađanje tijela od nezdravih tekućina i vraćanje kemijske ravnoteže.

Biološka škola mišljenja nastavila je „jačati i slabiti u vrijeme Hipokrata i Galena, ali je ponovo ojačana u 19. stoljeću zbog dva faktora“ (Barlow, 14). Prvo, otkriće i uzročnost sifilisi dvije, snažnu podršku najutjecajnijeg američkog psihijatra u to vrijeme, John P. Grey. Smatra se „prvakom biološke tradicije u Sjedinjenim Državama“ (Barlow, 14). John P. Grey bio je šef njujorške bolnice Utica. Vjerovao je da je ludilo uzrokovano fizičkim osobinama, koje su umanjile naglasak na psihološkim tretmanima. Područja psihopatologije, psihologije i psihijatrije sada su krenula u znanstvenom smjeru, dok su se prije na njih gledalo kao na duhovne i u uzrocima i u liječenju. Ovo ustupa mjesto moralnoj terapiji.

Godine 1793 Philippe Pinel, francuski ljekar koji je imao veliki utjecaj na razvoj humanijeg psihološkog pristupa njezi i čuvanju psihijatrijskih pacijenata, koji je u sadašnjosti češće poznat kao moralna terapija. On predstavlja moralna terapija i implicira humanije prakse u francuskim mentalnim ustanovama. „U 19. stoljeću psihički poremećaji pripisivani su mentalnom ili emocionalnom stresu, pa su pacijenti često bili suosjećajno tretirani u mirnom i higijenskom okruženju“ (Barlow, 17). Ovaj novi pristup bio je prilično različit od prethodnih praksi.

Godine 1848 Dorothea Dix, kao američki zagovornik mentalno bolesnih koji su se borili kroz lobiranje državnih zakonodavnih tijela i Kongres Sjedinjenih Država, pomogao je u stvaranju prve generacije američkih mentalnih azila koja uspješno vodi kampanje za humani tretman u američkim mentalnim ustanovama. Do sada je u povijesti mentalnih poremećaja dokumentacija prenijela načine na koji se ta pitanja percipiraju i rješavaju. Po prvi put na području mentalnih poremećaja, uvjerenje da pacijentima nije potrebno samo liječenje, već im je potrebno i suosjećanje. Ovaj pomak u mislima drastičan je u odnosu na teme prethodnika, ali će se pokazati kao vitalna komponenta kroz sadašnjost.

Drugi aspekt ovog vremenskog perioda koji je važan za primjenjiva polja je Emil Kraepelin, jedan od utemeljitelja moderne psihijatrije objavljuje rad na dijagnostici, klasificirajući brojne psihološke poremećaje iz biološke perspektive. Prije toga, dijagnoza, klasifikacija i stratifikacija još nisu bili uključeni. Stvarne 'riječi' mogle bi se pripisati ponašanju, koje bi onda prenijelo kombinirane simptome u zasebna i specifična područja. Još jedan ogroman korak u "progresivnom" smjeru za psihologe koji bi bio trajan i utjecajan.

Širom svijeta brojni pojedinci počeli su razvijati različite hipoteze, teorije i nove grane u području mentalnih poremećaja. Godine 1900 Sigmund Frojd, austrijski neurolog i osnivač psihoanalize, koja je klinička metoda za liječenje psihopatologije kroz dijalog između pacijenta i psihoanalitičara, objavljena pod naslovom „Tumačenje snova“. Dok je 1904 Ivan Pavlov, ruski fiziolog poznat prvenstveno po svom radu na klasičnom kondicioniranju dobio je Nobelovu nagradu zbog svojih studija o fiziologiji probave. Sa stanovišta bihevioralnih psihologa, oni koji su patili od određenih mentalnih poremećaja mogli bi se liječiti Pavlovljevim klasičnim uvjetovanjem. Oni ovog vremena započeli su praksu mijenjanja psihoza brojnih puteva činovima uslovljavanja i izumiranja.

Biheviorizam je skovao John B. Watson, američki psiholog koji je osnovao psihološku školu biheviorizma. Promijenio je psihologiju svojim govorom o psihologiji na koji biheviorista gleda, koji je održao na Univerzitetu Columbia 1913. godine. Johna B. Watsona Eksperimenti "Malog Alberta" koji se bave uslovljenim strahom, kroz upotrebu operantne kondicije. To je termin koji je kasnije skovao B.F. Skinner 1938. Objašnjava principe operativnog uvjetovanja kroz objavljivanje Ponašanja organizama-koji pojačanje i oblikovanje korišteni su kako bi se ‘ispravilo’ ponašanje pojedinca.

Naizgled 'šokantan' način liječenja. Može li terapija električnim šokom biti korisna za liječenje mentalnih poremećaja? [izvor]

Vraćajući se malo unatrag u vrijeme 1930. tretmani strujnog udara kao i operacije mozga, počeo se koristiti za liječenje psihopatologije. Osim psihohirurgija kao što su trephination, ECT je najkontroverzniji tretman za mentalne poremećaje. Ideje za to sežu još dalje, ali kako ne bi narušile kontinuitet Biheviorizam Skočio sam u svoju hronologiju. Benjamin Franklin „slučajno je otkrio, a zatim eksperimentalno potvrdio 1750 -ih, da je blagi električni udar izazvao kratke grčeve i gubitak pamćenja, ali inače nije nanio nikakvu štetu. Ubrzo zatim, prijatelj Franklina, holandskog ljekara, predložio je da ovaj šok može poslužiti kao lijek za depresiju. Od bušenja rupa u glavama ljudi kroz čin trepinacije do šokiranja ljudi kako bi ih 'izliječili' od njihovog mentalnog poremećaja trebalo je samo dva milenijuma. Mada, kasnije će na kraju dobiti na snazi.

1950 -ih mentalne bolnice počele su uključivati ​​praksu terapijom električnim šokommeđutim, koristili su ga više kao oruđe poslušnosti i zlostavljanja nego lijek za mentalne poremećaje. U današnjoj praksi ECT Pacijenti s elektrokonvulzivnom terapijom se anesteziraju kako bi se smanjila nelagoda i daju im se lijekovi za opuštanje mišića kako bi se spriječilo lomljenje kostiju od konvulzija tijekom napada. Način na koji ovi napadaji pomažu onima koji pate od depresije je sljedeći. ECT povećava razinu serotonina koji blokira hormone stresa i potiče neurogenezu u hipokampusu. U osnovi, pojedincu daje više sretnih kemikalija/osjećaja dobrog osjećaja/neurotransmitera, blokira negativne kemikalije i regenerira/revitalizira dijelove našeg mozga koji se bave emocijama, bilo je potrebno samo dva i pol stoljeća da se to riješi (Barlow).

Konačno, objavljeni su historiografski podaci o mentalnim poremećajima. Međunarodni statistički institut usvojio je prvi Međunarodna klasifikacija bolesti (ICD) 1893. 1952. prvo izdanje Dijagnostički i statistički priručnik (DSM-1) objavljuje se u Sjedinjenim Državama. Kako su godine odmicale, obje su revidirane i nastavljaju širiti svoju klasifikaciju kroz više izdanja. ICD-10 je najnoviji u svijetu, dok se DSM-5 prvenstveno koristi u Sjedinjenim Državama. Ovi priručnici klasificiraju način razmišljanja o mentalnim poremećajima u vrijeme njihovog objavljivanja. Kako priručnici napreduju, napreduju i načini na koje ljudi percipiraju mentalne bolesti.

Današnje studije o mentalnim poremećajima raspravljaju o tome jesu li ti poremećaji urođeni ili su naučeni, u osnovi koristeći primitivnu prirodu ovih tema utemeljujući vjerovanja, 'biološke ili fiziološke' uzročne uzroke. Jedno od trenutno najviše proučavanih područja u području mentalnih poremećaja psihopatija. Najviše su koncentrirani na kriminalce. Imajući to na umu, razvijeni su programi liječenja, kao i profesionalno prihvaćeni načini dijagnoze. Ovo samo dodaje vatru zabune kada su u pitanju mentalni poremećaji, budući da su oni koji su bili na ‘liječenju’ za psihopatija dokazati veću vjerovatnoću ponovnog uvrede. Sadašnji psiholozi to predviđaju mikročipovi bit će razvijeni i instalirani na određenim lokacijama mozga kod onih kojima je dijagnosticirana psihopatija. To bi im omogućilo da funkcioniraju „normalno“, ali mijenjajući neuronsko ožičenje ovih pojedinaca. To onda dovodi u pitanje moralističko ili etičko nagađanje ove hipotetičke prakse. Sve navedeno u ovom paragrafu može se citirati (Hare).

Istraživanje je pokazalo kroz 22 skale Roberta Harea da značajni lideri u globalnom društvu prikazuju osobine psihopatija. Najviši i najlošiji rezultat jednak je 40, dok je minimalni zahtjev za pojedinca ocjena 26 da se dijagnosticira kao psihopata. Prema studiji koju je sproveo dr Kevin Dutton na Univerzitetu Oxford, "Donald Trump postigao je nešto više od Adolfa Hitlera na ovoj ljestvici, a Hillary Clinton je postigla između Napoleona Bonapartea i Nerona". Ovo mentalni poremećaji očito nisu uvijek ekvivalentne negativnim prerogativima, ovisno o političkim i društvenim strukturama u kojima postoje.

Mentalni poremećaji kroz povijest, pa i u sadašnjosti, nastavljaju se istraživati ​​i razvijati na jako različite načine, međutim, "povijest psihijatrije nas uči da sumnjamo u nju, naglašavajući beskonačno promjenjiv i promjenjiv karakter psihijatrijskih entiteta" (Borch-Jacobsen , 19). Slično je kao i ostale kategorije koje proučavaju povjesničari, paradoksalno i vrtoglavo kontradiktorno. Mi kao budući povjesničari moramo biti svjesni ovih aspekata kako bismo napredak da usledi. „Ideja da se emocionalne reakcije javljaju refleksno i nenamjerno kao odgovor na unutarnje i vanjske podražaje ustrajna je u sadašnjosti i nastavlja činiti mogućim i uvjerljivim koncept poremećaji raspoloženja”(Jansson, 399).

U historiografiji mišljenja u psihologiji, kako vrijeme prolazi, o mentalnim se poremećajima razmišlja na mnogo različitih načina. [izvor]

(1) Barlow, Durand, Hofmann. Abnormalna psihologija Integrativni pristup. 8. izdanje, Cengage Learning, 2018.

(2) Borch-Jacobsen, Mikkel History of the Human Sciences, Vol 14 (2), May, 2001 pp. 19-38. Izdavač: Sage Publications [Članak iz časopisa], Baza podataka: PsycINFO

(3) Jansson, Asa. "Poremećaji raspoloženja i mozak: depresija, melanholija i historiografija psihijatrije." Povijest bolesti 55, br. 3 (2011): 393–99. doi: 10.1017/S0025727300005469.

(4) Pitsios, Theodoros i Vasiliki Zafiri. 2012. „Slučajevi trepinacije u starogrčkim lubanjama.“ Međunarodni časopis za brižne nauke 5 (3): 239–45. https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=104502198&site=eds-live&scope=site.

(5) Spanos, Nicholas P. 1978. “Vještičarenje u historijama psihijatrije: kritička analiza i alternativna konceptualizacija.” Psihološki bilten 85 (2): 417–39. doi: 10.1037/0033-2909.85.2.417.


Trepanacija, proces stvaranja rupe u lobanji za pristup mozgu, drevni je oblik primitivne kraniotomije. Postoje rasprostranjeni dokazi o doprinosu ove prakse drevnim civilizacijama u Evropi, Africi i Južnoj Americi, gdje su arheolozi iskopali hiljade trepaniranih lubanja koje datiraju iz perioda neolita. Malo se zna o trepanaciji u Kini, a općenito se vjeruje da su Kinezi koristili samo tradicionalnu kinesku medicinu i nehirurške metode za liječenje ozljeda mozga. Međutim, temeljita analiza dostupnih arheoloških i literarnih dokaza otkriva da se trepanacija široko primjenjivala u cijeloj Kini prije više hiljada godina. Otkopan je značajan broj trepaniranih kineskih lubanja koje pokazuju znakove zarastanja i ukazuju na to da su pacijenti preživjeli nakon operacije. Trepanacija se vjerojatno izvodila iz terapijskih i duhovnih razloga. Medicinski i historijski radovi iz kineske književnosti sadrže opise primitivnih neurokirurških zahvata, uključujući priče o hirurzima, poput legendarne Hua Tuo, i kirurške tehnike koje se koriste za liječenje patologija mozga. Nedostatak prevoda kineskih izvještaja na engleski jezik i nedostatak publikacija o ovoj temi na engleskom jeziku možda su doprinijeli zabludi da je drevna Kina lišena trepanacije. Ovaj članak sažima dostupne dokaze koji svjedoče o uspješnosti primitivne operacije lobanje u drevnoj Kini.

Izjava o sukobu interesa: Autori izjavljuju da je sadržaj članka sastavljen u nedostatku bilo kakvih komercijalnih ili finansijskih odnosa koji bi se mogli protumačiti kao potencijalni sukob interesa.


Kratki osvrt na ne tako kratku istoriju lobotomije

Lagani uspon i brzi pad lobotomije mogu nam dati pauzu da se zapitamo: Na kakvu će se današnju praksu u budućnosti gledati s užasom?

„Svaki ljekar ima drugačiju prirodu. Vjeruje se u princip: premum non nocere (ne šteti). Drugi kaže: melius anceps remedium quam nullum (bolje opasan lijek nego ništa). Naginjem se drugoj kategoriji. " -Gottlieb Burckhardt, otac psihokirurgije (1891) [1]

Psihokirurgija-loše definirana kombinacija neurokirurgije i psihijatrije-dugo je bila jedno od najkontroverznijih područja u medicini. Očarao je umove i liječnika i filozofa, imajući kompliciranu povijest medicinske nesigurnosti i etičke podjele. Možda je jedan od najpoznatijih pojmova u području psihokirurgije lobotomija- riječ koja se široko koristi za opisivanje različitih postupaka, kao što su leukotomija, topektomija i neuroinjekcija različitih sklerozirajućih agenasa. [2]

Podrijetlo psihokirurgije
Podrijetlo psihokirurgije može se pratiti do antike, s dokazima o kraniotomijama iz kamenog doba koje datiraju čak 5100. godine prije nove ere. [3] Arheološki nalazi ukazuju na to da su prahistorijski šamani mogli pristupiti mozgu trefinacijom, procesom koji uključuje bušenje ili urezivanje rupe u lubanji pomoću kirurškog alata s oštricom. [4] Trepinacija je dobro dokumentirana kroz ranu povijest koja vodi u predmoderna vremena - ne samo u medicinskoj literaturi nego i u određenim djelima vizualne umjetnosti. [5] Na primjer, renesansni slikar Hieronymus Bosch prikazuje psihokiruršku trefinaciju u jednom od svojih najpopularnijih djela, Vađenje kamena ludila (oko 1494). Jasno je da postoji dugogodišnje zanimanje za odnos mozga i ponašanja i potencijalnu ulogu psihokirurgije u manipulaciji ovom složenom vezom.


Ekstrakcija kamena ludila Hieronymus Bosch.
Reproducirano uz dozvolu Nacionalnog muzeja Prado, Mardid.

Tek sredinom 19. stoljeća psihokirurgija je poprimila poznatiji oblik, kada se znanstvena zajednica zainteresirala za prepoznatljiv neuropsihijatrijski slučaj Phineas Gage, 25-godišnjeg željezničkog radnika kojeg je kopljem bodio štap cm dugačak i 3 cm debeo kroz njegov prefrontalni korteks tokom nesrećne eksplozije na radnom mestu. [6,7] Na iznenađenje masa, Gage se udaljio od incidenta bez ikakvih značajnih somatskih pritužbi, ali onima koji su ga dobro poznavali, Gageu koji je preživio eksploziju nije bio Gage kojeg su poznavali ranije. Nekada uzoran građanin, postao je lako razdražljiv, dezinhibiran i izuzetno labilan. [8] Gageov ljekar pomno je pratio njegov slučaj i objavio sljedeći opis:

Prije ozljede, iako neobučen u školama, imao je uravnotežen um, a oni koji su ga poznavali gledali su ga kao pronicljivog, pametnog poslovnog čovjeka, vrlo energičnog i upornog u izvršavanju svih svojih operativnih planova. S tim u vezi, njegovo mišljenje se radikalno promijenilo, tako odlučno da su njegovi prijatelji i poznanici rekli da "više nije Gage." [9]

Slučaj Phineas Gage potaknuo je čitavo polje istraživanja specifičnog funkcioniranja različitih dijelova mozga i kako bi to moglo biti povezano s kliničko -patološkim metodama različitih psihijatrijskih bolesti sa sličnim inhibiranim prezentacijama.

Početak lobotomije
Inspiriran novim razumijevanjem frontalnog režnja i njegove neporecive sile u oblikovanju ljudskog ponašanja, švicarski psihijatar Gottlieb Burckhardt bio je prvi poznati liječnik koji je teorije o povezanosti ponašanja mozga pretočio u ciljanu kiruršku praksu. Radeći s malom kohortom pacijenata sa teškom shizofrenijom koji su bili neodoljivi na druge mjere liječenja, Burckhardt je uklonio segmente pacijentovog mozga kako bi liječio psihijatrijsku bolest i promijenio pacijenta, prema njegovim riječima, iz „uzbuđenog u tišeg dementnog [shizofrenog] [1] U svom značajnom istraživanju, za koje je izvijestio 1891., Burckhardt je izveo i dokumentirao više operacija otvorenog mozga na šest pacijenata sa shizofrenijom u rasponu od 10 godina-s različitim stupnjem uspjeha. Njegovi su se rezultati kretali od pacijenata koji su uspješno "utihnuti" procedurom (što je bio slučaj za tri od šest pacijenata) do jednog pacijenta koji je preminuo od postoperativnih komplikacija.6 Dok je Burckhardt namjeravao da korisnost njegove operacije bude "najviše palijativna" ”, Medicinsko je društvo oštro odbacilo njegovo istraživanje zbog visokog uznemirenja i krajnje nedjelotvornosti. Tako je Burckhardt napustio svoje istraživanje nakon objavljivanja svojih rezultata, a psihokirurško istraživanje je nestalo u pozadini nekoliko desetljeća. [10]

Početkom 1930 -ih psihohirurgija je doživjela nagli i iznenađujuće brz preporod. U Europi, portugalski neurolog António Egas Moniz i njegova neurokirurška kolegica Almeida Lima eksperimentirali su s vezama između frontalnih korteksa i talamusa i počeli polako ponovno uvoditi neka načela Burckhardtovog istraživanja. [11] Kako bi dodatno poboljšali Burckhardtovu kiruršku tehniku, dvojac je razvio ciljaniji, specifičniji proces nazvan leukotomija, koji je uključivao umetanje male kirurške šipke s uvlačećom žičanom omčom (zvanom leukotom) u mozak. Instrument bi se tada mogao koristiti za kavitaciju područja bijele tvari, s izričitom namjerom da se promijeni raspoloženje pacijenta. [6,11] Uz mnoštvo istraživanja koja su bila tek u povojima i bez davanja uvjerljivih rezultata koji bi potvrdili njihove nove tehnikom, Moniz i Lima počeli su s harizmom i političkim znanjem promovirati kontroverzni postupak u cijeloj Evropi. Zaista, tada je lobotomija počela prihvaćati kao primarni lijek za psihijatrijske bolesti-iako su Moniz i Lima vodili lošu evidenciju o praćenju pacijenata, pa su čak neke pacijente vratili u utočišta nakon operacije, da se više nikada ne vide. [ 11]

Kako je lobotomija popularizirana diljem Europe, postupak je također predstavljen željnoj sjevernoameričkoj medicinskoj publici. Neurolog Walter Freeman i neurokirurg James Watts zagovarali su ovu migraciju, s ciljem poboljšanja rezultata svojih međunarodnih kolega. [6] Dvojac je izmijenio postupak tako da nije zahtijevao ništa više od male rupe od 1 cm koja se mogla izbušiti iznad zigomatičnog luka za umetanje leukotoma. Ovo je nesumnjivo učinilo proceduru mnogo jednostavnijom i pomalo manje invazivnom, ali je ipak došlo sa inherentnim postoperativnim rizikom od napadaja, infekcija, pa čak i smrti. [6,12] Nadalje, Freeman se na kraju opčinio radom talijanskog kolege koji je razvio transorbitalni pristup postupku koji nije zahtijevao ništa više od jednostavnog instrumenta sličnog šiljkanju leda koji se mogao provući kroz orbitalnu kost i prenijeti preko prefrontalnog korteksa. On je brzo i željno usvojio ovu metodu krajem 1930 -ih. [13]

Rad Freemana i Wattsa toliko je pojednostavio lobotomiju da je Freeman započeo postupak bez pomoći svog neurohirurškog kolege i bez sterilnog polja koje je često bilo potrebno u operacijskoj sali. [5] To je Wattsa udaljilo od istraživanja para, jer je bio uznemiren grubom prirodom transorbitalnog pristupa i nije bio impresioniran podstandardnom, nesterilnom perioperativnom njegom koju je pružao Freeman. S vremenom je dvojac prekinuo njihove veze, ali Freeman je nastavio sa svojim strastvenim krstaškim pohodom populariziranjem transorbitalne lobotomije u cijeloj Sjevernoj Americi. [2] Desetine hiljada psihijatrijskih pacijenata prošlo je proceduru - sa različitim stepenom uspjeha - sve dok nedostatak dokaza koji podržavaju lobotomiju konačno nije sustigao Freemana i njegove psihohirurške kolege.

Pad lobotomije
Iako je uspon lobotomije bio spor i uzastopan, čini se da se njen smrt dogodio odjednom. Usred sve veće sumnje u postupak, Moniz je 1949. godine dobio Nobelovu nagradu za fiziologiju ili medicinu za svoj raniji rad na spornoj hirurgiji. U trenutku je globalna medicinska zajednica bacila kritičko oko na istraživanja Burckhardta, Moniza i Lime, te Freemana i Watta, i tako je počeo pad. [6] Kritičari su osporavali da lobotomija "nije donijela najveću korist čovječanstvu" - koji je bio naveden kriterij za Nobelovu nagradu - nego su tvrdili da je nanijela ozbiljniju štetu. [14] Brzo je nastala impresivna biblioteka literature o antilobotomiji.

Lobotomija je doista depopularizirana tek kada je klorpromazin uveden na tržište psihofarmaceutika. Klorpromazin je bio prvi psihoterapeutski lijek koji je odobren za liječenje shizofrenije s pozitivnim učinkom, a tijekom prve godine na tržištu primijenjen je kod približno 2 milijuna pacijenata. [15] Sa sigurnijom i pouzdanijom opcijom koja je sada dostupna cijeloj medicinskoj zajednici, lobotomija je službeno pala u nemilost.

Ovaj članak je recenziran.

Reference

1. Burckhardt G. 1891. Ueber Rindenexcisionen, als Beitrag zur operativen Therapie der Psychosen [O kortikalnoj eksciziji, kao prilog kirurškom liječenju psihoze]. Allgemeine Zeitschrift fur Psychiatrie und psychisch-gerichtliche Medicin [Opći časopis za psihijatriju i mentalnu sudsku medicinu]. 189147: 463-548. Njemački.

2. Kucharski A. Povijest frontalne lobotomije u Sjedinjenim Državama, 1935-1955. Neurokirurgija. 198414: 765-772.

3. Alt KW, Jeunesse C, Buitrago-Téllez CH, et al. Dokazi za operaciju lobanje u kamenom dobu. Priroda. 1997387: 360.

4. Rifkinson-Mann S. Kranijalna hirurgija u drevnom Peruu. Neurokirurgija. 198823: 411-416.

5. Faria MA. Nasilje, mentalne bolesti i mozak - kratka povijest psihokirurgije: prvi dio - od trefinacije do lobotomije. Surg Neurol Int. 20134: 49.

6. Mashour G, Walker E, Martuza R. Psychosurgery: Past, present, and future. Brain Res Brain Res Rev. 200548:409-419.

7. Ordia JI. Neurologic function seven years after crowbar impalement of the brain. Surg Neurol. 198932:152-155.

8. Damasio H, Grabowski T, Frank R, et al. The return of Phineas Gage: Clues about the brain from the skull of a famous patient. Nauka. 1994264:1102-1105.

9. Harlow JM. Recovery from the passage of iron bar through the head. Publ Mass Med Soc. 18682:327-347.

10. Joanette Y, Stemmer B, Assal G, et al. From theory to practice: The unconventional contribution of Gottlieb Burckhardt to psychosurgery. Brain Lang. 199345:572-587.

11. Valenstein ES. Great and desperate cures: The rise and decline of psychosurgery and other radical treatments for mental illness. New York: Basic Books 1986.

12. Freeman W, Watts JW. Prefrontal lobotomy in the treatment of mental disorders. South Med J. 193730:23-31.

13. Pressman JD. Sufficient promise: John F. Fulton and the origins of psychosurgery. Bull Hist Med. 198862:1-22.

14. Lindsten J, Ringertz N. The Nobel Prize in Physiology or Medicine, 1901-2000. Nobelprize.org. 26 June 2001. www.nobelprize.org/nobel_prizes/themes/medicine/lindsten-ringertz-rev/.

15. Feldman RP, Goodrich JT. Psychosurgery: A historical review. Neurosurgery. 200148:647-659.

Mr Gallea is a third-year medical student at the University of British Columbia.


Primary Care Procedures: Trephination of Subungual Hematoma

Subungual hematoma is a fairly common condition. The severe pain that results, caused by the buildup of pressure in a closed space, persists for days if the condition is not treated. However, the blood under the nail can be easily removed-and the pain almost completely relieved-by timely nail trephination. Here I describe techniques that have worked well in my practice.

Figure 1 – The subungual hematoma on this patient’s left thumb would be classed as complex, on account of the damage to the cuticle. (Courtesy of Alexander K. C. Leung, MD)

Subungual hematomas may be simple or complex. Complex hematomas are accompanied by a fracture, nail base dislocation, tissue loss, or skin laceration (Figure 1). Simple hematomas are characterized by an intact nail and nail margins with no other associated injury. 1

Although most subungual hematomas that appear simple are not accompanied by fracture, it is usually wise to obtain radiographs to be sure. However, some authorities suggest that radiographs are unnecessary in patients who exhibit no worrisome findings after the hematoma is drained. 2

When a sudden darkening appears beneath a nail following an injury, the diagnosis of subungual hematoma is fairly straightforward. If the patient has no history of significant trauma, consider other conditions that may have a similar appearance, such as subungual melanoma, subungual nevus, and Kaposi sarcoma. 1 PREPARATION FOR DRAINAGE
Nail trephination can be successfully performed up to 36 hours after injury-and possibly even later-because the blood under the nail will not coagulate during this period. 3 An underlying fracture is not considered a contraindication to nail trephination. 3

Before drainage, prepare the nail with povidone-iodine solution or alcohol. If the only procedure to be performed is trephination, local anesthesia is generally not necessary.

Some authorities have recommended removing the nail plate and repairing the nail bed for subungual hematomas that involve more than 50% of the nail. Because nail bed repair is difficult at best, and because the nail itself acts as an anatomical splint, this recommendation seems to add risk and pain with little benefit. Better data support the less invasive approach.1 If the nail base is dislocated, however, as is often the case when a crush injury involves a tuft fracture, I do remove the nail and repair the bed.

DIFFERENT TREPHINATION TECHNIQUES

Figure 2 – An electrocautery unit such as this may be used to drain a subungual hematoma by melting a hole in the nail.

There are a variety of drainage methods. One of the techniques most commonly taught to new practitioners is to employ heat to melt a hole in the nail. A heated paper-clip tip or a portable medical electrocautery unit may be used (Figure 2). 3 Some clinicians feel that trephination accomplished through the use of heat is more painful than other methods. There is also a possibility that the heat will cause the blood to coagulate and thus limit drainage. However, I have not found this to be a problem.

At least 2 medical devices for draining subungual hematomas quickly and painlessly-and without heat-have been described. The first is a medical drill (PathFormer). 4 Although I have no experience with this device, it is reported to be quite effective and painless. The second device, a carbon-dioxide laser, has also been used to drain subungual hematomas without pain. 2 This might be a good choice for a dermatologist or primary care provider who already has one in the office. Despite their advantages, the cost of both these devices would likely be an obstacle.

HOW TO DRAIN A SUBUNGUAL HEMATOMA WITH AN 18-GAUGE NEEDLE
My preferred method for draining a subungual hematoma is to use an 18-gauge needle as a twist drill this method employs easily accessed equipment and is practically painless. After applying a topical antiseptic, such as povidone-iodine solution, position a hypodermic needle with the tip in the center of the hematoma and hold the hub between the index finger and thumb (Figure 3). Then roll the needle back and forth so that it slowly bores into the nail plate. Within less than a minute, blood should start to emerge from the hole. At this point the tip of the needle is within the hematoma and has not touched the sensitive nail bed (Figure 4). Continue drilling until the hole has widened sufficiently or until the first sign of discomfort from the patient (which will be a signal that the needle has touched the nail bed). Up to this point, the procedure is typically painless. The experience of draining 3 or 4 hematomas in this manner provides a good feel for that point just before the nail bed is reached. Stopping there makes for a completely painless procedure.

Figure 3 – To drain a subungual hematoma with an 18-gauge needle, hold the hub between your thumb and index fingers and position the tip in the center of the hematoma. Then roll the needle back and forth so that it slowly bores into the nail plate.

Figure 4 – When draining a subungual hematoma with a needle, try to stop just before the needle reaches the sensitive nail bed.

AFTER-CARE AND FOLLOW-UP

Figure 5 –The longitudinal ridging evident on this patient's fingernail is the result of a prior subungual hematoma with fracture.

After the hematoma has been drained, use a 4 3 4-in gauze pad to wick up as much blood as possible. One source has suggested using a capillary tube for this purpose. 2

Finally, apply a sterile dressing. Consider sending the patient home with a sterile needle to use should dried blood block the hole. Antibiotics may be prescribed but are generally unnecessary even if there is an accompanying fracture.

Be sure to warn the patient that the nail may be lost, although eventually a new one will grow to replace it. Even more important is to warn the patient that there is a 2% to 15% risk of permanent nail deformity as a result of the initial injury to the nail bed (Figure 5). 1

Simple subungual hematomas rarely require further care. Complex hematomas that are sutured or involve fractures of the distal tuft will require monitoring of wound healing, suture removal, and/or referral to an orthopedist.


A brief history of epilepsy and its therapy in the Western Hemisphere

The history of epilepsy and its treatment in the western world dates back at least 4 millennia to the ancient civilization of the middle east. Past and present treatments have been empirical, usually reflecting the prevailing views of epilepsy, be they medical, theological or superstitious. Ancient physicians relied on clinical observation to distinguish between epileptic syndromes and infer their cause. Early pathophysiological theories of epilepsy correctly identified the brain as the site of the problem, but emphasized incorrect causes such as an excess of phlegm in the brain. Treatments consisted of prescribed diets or living conditions, occasional surgery such as bloodletting or skull trephination and medicinal herbs. These treatments, often ineffective, had the intellectual advantage of being based on pathophysiological principles, unlike current, more empirical, therapies. The unfortunate but widely held view of epilepsy as being due to occult or evil influences gained adherents even in the medical world during ancient times, and the later acceptance of Christianity allowed theological interpretations of seizures as well. Magical or religious treatments were more frequently prescribed as a result, practices which persist to this day. In the Renaissance an attempt was made to view epilepsy as a manifestation of physical illness rather than a moral or occult affliction, but it was during the Enlightenment that epilepsy was viewed along more modern lines, helped by advances in anatomy and pathology and the development of chemistry, pharmacy and physiology. The idea that focal irritation may cause seizures came about from clinical and experimental work, and was supported by the successful control of seizures by the (sedative) bromides and barbiturates in the late 19th century. The introduction of phenytoin showed that non-sedative drugs could be effective in controlling seizures as well, and the development of in vivo seizure models widened the scope of pharmaceutical agents tested for their efficacy against epilepsy. Increasing knowledge of the cellular mechanisms of epilepsy will, hopefully, allow the development and introduction of drugs with increasing specificity against seizure activity and the development of epilepsy.


The 19th and 20th Century Treatments

During the late 19th and early 20th centuries, treatments for severe depression generally weren't enough to help patients.

Desperate for relief, many people turned to lobotomies, which are surgeries to destroy the brain's prefrontal lobe. Though reputed to have a "calming" effect, lobotomies often caused personality changes, a loss of decision-making ability, poor judgment, and sometimes even death.

Electroconvulsive therapy (ECT), which is an electrical shock applied to the scalp in order to induce a seizure, was also sometimes used for patients with depression.

In the 1950s and 60s, doctors divided depression into subtypes of "endogenous" and "neurotic" or "reactive." Endogenous depression was thought to result from genetics or some other physical defect, while the neurotic or reactive type of depression was believed to be the result of some outside problems such as a death or loss of a job.

The 1950s were an important decade in the treatment of depression thanks to the fact that doctors noticed that a tuberculosis medication called isoniazid seemed to be helpful in treating depression in some people.   Where depression treatment had previously been focused only on psychotherapy, drug therapies now started to be developed and added to the mix.

In addition, new schools of thought, such as cognitive behavioral and family systems theory emerged as alternatives to psychodynamic theory in depression treatment.

One of the first drugs to emerge for the treatment of depression was known as Tofranil (imipramine), which was then followed by a number of other medications categorized as tricyclic antidepressants (TCAs). Such drugs provided relief for many people with depression but were often accompanied by serious side effects that included weight gain, tiredness, and the potential for overdose.

Other antidepressants later emerged, including Prozac (fluoxetine) in 1987, Zoloft (sertraline) in 1991, and Paxil (paroxetine) in 1992. These medications, known as selective serotonin reuptake inhibitors (SSRIs), target serotonin levels in the brain and usually have fewer side effects than their predecessors.

Newer antidepressant drugs that have emerged in the past couple of decades include atypical antidepressants such as Wellbutrin (bupropion), Trintellix (vortioxetine), and serotonin-norepinephrine reuptake inhibitors (SNRIs).


Trephination Timeline - History

If you read the medical news lately you may have seen a headline title Skeleton May Show Ancient Brain Surgery. This article was about an 1800 year old skeleton found in Veria, Greece. The skeleton was of a woman of about 25 years of age that suffered severe head trauma and underwent cranial surgery, unfortunately evidence shows that she did not survive.

There is an interesting history of skull surgery, known as trepanation, which comes from the Greek word trypanon, meaning auger or borer. Cranial trepanation has caught the interest of surgeons and archeologist since the 1860's, when it was first realized that ancient humans had scraped or cut holes in the skulls of living persons in France and Peru.

Trepanation is serious enough surgical procedure in this day and age, could this procedure have taken place as a routine operation as long ago as 2000 BC? We do have a historical record of thousands of skulls with evidence of this surgery. Sometimes historical records suggest a reality that we find hard to accept.

Maybe the romantic in us wants to believe that our ancestors could accomplish this but logic tells us that they didn’t have the technology or medical understanding to perform this surgery. They must have done it on dying or dead patients, that would be the logical answer. Unfortunately historical evidence exists that proves beyond any doubt that patients not only were alive when they had cranial surgery but survived in most cases, and many endured several of these operations over a lifetime.

In studies of healing patterns after primitive trepanations some assumptions can be made:

If there is no sign of biological activity around the surgical site, then death was almost immediate.

If there is a discrete ring of superficial osteoporosis around the wound then it is likely that the patient has lived 1 to 4 weeks postoperatively.

When the edge of the wound reaches an equilibrium and calcium is deposited where new bone forms radial striations, and eventually the edge consolidates the patient has survived several months postoperatively. (Marino p946) Credit: www.musees-haute-normandie.fr

Why would primitive cultures of France, nearly 4000 years ago, practice trepanation? The suggested reasons for this surgery are numerous but not substantiated. Researchers over the last century and a half have speculated that cranial surgery was done in cases of trauma from battle or accident, cranial infections, headaches, mental disease, and religious rituals. (Marino p944) Rituals involving the opening of the skull were believed to facilitate the exit of evil spirits that caused epilepsy. This seems plausible because in almost every age and culture epileptic seizures were believed to be the work of evil spirits. (Finger p915)

Some of these reasons for trepanation, though logical do not hold up under scrutiny. There is no gender difference in the distribution of the older French skulls, if combat had caused injury we would expect more males to be candidates for this procedure. Also if war were a major cause of head injury there would be more surgeries to the left side of the skull, if they were struck by a right-handed adversary.(Clower p1421)

In the study of trepanation over the last one hundred and fifty years two men stand out Dr. Paul Broca (1824-1880) and Dr.Victor Horsley (1857-1916). Dr. Broca was not the first person to find, examine or collect trepanned skull but he was the first person to understand and explain what he saw. Horsley's interest amounted to little more than a passing fancy, but his theories regarding the origins of the practice of trepanation contributed significantly to our understanding. Unfortunately neither Broca nor Horsley’s theories have withstood the test of time.

The theories of Broca and Horsley remain widely cited in the anthropological and archeological literature. (Finger p911) Scientists still compare and contrast Horsley's empirical-surgical theory of trepanation with the more anthropological-medical approach chosen by Broca, who attempted to connect seizure disorders in children to supernatural events. (Finger p916) "For Broca, the major stumbling block proved to be the lack of solid evidence to prove that young people were routinely chosen for the operation." Without the age factor, his theory is more plausible.

For Horsley, the idea that the openings were above the motor cortex proved problematic. Without this feature, his notion of traumatic injury also seems more reasonable. (Finger p916) It is interesting that Horsley was one of the first researchers to conclude that the "motor cortex" is smaller than he originally thought and probably did not extend back to include the parietal lobe. Horsley's later motor cortex mapping research helped to undermine the very trepanation theory he had proposed.(Finger p915)

Horsley's general thesis, that blows to the skull with or without epilepsy might have been the initial reason trepanation was performed, is more likely. The best empirical support for the skull fracture theory comes not from French anthropological sites, but from skulls found in Peru that he did not examine. (Finger p915) Peruvian skulls have a male-to-female ratio that is approximately 4:1, about half of the skulls have facial area damage, and they have significantly more trepanations on left side. This suggest that Peruvian physicians saw many more head injuries caused by combat among right handed warriors.(Finger p916) Notably missing from the 20th-century scientific literature is evidence that trepanation was performed for religious, magical, or cultural reasons.

Why did these patients survive cranial surgery? In the documented cases of cranial surgery recorded by French anthropologist, that took place over 4,000 years, I have not read of a solid defendable hypothesis. Of the cases documented from Peru until 500 years ago I have some ideas. Survival of surgery is a quality-of-life issue. The citizens of pre-Columbian Peru had a substantially higher quality-of-life than their counterparts in Medieval and Renaissance Europe.

Examination of Peruvian skulls, by today’s physicians, reveals that these cranial surgeries rarely became infected, and most survived. Even more impressive are the skulls exhibiting successful cranio-plasties (plates inserted into the trephination holes) made of silver and gold, which were placed with such skill that the bone healed around them. (Marino p942 this reference has pictures of sculls with gold cranio-plasties that is well worth the trip to a medical library to see) In contrast, during the 18th century, trephination of the cranium in Europe reached a nearly 100% fatality rate.(Marino p945) Comparing the two cultures may give a clue to why the Peruvian patient’s quality-of-life was better and therefor he/she was more likely to survive.

If you are reading this from a North American point-of-view you probably don’t have a preconceived view of life in South America one thousand years ago, this is a good situation. To better understand the relative timelines and pre-Columbian empires a short review is appropriate so as not to confuse the different cultures. Reviewing the map from north to south the Aztecs settled in what is now central Mexico on small islands in Lake Texcoco where they founded the city of Tenochtitlan (circa 1300 ad) that is now Mexico City. They created a cultural and political empire during the 15th century. Looking farther south the Maya controlled southern Mexico from about 50 BC until the Spanish conquest in the 16th century. The Maya empire reached its cultural and political zenith about 550-900 AD. They controlled the area of southern Mexico and Honduras

The Inca empire, which we are interest in, was by far the largest pre-Columbian state, extending from Peru to Chile including western and central South America. This area was developed by the Chavin-Sechin (900 to 200 BC), the Huari-Tiahuanaco (750 BC to AD 1000), and the Moche-Chimfi cultures (200 BC to AD 1400).(Marino p941) During each of these periods the population reached higher levels of culture under paternal monarchs and each of these cultures were based on agricultural socialism. (Marino p942) Historically the Incas came late on the scene. The expansion of the Inca empire was achieved in some part by military conquests. Not all groups were brought into the realm by direct military action, many joined in alliances with the Incas as the result of peaceful overtures from the expanding state. Others joined out of fear that military intervention would result if an invitation to peaceful alliance were rejected. During this time the population detribalized and culture soared. (Marino p942) Quality of life was improving because of "wise and benevolent rulers."

Before Francisco Pizarro’s conquest of the Inca’s, their empire was equivalent in area to France, Belgium, Holland, Italy, and Switzerland combined, measuring approximately 980,000 km2. (Marino p941) At its height the Inca empire had an estimated 12 million people in much of what is now Peru and Ecuador and large parts of Chile, Bolivia, and Argentina. At the beginning of the Renaissance (circa 1500 AD) there were about 73 million people living in Europe. (Manchester p47)

It may be harder for you to understand Europe of 1000 to 1500 AD, you have to abandon your High School and Hollywood version of Medieval Europe and dig deep to develop a realistic world view. With the fall of the Roman Empire social structure and public works infrastructure collapsed as barbarian hordes overran Europe. As Europe emerged from the Dark Ages, life was not good even in the best of times for the average person.

European political institutions evolved over the centuries. Medievalism was born in the decaying ruins after the barbarian tribes had overwhelmed the Roman Empire. A new aristocracy of nomadic tribal leaders eventually became the ruling nobles of Europe. These militant lords, enriched by plunder and conquest were not "paternal" leaders.

Cities in Europe and Peru are not related in structure or function. In Europe people lived in walled towns for protection. In Peru the detribalized population was united, cities were cultural and religious centers, people lived in surrounding countryside. The wall around a town in Europe was its first line of defense. Therefore the land within was very valuable, and not an inch of could be wasted. The twisting streets were extremely narrow and were not paved Doors opened directly onto streets which were filthy, urine and solid waste were simply dumped out windows. Sunlight rarely reached the ground level, because the second story of each building always extended out over the first story, and the third story extended over the second, nearly meeting the building on the other side of the street. (Manchester p48)

The walled town was not typical of Europe though. Between 80 and 90 percent of the population lived in villages of fewer than a hundred people. These villages were fifteen or twenty miles apart surrounded by endless forest. (Manchester p53) Unless a person was a noble or priest his/her mental geography limited their world to what they knew. If war took a man even a short distance form his nameless village, the chances of his returning were slight, and finding his way back alone was virtually impossible. "Each hamlet was inbred, isolated, unaware of the world beyond the most familiar local landmark."(Manchester p21)

Cities in Peru did not have the cramped population and unsanitary conditions of Europe. Nor did they have the pollution-producing industries emerging in Europe. These people were engaged the cooperative efforts of agriculture, mining, herding, and fishing. They had a rural lifestyle in small villages over the high plateaus and coastal lowlands. Their cities appeared to be cultural centers where people would travel to, they lived in the outlying country side. Because even the remote mountain villages were tied to the rest of the empire with an intricate road system of approximately 20,000 km for rapid messenger service to communicate across the empire the pre-Columbian people had a much broader mental geography.

In Europe at the end of the Dark Ages agriculture and transportation of foodstuffs were inefficient, the population was never fed adequately from year to year. Famines, Black Death and recurring pandemics repeatedly thinned the population of Europe at least once a generation after 1347(Manchester p5). The Peruvians demonstrated knowledge of the contagion mechanisms of typhus (which would be understood in Europe only at the beginning of the twentieth century). They fought it with isolation measures and recognized the role of body lice in its spread. It is also evident that they understood the means by which malaria, endemic on the Peruvian coast, was spread. Houses were routinely built in the high and sandy part of the valleys, outside of the access radius of the mosquito vectors. (Marino p942 ) Tuberculosis, whose cause and spread depends essentially on poor social conditions was not endemic in their culture, Europe was not so lucky.

There are numerous reports in historical chronicles that refer to the pharmacological wealth of South America that was used by the pre-Columbian cultures. Many of these drugs could help the patient survive trepadation. The most obvious would be drugs that could be used for anesthesia. This could have been accomplished with drugs known to be used by the Incas such as, coca, datura, ili yuca. It is know that alcoholic beverages such as chicha, made of fermented corn, was given to patients, causing a relaxed or sedated state. The next most obvious drug choice would seem to be an antiseptics to prevent infection, such as, Peru balsam, tannin, saponins, and cinnamic acid. These were available and used for embalming the dead, they may have been used in surgery. It would be prudent to have a good drug to control bleeding, this could have been done with herbal extracts of Indean ratania root, pumachuca shrub, and preparations high in tannic acid. (Marino p947) Beyond surgery a drug used then as well as today to control Malaria is quinine. It is well known that they used the bark of the cincona tree as a source of quinine to treat malaria. (Marino p943) The tragedy of the pre-Columbian historical period is the lack of written records (Marino p942) this would have provided remarkable insights into early surgeons and their medical practices.

Clower, William & Finger, Stanley, Discovering Trepanation: the contribution of Paul Broca, Neurosurgery Vol. 49 No. 6, p.1417-1425, December 2001

Finger, stanley & Clower, William T., Victor Horsley on "Trephining in Pre-historic Times," Neurosurgery, vol. 48, Number 4, p. 911- 918, April 2001

Manchester, William, A World Lit Only By Fire, Litle, Brown and Company, Boston, 1993.

Marino, Raul & Gonzales-Portillo, Marco, Preconquest Peruvian Neurosurgeons: A study of Inca and Pre-Columbian Trephination and the Art of Medicine in Ancient Peru, Neurology, vol. 47, No 4, p. 940 – 955, October 2000,


Trephination Timeline - History

A short history of brain research

Despite the fact that the understanding of the human brain is still in its infancy, it appears that brain surgery is one of the oldest of the practiced medical arts. Evidence of “trepanation” can be found in archaeological remains dating back to the Neolithic period – around 10,000 BC. Trepanation (also known as trepanning, trephination, trephining or burr hole) is surgery in which a hole is drilled into the skull to expose the brain.

Cave paintings from the late Stone Age suggest that people believed the practice would cure epileptic seizures, migraines and mental disorders, perhaps in the belief that the operation would allow evil spirits to escape. There is also some evidence that such surgery was undertaken to prevent blood clots forming and to remove bone fragments following a head injury.

The following list details some of the key events and discoveries that have helped shaped our understanding of the brain today:

Hippocrates, the father of modern medical ethics, wrote many texts on brain surgery. Born on the Aegean Island of Cos in 470 BC, Hippocrates was quite familiar with the clinical signs of head injuries and he was the first known person to speculate that the two halves of the brain were capable of independent processing, which he termed "mental duality".

The study of the brain suffered a setback in the seventeenth century when René Descartes, the French philosopher and founding father of modern medicine, was forced to do a deal with the Pope in order to get the bodies he needed for dissection. The Pope agreed on the understanding that Descartes would not have anything to do with the soul, mind or emotions, as those were seen as the realm of the church. Unfortunately, this agreement set the tone for Western science for the next two centuries, dividing the human experience into two distinct and separate spheres that could never overlap. Even today many people are sceptical of illnesses that are defined as being psychosomatic (illnesses where the symptoms are caused by mental processes of the sufferer).

Franz Joseph Gall, a German anatomist, founded the science of phrenology, which holds that a person’s character can be determined by reading the configuration of bumps on the skull.

As peculiar as this theory may seem, it was widely accepted at the time. At the height of the phrenology craze, some people suggested that politicians should be chosen based on the shape of their skulls while others claimed to be able to detect signs of latent delinquency in children based on the bumps on their heads.

A North American railway worker by the name of Phineas Gage suffered damage to the frontal lobe of his brain when it was pierced by a metal rod that shot through his skull during an explosion.

Although Gage survived the accident, he experienced profound mood and behaviour changes. A quiet, industrious worker before the accident, Gage became a surly, aggressive man who could not hold down a job.

This famous case, now found in countless neuroscience textbooks, was an important milestone in the study of the brain’s anatomy because it suggested that important parts of the personality reside in the frontal lobe. These findings indirectly lead to the development of the procedure called lobotomy, which was based on the theory that the removal of portions of the frontal lobe could cure mental derangement and depression.

Charles Darwin published his book “The Expression of the Emotions in Man and Animals” in which he traces the origins of emotional responses and facial expressions in humans and animals, making note of the striking similarities between species. Later, in an unpublished notebook, Darwin proposes the theory that blushing is a clear indication of consciousness. He notes that of all the animals, only humans blush and claims that this is because they are the only ones capable of self-consciously imagining what others are thinking of them.

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