7. Medicine

7.1 Acupuncture

Acupuncture is an alternative medicine methodology originating in ancient China that treats patients by manipulating thin, solid needles that have been inserted into acupuncture points in the skin. According to Traditional Chinese medicine, stimulating these points can correct imbalances in the flow of qi through channels known as meridians. Scientific research has not found any histological or physiological correlates for qi, meridians and acupuncture points, and some contemporary practitioners needle the body without using the traditional theoretical framework.

The precise start date of acupuncture’s use in China and how it evolved from early times are uncertain. One explanation is that some soldiers wounded in battle by arrows were believed to have been cured of chronic afflictions that were otherwise untreated, and there are variations on this idea. Sharpened stones known as Bian shi have been found in China, suggesting the practice may date to the Neolithic or possibly even earlier in the Stone Age. Hieroglyphs and pictographs have been found dating from the Shang Dynasty (1600–1100 BCE)

The earliest written record of acupuncture is found in the Huangdi Neijing (translated as The Yellow Emperor’s Inner Canon), dated approximately 200 BCE. It does not distinguish between acupuncture and moxibustion and gives the same indication for both treatments. The Mawangdui texts, which also date from the 2nd century BCE (though antedating both the Shiji and Huangdi Neijing), mention the use of pointed stones to open abscesses, and moxibustion, but not acupuncture. However, by the 2nd century BCE, acupuncture replaced moxibustion as the primary treatment of systemic conditions.  — Wikipedia

7.2 Trepanation

Primitive cranial trephining, the surgical opening of the skull performed with primitive tools and techniques, is one of the most fascinating surgical practices in human history. It probably started in the Neolithic at least 7000 years ago.

In Mexico, China, and Europe, archaeologists continue to find ancient human skulls with holes carefully drilled into them by a process called trepanation. Recent findings by Prof. Yuri Moskalenko, head of the Comparative Physiology of Circulation Laboratory in St. Petersburg, working in collaboration with Amanda Feilding, have shown that these holes may not have been the products of religious rituals as is commonly thought but, in fact, medical procedures.

Images Source: http://www.beckleyfoundation.org/2010/09/14/trepanation/
Related Link: http://scienceblogs.com/neurophilosophy/2008/01/24/an-illustrated-history-of-trep/

 Trepanation in ancient times

Trepanation has been practiced since thousands of years. It is possibly one of the earliest forms of surgical intervention on the head of which we have any authentic record and its practice is widely spread in space and time. Trepanation of the human skull is the removal of a piece of calvarium with out damage to the underlying blood-vessels, meninges and brain. In some parts of the world it is still practised in its early form by native medicine men.

Trepanation as performed by man in prehistoric and early historic times shows an astonishing degree of technical skill. And certainly the number of survivals of this operation testify to the competence of the early surgeons. For a long time medical science doubted the existence of healed prehistoric trepanations, since eighteenth and nineteenth century surgeons of the pre-antiseptic era rejected this procedure owing to the almost one hundred per cent mortality (Schröder, 1957).

However, as evidence of trepanation appeared in the South Sea Islands and in North Africa, these doubts were gradually removed. According to Rytel (1962) the first reference to trepanation dates from 1849 (Atlas de Morton, Cranea Americana). Bartucz (1964) claims that Dr. E. Kovaces of Hungary was the first to describe in 1853 an actual trepanation found at Vereb.

Image from Prehistoric Trepanation in the Cuzco Region of Peru:
A View Into an Ancient Andean Practice

Another of the earliest to be recognized as such was noted by E.G. Squier on a skull from Cuzco during his tour of 1863-65 through Peru (Stewart, 1958). He consulted Paul Broca, the noted French physical anthropologist of the time whose interest led to the recognition of Neolithic trepanations in France. And thus gradually more skulls came to light showing this early surgical interference. The realization that this practice has survived until the present day has greatly increased our knowledge of this operation. The most important contributions on this subject are the study by Guiard (1930), the survey of European trepanations by Piggott (1940) and the more recent general review by Stewart (1958). This particular account will deal with the prehistoric and early historic aspects of trepanation and note certain of its mediaeval features.

Trepanation is one of the oldest surgical procedure being practiced by humans. Skulls with holes bored in them have been found by archaeologists from as far back as 3000 BC. The oldest of these occur in the Danube Basin. Hundreds of skulls with traces of trepanation are known all over Europe — in Denmark, Sweden, Poland, France, Spain, and the British Isles. A Swedish physician, Professor Folke Henschen, reports that Soviet archaeologists, along the Dnieper River in the 1960s, found crania with oval left-side trepanation holes of 16-18 mm (0.6-0.7 in) diameter. These were thought to date from the Mesolithic, or Middle Stone Age.

If so, we must raise the age of this practice to some 12,000 years. Trepanation in Sweden, 1761 The greatest Swedish surgeon of the eighteenth century was Olaf af Acrel, chief physician at the Seraphim Hospital. He described the purpose of trepanation as follows: “Trepanation of the skull is intended to release what has forced its way out of the bloodvessels, or to lift up and remove what, having been forced in, causes meningitis (irritation of the brain membrane) — or to both of these ends together,” The amazing thing about such crania is that evidence exists for the patients having survived the operation. Holes in bone are healed by new formation of bone tissue, and the sharp edges of bored or hacked holes become rounded off by so-called callus tissue.

This proof of healing is more the rule than the exception. In one study of skull material from the Yantyo tribe in Peru, a researcher found callus tissue in 250 out of 400 crania. Verifications in Europe are fewer, but even here it has been confirmed that most of the patients survived. Further proof of this–and reason for believing in the method–is the discovery of skulls which were trepanned more than once. The record seems to be held by an Inca at Cuzco with seven bore-holes, at least some of which were made on separate occasions. In England, during the late Middle Ages, trepanners used special saws of the kind shown here — according to a 15th-century manuscript based on the ancient Greek writings of Hippocrates, who had recommended trepanation for light head wounds. Archaeologists have found that such saws, and other fine tools for wound treatment, were used as early as 300 BC by Celtic warrior-surgeons in Germany and Hungary. Nowadays, trepanation is performed to relieve acute pressure on the brain. The usual cause is internal bleeding after a blow on the head. In this case, the operation has a rational justification. The Stone Age finds, and customs of primitive peoples, indicate that our ancestors also used trepanation for such injuries. However, the great majority of skulls show that the operation was done on an intact cranium with no previous signs of violence. Here it must have been intended to relieve an apparent excess of pressure, which is easy to imagine in the event of, for example, migraine or sudden headaches of other kinds. Magic has obviously played a role as well. The belief that an evil spirit lives in the head and must be let out is very old.

But the possibility of repeatedly letting out such spirits has, so far as we know, never existed. Werner von Heidenstam s fine description of a Stone Age leader in The Swedes and their Chieftains (1908) must, sadly, be ascribed to fantasy: “On their bare heads, a small lid was attached over a round hole, which had been bored right in the crown-bone. Such a hole was held in great reverence, and belonged only to the most eminent. Through it, evil vapors were able to escape, and the sunlight could enter to absorb their spirits after death.” There were at least four different methods of trepanning. The crudest was to simply scrape a hole in the skull-cap, with patience and a piece of flint or a polished mussel-shell. A second method was to make a circular cut in the bone with a flint or obsidian knife, and to deepen it until the hard brain-membrane was reached. Alternatively, and doubtless worse for the patient, a hammer and chisel were used to cut four grooves in a cross shape, then lift out the square piece at their center.

Most elegant, though, was the procedure which gave this operation its name. With a drill-bore, called trypanon in Greek, a wreath of tiny holes was made. These could be united easily with a chisel or knife. Such an operation took little time even with primitive tools. An adept French surgeon, J. Lucas-Championnière (1843-1913), experimenting with instruments of flint, needed only 35 minutes to complete the operation. During the nineteenth century, a scientist travelling in the South Pacific saw a medicine-man do it in half an hour. His patient woke up after several days of unconsciousness and regained perfect health! The medicine-men or shamans who dealt with trepanations stood high in society. They could also earn a fortune from the practice. Not only may we assume that they were well rewarded by every cured patient and his family. In addition, they conducted a lively trade with the pieces of bone which they extracted from people s skulls. Such amulets were greatly prized for magical protection from illness and accidents. Researchers have even wondered whether the demand for skull-bone contributed to the prescription of trepanations. There are actual records of amulets measuring about 8-9 cm (3.1-3.5 in). No medical reason can exist for making such enormous holes, and it is very unlikely that the patients survived the serious risk of infection with meningitis.

Source: http://www.trepanationguide.com/trepanation_in_ancient_times.htm

Related Links:

• An illustrated history of trepanation
• http://www.trepanationguide.com/trepanation_in_ancient_times.htm
• http://home.southernct.edu/~andrushkov1/Andrushko_and_Verano_2008.pdf

• TREPHINATION, AN ANCIENT SURGERY

7.3 Anesthetics

Anesthesia, or anaesthesia, traditionally meant the condition of having sensation (including the feeling of pain) blocked or temporarily taken away. It is a pharmacologically induced and reversible state of amnesia, analgesia, loss of responsiveness, loss of skeletal muscle reflexes or decreased stress response, or all simultaneously. These effects can be obtained from a single drug which alone provides the correct combination of effects, or occasionally a combination of drugs (such as hypnotics, sedatives, paralytics and analgesics) to achieve very specific combinations of results. This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise experience. An alternative definition is a “reversible lack of awareness,” including a total lack of awareness (e.g. a general anesthetic) or a lack of awareness of a part of the body such as a spinal anesthetic. The pre-existing word anesthesia was suggested by Oliver Wendell Holmes, Sr. in 1846 as a word to use to describe this state.

Types of anesthesia include local anesthesia, regional anesthesia, general anesthesia, and dissociative anesthesia. Local anesthesia inhibits sensory perception within a specific location on the body, such as a tooth or the urinary bladder. Regional anesthesia renders a larger area of the body insensate by blocking transmission of nerve impulses between a part of the body and the spinal cord. Two frequently used types of regional anesthesia are spinal anesthesia and epidural anesthesia. General anesthesia refers to inhibition of sensory, motor and sympathetic nerve transmission at the level of the brain, resulting in unconsciousness and lack of sensation. Dissociative anesthesia uses agents that inhibit transmission of nerve impulses between higher centers of the brain (such as the cerebral cortex) and the lower centers, such as those found within the limbic system.

Attempts at producing a state of general anesthesia can be traced throughout recorded history in the writings of the ancient Sumerians, Babylonians, Assyrians, Egyptians, Greeks, Romans, Indians, and Chinese. During the Middle Ages, which correspond roughly to what is sometimes referred to as the Islamic Golden Age, scientists and other scholars made significant advances in science and medicine in the Muslim world and Eastern world, while their European counterparts also made important advances.

Maharshi Sushruta is the father of surgery. 2600 years ago he and health scientists of his time conducted complicated surgeries like caesareans, cataract, artificial limbs, fractures, urinary stones and even plastic surgery.

History

Throughout Europe, Asia, and the Americas a variety of Solanum species containing potent tropane alkaloids were used, such as mandrake, henbane, Datura metel, and Datura inoxia. Ancient Greek and Roman medical texts by Hippocrates, Theophrastus, Aulus Cornelius Celsus, Pedanius Dioscorides, and Pliny the Elder discussed the use of opium and Solanum species. In 13th century Italy, Theodoric Borgognoni used similar mixtures along with opiates to induce unconsciousness, and treatment with the combined alkaloids proved a mainstay of anesthesia until the nineteenth century. In the Americas coca was also an important anesthetic used in trephining operations. Incan shamans chewed coca leaves and performed operations on the skull while spitting into the wounds they had inflicted to anesthetize the site. Alcohol was also used, its vasodilatory properties being unknown. Ancient herbal anesthetics have variously been called soporifics, anodynes, and narcotics, depending on whether the emphasis is on producing unconsciousness or relieving pain.

The use of herbal anesthesia had a crucial drawback compared to modern practice—as lamented by Fallopius, “When soporifics are weak, they are useless, and when strong, they kill.” To overcome this, production was typically standardized as much as feasible, with production occurring from specific locations (such as opium from the fields of Thebes in ancient Egypt). Anesthetics were sometimes administered in the “spongia somnifera”, a sponge into which a large quantity of drug was allowed to dry, from which a saturated solution could be trickled into the nose of the patient. At least in more recent centuries, trade was often highly standardized, with the drying and packing of opium in standard chests, for example. In the 19th century, varying aconitum alkaloids from a variety of species were standardized by testing with guinea pigs. Trumping this method was the discovery of morphine, a purified alkaloid that could be injected by hypodermic needle for a consistent dosage. The enthusiastic reception of morphine led to the foundation of the modern pharmaceutical industry.

The first effective local anesthetic was cocaine. Isolated in 1859, it was first used by Karl Koller, at the suggestion of Sigmund Freud, in eye surgery in 1884. German surgeon August Bier (1861–1949) was the first to use cocaine for intrathecal anesthesia in 1898. Romanian surgeon Nicolae Racoviceanu-Pite?ti (1860–1942) was the first to use opioids for intrathecal analgesia; he presented his experience in Paris in 1901. A number of newer local anesthetic agents, many of them derivatives of cocaine, were synthesized in the 20th century, including eucaine (1900), amylocaine (1904), procaine (1905), and lidocaine (1943).

Early Arab writings mention anesthesia by inhalation. This idea was the basis of the “soporific sponge” (“sleep sponge”), introduced by the Salerno school of medicine in the late twelfth century and by Ugo Borgognoni (1180-1258) in the thirteenth century. The sponge was promoted and described by Ugo’s son and fellow surgeon, Theodoric Borgognoni (1205-1298). In this anesthetic method, a sponge was soaked in a dissolved solution of opium, mandragora, hemlock juice, and other substances. The sponge was then dried and stored; just before surgery the sponge was moistened and then held under the patient’s nose. When all went well, the fumes rendered the patient unconscious.

In 1275, Spanish physician Raymond Lullus, while experimenting with chemicals, made a volatile, flammable liquid he called sweet vitriol. Sweet vitriol, or sweet oil of vitriol, was the first inhalational anesthetic used for surgical anesthesia. It is no longer used often because of its flammability. In the 16th century, a Swiss-born physician commonly known as Paracelsus made chickens breathe sweet vitriol and noted that they not only fell asleep but also felt no pain. Like Lullus before him, he did not experiment on humans. In 1730, German chemist Frobenius gave this liquid its present name, ether, which is Greek for “heavenly.” But 112 more years would pass before ether’s anesthetic powers were fully appreciated.

Meanwhile, in 1772, English scientist Joseph Priestley discovered the gas nitrous oxide. Initially, people thought this gas to be lethal, even in small doses. However, in 1799, British chemist and inventor Humphry Davy decided to find out by experimenting on himself. To his astonishment he found that nitrous oxide made him laugh, so he nicknamed it laughing gas. Davy wrote about the potential anesthetic properties of nitrous oxide, but nobody at that time pursued the matter any further.

The first attempts at general anesthesia were probably herbal remedies administered in prehistory. Alcohol is the oldest known sedative; it was used in ancient Mesopotamia thousands of years ago

Opium

It has long been written that the Sumerians cultivated and harvested the opium poppy (Papaver somniferum) in lower Mesopotamia as early as 3400 BC,[3][4] though this has been disputed.[5] The most ancient testimony concerning the opium poppy found to date was inscribed in cuneiform script on a small white clay tablet at the end of the third millennium BC.

The ancient Egyptians were known to have had some surgical instruments,[12][13] as well as certain crude analgesics and sedatives, including possibly an extract prepared from the mandrake fruit.[14] The use of preparations similar to opium in surgery is recorded in the Ebers Papyrus, an Egyptian medical papyrus written in the Eighteenth dynasty.[10][12][15] However, it is questionable whether opium itself was known in ancient Egypt at that time.[16] The Greek gods Hypnos (Sleep), Nyx (Night), and Thanatos (Death) were often depicted holding poppies.[17]

Prior to the introduction of opium to ancient India and China, these civilizations pioneered the use of cannabis incense and aconitum. c. 400 BC, the Sushruta Samhita (a text from the Indian subcontinent on ayurvedic medicine and surgery) advocates the use of wine with incense of cannabis for anesthesia.[18] By the 8th century AD, Arab traders had brought opium to India[19] and China.[20]

China

Bian Que (c. 300 BC) was a legendary Chinese internist and surgeon who reportedly used general anesthesia for surgical procedures. It is recorded in the Book of Master Han Fei (c. 250 BC), the Records of the Grand Historian (c. 100 BC), and the Book of Master Lie (c. AD 300) that Bian Que gave two men, named “Lu” and “Chao”, a toxic drink which rendered them unconscious for three days, during which time he performed a gastrostomy upon them.

Hua Tuo (Chinese:??? c. AD 145-220) was a Chinese surgeon of the 2nd century AD. According to the Records of Three Kingdoms (c. AD 270) and the Book of the Later Han (c. AD 430), Hua Tuo performed surgery under general anesthesia using a formula he had developed by mixing wine with a mixture of herbal extracts he called mafeisan. Hua Tuo reportedly used mafeisan to perform even major operations such as resection of gangrenous intestines. Before the surgery, he administered an oral anesthetic potion, probably dissolved in wine, in order to induce a state of unconsciousness and partial neuromuscular blockade.

The exact composition of mafeisan, similar to all of Hua Tuo’s clinical knowledge, was lost when he burned his manuscripts, just before his death.[27] The composition of the anesthetic powder was not mentioned in either the Records of Three Kingdoms or the Book of the Later Han. Because Confucian teachings regarded the body as sacred and surgery was considered a form of body mutilation, surgery was strongly discouraged in ancient China. Because of this, despite Hua Tuo’s reported success with general anesthesia, the practice of surgery in ancient China ended with his death.

Anesthesia awareness

Anesthesia awareness — or unintended intra-operative awareness — occurs during general anesthesia, on the operating table, when the patient has not been given enough of the general anesthetic or analgesic to render the patient unconscious during general anesthesia (often when agents used to paralyze the patient have been administered). In brief, it is the post-operative recall of intra-operative events.

Awareness occurs when patients have anesthesia that is inadequate to keep them unconscious during an operation. The incidence of this anesthesia complication is variable and seems to affect 0.2% to 40% of patients according to the surgical setting carried out. This variation reflects the surgical setting as well as the physiological state of the patient. Thus, the incidence of memorization would be 0.2% in general surgery, about 0.4% during caesarean section, between 1 and 2% during cardiac surgery and between 10% and 40% for anesthesia of the traumatized. 

The majority of these do not feel pain although around one third did, be it a sore throat from an endotracheal tube or pain from the incision site. The incidence is halved in the absence of neuro-muscular blockade. In this situation, the patient may feel the pain or pressure of surgery, hear conversation or experience air hunger or difficulty breathing. The patient may be unable to communicate any distress because they have been given a paralytic/muscle relaxant; without this, they can move and the anesthesiologists are alerted and provide more anesthetic drugs to render the patient unconscious again.

If anesthesia awareness does occur, about 42% feel the pain of the operation, 94% experience panic/anxiety (sometimes because they cannot breathe) because they have not been warned that they will be paralysed, and 70% experience lasting symptoms which may be psychological and may be physical or neurological. The quoted incidences are controversial as many cases of “awareness” are open to interpretation. These usually involve feeling severe pain, clear recall of the conversations of the operating room staff or suffocation. Some patients undergo sedation for smaller procedures such as biopsies and colonoscopies and are told they will be asleep, although in fact they are getting a sedation that may allow some level of awareness as opposed to a “general anesthetic”

Source: — Wikipedia

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