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Il tempio di Esculapio sull’isola tiberina - Scripta Manent

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Il Tempio di Esculapio era un antico tempio romano dedicato ad Asclepio, il dio greco della medicina, ed era eretto sull’Isola Tiberina a Roma. Il tempio venne costruito tra gli anni 293 e 290 a.C. era dedicato al Dio greco della medicina, Asclepio. Secondo la leggenda, una pestilenza colpì Roma nel…

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Historisk oversigt over behandling af psykisk sygdom

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Historisk oversigt over behandling af psykisk sygdom

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References to mental illness can be found throughout history. The evolution of mental illness, however, has not been linear or progressive but rather cyclical. Whether a behavior is considered normal or abnormal depends on the context surrounding the behavior and thus changes as a function of a particular time and culture. In the past, uncommon behavior or behavior that deviated from the sociocultural norms and expectations of a specific culture and period has been used as a way to silence or control certain individuals or groups. As a result, a less cultural relativist view of abnormal behavior has focused instead on whether behavior poses a threat to oneself or others or causes so much pain and suffering that it interferes with one's work responsibilities or with one's relationships with family and friends.

Engravings from 1525 showing trephination. It was believed that drilling holes in the skull could cure mental disorders. [Image: Peter Treveris, CC0 Public Domain, https://goo.gl/m25gce]

Throughout history there have been three general theories of the etiology of mental illness: supernatural, somatogenic, and psychogenic. Supernatural theories attribute mental illness to possession by evil or demonic spirits, displeasure of gods, eclipses, planetary gravitation, curses, and sin. Somatogenic theories identify disturbances in physical functioning resulting from either illness, genetic inheritance, or brain damage or imbalance. Psychogenic theories focus on traumatic or stressful experiences, maladaptive learned associations and cognitions, or distorted perceptions. Etiological theories of mental illness determine the care and treatment mentally ill individuals receive. As we will see below, an individual believed to be possessed by the devil will be viewed and treated differently from an individual believed to be suffering from an excess of yellow bile. Their treatments will also differ, from exorcism to blood-letting. The theories, however, remain the same. They coexist as well as recycle over time.

Trephination is an example of the earliest supernatural explanation for mental illness. Examination of prehistoric skulls and cave art from as early as 6500 BC has identified surgical drilling of holes in skulls to treat head injuries and epilepsy as well as to allow evil spirits trapped within the skull to be released ( Restak, 2000). Around 2700 BC, Chinese medicine's concept of complementary positive and negative bodily forces ("yin and yang") attributed mental (and physical) illness to an imbalance between these forces. As such, a harmonious life that allowed for the proper balance of yin and yang and movement of vital air was essential ( Tseng, 1973).

Mesopotamian and Egyptian papyri from 1900 BC describe women suffering from mental illness resulting from a wandering uterus (later named hysteria by the Greeks): The uterus could become dislodged and attached to parts of the body like the liver or chest cavity, preventing their proper functioning or producing varied and sometimes painful symptoms. As a result, the Egyptians, and later the Greeks, also employed a somatogenic treatment of strong smelling substances to guide the uterus back to its proper location (pleasant odors to lure and unpleasant ones to dispel).

Throughout classical antiquity we see a return to supernatural theories of demonic possession or godly displeasure to account for abnormal behavior that was beyond the person's control. Temple attendance with religious healing ceremonies and incantations to the gods were employed to assist in the healing process. Hebrews saw madness as punishment from God, so treatment consisted of confessing sins and repenting. Physicians were also believed to be able to comfort and cure madness, however.

Greek physicians rejected supernatural explanations of mental disorders. It was around 400 BC that Hippocrates (460-370 BC) attempted to separate superstition and religion from medicine by systematizing the belief that a deficiency in or especially an excess of one of the four essential bodily fluids (i.e., humors)-blood, yellow bile, black bile, and phlegm-was responsible for physical and mental illness. For example, someone who was too temperamental suffered from too much blood and thus blood-letting would be the necessary treatment. Hippocrates classified mental illness into one of four categories-epilepsy, mania, melancholia, and brain fever-and like other prominent physicians and philosophers of his time, he did not believe mental illness was shameful or that mentally ill individuals should be held accountable for their behavior. Mentally ill individuals were cared for at home by family members and the state shared no responsibility for their care. Humorism remained a recurrent somatogenic theory up until the 19th century.

Many of Hippocrates' medical theories are no longer practiced today. However, he pioneered medicine as an empirical practice and came up with the "Hippocratic oath," which all doctors must swear to before joining the profession (i.e., the promise to never intentionally harm a patient). [Image: Wellcome Images, https://goo.gl/dX21yj, CC BY 4.0, https://goo.gl/FJIuOM]

While Greek physician Galen (AD 130-201) rejected the notion of a uterus having an animistic soul, he agreed with the notion that an imbalance of the four bodily fluids could cause mental illness. He also opened the door for psychogenic explanations for mental illness, however, by allowing for the experience of psychological stress as a potential cause of abnormality. Galen's psychogenic theories were ignored for centuries, however, as physicians attributed mental illness to physical causes throughout most of the millennium.

By the late Middle Ages, economic and political turmoil threatened the power of the Roman Catholic church. Between the 11th and 15th centuries, supernatural theories of mental disorders again dominated Europe, fueled by natural disasters like plagues and famines that lay people interpreted as brought about by the devil. Superstition, astrology, and alchemy took hold, and common treatments included prayer rites, relic touching, confessions, and atonement. Beginning in the 13th century the mentally ill, especially women, began to be persecuted as witches who were possessed. At the height of the witch hunts during the 15th through 17th centuries, with the Protestant Reformation having plunged Europe into religious strife, two Dominican monks wrote the Malleus Maleficarum (1486) as the ultimate manual to guide witch hunts. Johann Weyer and Reginald Scot tried to convince people in the mid- to late-16th century that accused witches were actually women with mental illnesses and that mental illness was not due to demonic possession but to faulty metabolism and disease, but the Church's Inquisition banned both of their writings. Witch-hunting did not decline until the 17th and 18th centuries, after more than 100,000 presumed witches had been burned at the stake ( Schoeneman, 1977; Zilboorg & Henry, 1941).

Modern treatments of mental illness are most associated with the establishment of hospitals and asylums beginning in the 16th century. Such institutions' mission was to house and confine the mentally ill, the poor, the homeless, the unemployed, and the criminal. War and economic depression produced vast numbers of undesirables and these were separated from society and sent to these institutions. Two of the most well-known institutions, St. Mary of Bethlehem in London, known as Bedlam, and the Hôpital Général of Paris-which included La Salpêtrière, La Pitié, and La Bicêtre-began housing mentally ill patients in the mid-16th and 17th centuries. As confinement laws focused on protecting the public from the mentally ill, governments became responsible for housing and feeding undesirables in exchange for their personal liberty. Most inmates were institutionalized against their will, lived in filth and chained to walls, and were commonly exhibited to the public for a fee. Mental illness was nonetheless viewed somatogenically, so treatments were similar to those for physical illnesses: purges, bleedings, and emetics.

While inhumane by today's standards, the view of insanity at the time likened the mentally ill to animals (i.e., animalism) who did not have the capacity to reason, could not control themselves, were capable of violence without provocation, did not have the same physical sensitivity to pain or temperature, and could live in miserable conditions without complaint. As such, instilling fear was believed to be the best way to restore a disordered mind to reason.

By the 18th century, protests rose over the conditions under which the mentally ill lived, and the 18th and 19th centuries saw the growth of a more humanitarian view of mental illness. In 1785 Italian physician Vincenzo Chiarughi (1759-1820) removed the chains of patients at his St. Boniface hospital in Florence, Italy, and encouraged good hygiene and recreational and occupational training. More well known, French physician Philippe Pinel (1745-1826) and former patient Jean-Baptise Pussin created a " traitement moral" at La Bicêtre and the Salpêtrière in 1793 and 1795 that also included unshackling patients, moving them to well-aired, well-lit rooms, and encouraging purposeful activity and freedom to move about the grounds ( Micale, 1985).

In England, humanitarian reforms rose from religious concerns. William Tuke (1732-1822) urged the Yorkshire Society of (Quaker) Friends to establish the York Retreat in 1796, where patients were guests, not prisoners, and where the standard of care depended on dignity and courtesy as well as the therapeutic and moral value of physical work ( Bell, 1980).

Dorothea Dix worked to change the negative perceptions of people with mental illness and helped create institutions where they could receive compassionate care. [Image: State Archives of North Carolina, https://goo.gl/wRgGsi, no known copyright restrictions]

While America had asylums for the mentally ill-such as the Pennsylvania Hospital in Philadelphia and the Williamsburg Hospital, established in 1756 and 1773-the somatogenic theory of mental illness of the time-promoted especially by the father of America psychiatry, Benjamin Rush (1745-1813)-had led to treatments such as blood-letting, gyrators, and tranquilizer chairs. When Tuke's York Retreat became the model for half of the new private asylums established in the United States, however, psychogenic treatments such as compassionate care and physical labor became the hallmarks of the new American asylums, such as the Friends Asylum in Frankford, Pennsylvania, and the Bloomingdale Asylum in New York City, established in 1817 and 1821 ( Grob, 1994).

Moral treatment had to be abandoned in America in the second half of the 19th century, however, when these asylums became overcrowded and custodial in nature and could no longer provide the space nor attention necessary. When retired school teacher Dorothea Dix discovered the negligence that resulted from such conditions, she advocated for the establishment of state hospitals. Between 1840 and1880, she helped establish over 30 mental institutions in the United States and Canada ( Viney & Zorich, 1982). By the late 19th century, moral treatment had given way to the mental hygiene movement, founded by former patient Clifford Beers with the publication of his 1908 memoir A Mind That Found Itself. Riding on Pasteur's breakthrough germ theory of the 1860s and 1870s and especially on the early 20th century discoveries of vaccines for cholera, syphilis, and typhus, the mental hygiene movement reverted to a somatogenic theory of mental illness.

European psychiatry in the late 18th century and throughout the 19th century, however, struggled between somatogenic and psychogenic explanations of mental illness, particularly hysteria, which caused physical symptoms such as blindness or paralysis with no apparent physiological explanation. Franz Anton Mesmer (1734-1815), influenced by contemporary discoveries in electricity, attributed hysterical symptoms to imbalances in a universal magnetic fluid found in individuals, rather than to a wandering uterus ( Forrest, 1999). James Braid (1795-1860) shifted this belief in mesmerism to one in hypnosis, thereby proposing a psychogenic treatment for the removal of symptoms. At the time, famed Salpetriere Hospital neurologist Jean-Martin Charcot (1825-1893), and Ambroise Auguste Liébault (1823-1904) and Hyppolyte Bernheim (1840-1919) of the Nancy School in France, were engaged in a bitter etiological battle over hysteria, with Charcot maintaining that the hypnotic suggestibility underlying hysteria was a neurological condition while Liébault and Bernheim believed it to be a general trait that varied in the population. Josef Breuer (1842-1925) and Sigmund Freud (1856-1939) would resolve this dispute in favor of a psychogenic explanation for mental illness by treating hysteria through hypnosis, which eventually led to the cathartic method that became the precursor for psychoanalysis during the first half of the 20th century.

Psychoanalysis was the dominant psychogenic treatment for mental illness during the first half of the 20th century, providing the launching pad for the more than 400 different schools of psychotherapy found today (Magnavita, 2006). Most of these schools cluster around broader behavioral, cognitive, cognitive-behavioral, psychodynamic, and client-centered approaches to psychotherapy applied in individual, marital, family, or group formats. Negligible differences have been found among all these approaches, however; their efficacy in treating mental illness is due to factors shared among all of the approaches (not particular elements specific to each approach): the therapist-patient alliance, the therapist's allegiance to the therapy, therapist competence, and placebo effects ( Luborsky et al., 2002; Messer & Wampold, 2002).

In contrast, the leading somatogenic treatment for mental illness can be found in the establishment of the first psychotropic medications in the mid-20th century. Restraints, electro-convulsive shock therapy, and lobotomies continued to be employed in American state institutions until the 1970s, but they quickly made way for a burgeoning pharmaceutical industry that has viewed and treated mental illness as a chemical imbalance in the brain.

Both etiological theories coexist today in what the psychological discipline holds as the biopsychosocial model of explaining human behavior. While individuals may be born with a genetic predisposition for a certain psychological disorder, certain psychological stressors need to be present for them to develop the disorder. Sociocultural factors such as sociopolitical or economic unrest, poor living conditions, or problematic interpersonal relationships are also viewed as contributing factors. However much we want to believe that we are above the treatments described above, or that the present is always the most enlightened time, let us not forget that our thinking today continues to reflect the same underlying somatogenic and psychogenic theories of mental illness discussed throughout this cursory 9,000-year history.

Up until the 1970's, homosexuality was included in the DSM as a psychological disorder. Thankfully, society and clinical understanding changed to recognize it didn't belong. [Image: Rene Walter, https://goo.gl/CcJAA1, CC BY-NC-SA 2.0, https://goo.gl/Toc0ZF]

Progress in the treatment of mental illness necessarily implies improvements in the diagnosis of mental illness. A standardized diagnostic classification system with agreed-upon definitions of psychological disorders creates a shared language among mental-health providers and aids in clinical research. While diagnoses were recognized as far back as the Greeks, it was not until 1883 that German psychiatrist Emil Kräpelin (1856-1926) published a comprehensive system of psychological disorders that centered around a pattern of symptoms (i.e., syndrome) suggestive of an underlying physiological cause. Other clinicians also suggested popular classification systems but the need for a single, shared system paved the way for the American Psychiatric Association's 1952 publication of the first Diagnostic and Statistical Manual (DSM).

The DSM has undergone various revisions (in 1968, 1980, 1987, 1994, 2000, 2013), and it is the 1980 DSM-III version that began a multiaxial classification system that took into account the entire individual rather than just the specific problem behavior. Axes I and II contain the clinical diagnoses, including intellectual disability and personality disorders. Axes III and IV list any relevant medical conditions or psychosocial or environmental stressors, respectively. Axis V provides a global assessment of the individual's level of functioning. The most recent version -- the DSM-5-- has combined the first three axes and removed the last two. These revisions reflect an attempt to help clinicians streamline diagnosis and work better with other diagnostic systems such as health diagnoses outlined by the World Health Organization.

While the DSM has provided a necessary shared language for clinicians, aided in clinical research, and allowed clinicians to be reimbursed by insurance companies for their services, it is not without criticism. The DSM is based on clinical and research findings from Western culture, primarily the United States. It is also a medicalized categorical classification system that assumes disordered behavior does not differ in degree but in kind, as opposed to a dimensional classification system that would plot disordered behavior along a continuum. Finally, the number of diagnosable disorders has tripled since it was first published in 1952, so that almost half of Americans will have a diagnosable disorder in their lifetime, contributing to the continued concern of labeling and stigmatizing mentally ill individuals. These concerns appear to be relevant even in the DSM-5 version that came out in May of 2013.

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This module is divided into three parts. The first is a brief introduction to various criteria we use to define or distinguish between normality and abnormality. The second, largest part is a history of mental illness from the Stone Age to the 20th century, with a special emphasis on the recurrence of three causal explanations for mental illness; supernatural, somatogenic, and psychogenic factors.

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Filmatisering af Noah Gordons roman The Physician om en ung engelsk mands møde med Avicenna (Ibn Sina) i Persien

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Da befolkningen led under pesten, blev udsendinge sendt af sted, for at de skulle overføre Æskulaps statue fra Epidauros til Rom, og de hjembragte (deportaverunt) en slange, som var gået ombord (contulerat) på deres skib, og det står fast (constabat), at i denne (in quo) var selve guden til stede, og da denne var ankommet til Tiberøen, blev et tempel for Æskulap anlagt på samme sted (eodem loco).

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Roman Medical History: History of Neurosurgery

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Henrik Harpestreng - Hvid benediktinertidsel og Mynte

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I 1834 kunne Bibliotek for Læger berette om "en betydelig Hoved-Beskadigelse heldigen behandlet paa Almindelig Hospital ved Trepanation".

Trepanation hører sammen med omskæring til verdens ældste kirurgiske indgreb. Ved trepanation fjernes et stykke af hjerneskallen, eller der bores et hul. Den tidligste beskrivelse af indgrebet skyldes Hippokrates - lægekunstens fader - omkring 400 år f.v.t. I et skrift, som med stor sikkerhed menes at stamme fra hans egen hånd, klassificerede han forskellige typer kranietraumer og definerede, hvilke af dem der indikerede trepanation

Halvdelen overlevede

Ganske vist blev der trepaneret i Grækenland, længe før Hippokrates levede (ca. 460 - 370 f.v.t.), men på hans tid var operationen "gået af mode" i hjemlandet. Han kan derfor have lært indgrebet under et ophold i Marseilles, hvor gallerne havde trepaneret siden stenalderen.

Hippokrates anbefaler åbning af kraniet i de tilfælde, hvor der pga. kraniebrud skal fjernes knoglesplinter, som er trængt ind i kraniet og presser på hjernen.

Arkæologer har fundet flere end 1.500 trepanerede kranier på alle kontinenter. De ældste kendte fund stammer fra omkring 8.000 f.v.t. Da arkæologer i 1958 udgravede ruinerne af Jeriko i Jordan-dalen, fandt de et 4.000 år gammelt kranie med fire huller efter trepanation, hvoraf flere viste heling af knogleranden. Patienten har altså overlevet operationen.

Fra dansk bondestenalder (3900-1700 f.v.t.) kendes 12 trepanerede kranier. At dømme efter helingen har cirka halvdelen overlevet.

At trepanere er ikke helt enkelt, hvis patienten skal have en chance for at overleve. Hjerneskallen skal bores igennem, så knoglestykket kan udtages, men uden at beskadige hjernehinderne. I stenalderen ville "kirurgen" formentlig skære i huden og krænge skalpen væk, så han med en flinteflække kunne skrabe eller bore sig igennem - en langvarig og pinefuld proces.

På Hippokrates' tid kunne man anvende et perforerende bor - græsk: trúpanon - som har lagt navn til operationen, eller et hult, cirkulært bor (príon), der kunne udtage et rundt stykke hjerneskal.

Stenalder-skadestue

Mens man har nogenlunde klarhed over, hvordan, er der uenighed om, hvorfor man trepanerede. I begyndelsen af det 20. århundreder kunne antropologiske undersøgelser i bl.a. Afrika fastslå, at man udførte indgrebet for at lindre smerter, f.eks. efter kranietraumer eller ved migræne. Det er nærliggende at antage, at det samme var formålet i forhistorisk tid, da mange af de fundne kranier har spor efter hovedlæsioner eller neurologiske lidelser. Den antagelse forstærkes af, at de fleste trepanationer er foretaget på kraniets forreste, venstre side - hvor et slagvåben, ført af en højrehåndet fjende, ville ramme.

Desuden stammer langt de fleste trepanerede kranier fra mænd. Derfor er det sandsynligt, at trepanation fortrinsvis er sket som livreddende indgreb efter kranielæsioner, som det også var tilfældet i den nævnte kasuistik fra 1834.

Trepanation var et nærliggende behandlingsvalg ved et kraniebrud, hvor man for eksempel vil fjerne knoglesplinter og lette trykket fra blodansamlinger. Behandlingen er formentlig udviklet gennem trial and error, indtil den forhistoriske kirurg har fundet ud af at undgå punktering af hjernehinden.

Om Eftermiddagen Kl. 1½ døde gehejmeconferensraad Baron Krag Juul Wind af en Podagra eller Sygdom i Fødderne, der var slaget op i Hovedet og foraarsaget Apopleksi, saa at han var blevet trepaneret ...

Ritual?

Trepanation kan også have haft rituelle formål. Den teori underbygges af adskillige gravfund i det sydligste Rusland nær Sortehavet, som kan dateres til mellem 3.000 og 5.000 f.v.t.

En af begravelserne omfattede fem voksne: tre kvinder og to mænd samt et spædbarn og en ung pige. Det interessante var, at to af kvinderne, to af mændene og pigen alle var blevet trepaneret. Alle indgrebene var foretaget på samme sted. At finde fem trepanerede individer i den samme grav, og at det livsfarlige indgreb et sket uden påviselig medicinsk årsag, kan tyde på et rituelt formål.

De fleste af de syd-russiske trepanerede viser tegn på delvis heling og har altså overlevet. En enkelt er død under eller lige efter indgrebet. Hos fire tyder delvis heling på en overlevelse på mindre end to måneder. De øvrige har overlevet i flere år.

Om der har været tale om en slags risikabelt "overgangsritual", eller om man har troet, at indgrebet ville give de trepanerede personer særlige egenskaber, kan man naturligvis kun gisne om.

Men i en tid, hvor synet på sygdom og helbredelse var magisk, kan det rituelle indgreb også have haft et behandlingssigte: Hvis migrænen eller epilepsien skyldes onde ånder, giver det jo en slags mening at bore et hul, som den sygdomsfremkaldende ånd kan slippe ud af.

Magien kan også bestå i at genopvække en person, som tilsyneladende var død efter et mindre hovedtraume, der ikke har afsat spor i kraniet, men har forårsaget intrakraniel blødning og bevidstløshed. Det kan så også forklare, hvorfor nogle trepaneringer ikke er nået helt igennem knoglen; den "døde" er vågnet op undervejs,

Mursten og apopleksi

Selv om europæisk middelalder kan opvise adskillige gruopvækkende kirurgiske procedurer, var trepanation af en eller anden grund gået af mode. Indgrebet blev dog udført, da den 13-årige kong Henrik I af Castilien i 1217 fik en tagsten i hovedet. Formentlig i et forsøg på at behandle blødning trepanerede lægerne ham. Desværre overlevede den unge konge ikke.

1700-tallets kirurger foretog mere eller mindre rutinemæssigt trepanationer - og ikke altid med heldigt resultat. Den 30. april skrev søofficeren Peter Schiønning i sin dagbog:

"Om Eftermiddagen Kl. 1½ døde gehejmeconferensraad Baron Krag Juul Wind af en Podagra eller Sygdom i Fødderne, der var slaget op i Hovedet og foraarsaget Apopleksi, saa at han var blevet trepaneret (...) Jeg vidste ikke af hans Sygdom at sige førend i Søndags d. 28. da jeg var hos Admiral Kaas, som fortalte mig det, da den var kommen pludselig og strax blev uden Samling (...) Jeg mistede i ham en meget god Ven".

I den beskrivelse af en vellykket trepanation, som blev nævnt indledningsvist, var patienten en 12-årig dreng, som ved et uheld havde fået "et Slag i Hovedet af en Del Mursteen, som nedfaldt fra Gavlen af et temmelig højt Huus, tilhørende Major Bruun paa Store Kjøbmagergade".

Ved indlæggelsen var han uden bevidsthed, puls og åndedræt var "svage", og kraniet havde fået hele tre frakturer. Under operationen (usteril og uden bedøvelse) blev fjernet bensplinter og afsavet fremstående knoglestykker. Nedtrykkede kraniedele blev bortskåret med "tvende Trepan-Kroner". Drengen overlevede "og har ingen Skade lidt paa de aandige Functioner. Arret paa Hovedet er fast", slutter artiklen.

Don't try this at home

I nyere tid er den oldgamle behandling dukket op igen - i det mindste hos nogle få, som ved at bore hul i kraniet (eller få nogen til det) mener at kunne opnå en højere form for bevidsthed. Tendensen dukkede op i 1960'erne i alternative miljøer som en vej til at blive "permanent høj". Med henvisning til østens mystik talte nogen om at "åbne det tredje øje". Forskellen på et tredje øje og en lobotomi er imidlertid hårfin, og der findes ingen evidens for, at trepanation er vejen til andet end en potentiel hjernebetændelse og risiko for at påføre sig selv epilepsi, hjerneblødning og død.

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Indgreb, overgreb - eller bare hul i hovedet?

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I 1834 kunne Bibliotek for Læger berette om "en betydelig Hoved-Beskadigelse heldigen behandlet paa Almindelig Hospital ved Trepanation". Trepanation hører sammen med omskæring til verdens ældste kirurgiske indgreb. Ved trepanation fjernes et stykke af hjerneskallen, eller der bores et hul. Den tidligste beskrivelse af indgrebet skyldes Hippokrates - lægekunstens fader - omkring 400 år f.v.t.

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Ancient & Medieval Medicine: Crash Course History of Science #9