Η ιστορική εξέλιξη του ακρωτηριασμού των κάτω μελών

Abstract

This thesis attempts to approach the medical, historical, legal and social aspects of the development of mutilation from antiquity until today. Through this effort, it is presented the progress of surgical techniques, the development of prosthetics, the contribution of anesthesia in the treatment of pain and antisepsis to drastically reduce infections. Secondary but equally essential goal of this work is to highlight the way in which the surgical amputation was influenced from the progress of the knowledge of the human body and from the social and economic conditions prevailing in the medical world at various times, especially from the reformistic temperament of various intellectual and prestigious men lived in these periods. Finally, the present thesis aims to provide a trigger for further discussion between the involved social actors of the place, academic and educational community and through this to achieve better social rehabilitation of amputated people. The preparation of this thesis was achieved by collecting, recording, studying and criticizing various primary and secondary sources relating to amputation in different periods. In particular for the realization of this thesis was necessary to look up: a) references to historical figures, writers, academics and philosophers who contributed to projects, teaching and overall attitude, both in the formation of a basic framework of medical and secondly, the development of surgical amputation. b) findings of archaeologists and other scientists as vases, scrolls, tools, skeletal remains that suggested the practice of mutilation c) In the published medical articles and historical scientific journals d) legal books and scientific articles from current or past societies which were recording the practice of amputation as a penalty or punishment e) books and scientific articles in psychology and sociology, which dealt with the psychology of amputees and the optimal approach for their smooth reintegration into society f) In scattered historical books, anthologies, monographs, diaries, military reports, narratives, correspondence and poetry g) In biographies of general surgeons, orthopedic and vascular surgeons h) biographies of historians, anthropologists, celebrity army peoplei) In visual materials such as photographs, cartoonist, paintings and engravings depicting historical events, monuments, medical facilities, methods and practices of amputationj) The power of the internet. Once the material under investigation was collected, it was grouped into periods, translated most of the English and French language in Greek, which were critically evaluated and conclusions were drawn. Amputation of upper and especially the lower limbs is perhaps the oldest medical intervention in the history of medicine. Reports and findings are suggestive that limb amputations were carried out often in the pre-Hippocratic period and in various populations and cultures for reasons that were not always related to the treatment of an illness. Hippocrates and others at later stages have described in detail the technique of amputation of their preference and the reasons for choosing this technique. Amputations continued to be so during the Roman and in the Byzantine period. One could say that in these periods limb amputation was mainly performed for traumatic injuries, especially in the war, or as a punishment of those acting against the state power or committed to criminal actions and were intended as exemplary. In the early Middle Ages little progress accomplished in the art of mutilation but by the middle of this period onwards and on the Renaissance the technique of amputation has been subjected to major changes in both the technique to give better stump, and the way of vessel ligation, as well as in the rapid management of patients requiring amputation, especially the wounded on the battlefield. It is particularly important to recognize that the evolution of amputation at every stage in both the Middle Ages and the Renaissance and in modern times was intertwined with the wars that took place, since the majority of the wounded needed to have some form of amputation. It is also characteristic that the forms in which battles were fought and the weapons used were changing the management requirements of injured soldiers and citizens.It is well understood that in all time periods the need for some degree of recovery of the activity of amputees was desirable from themselves as well as from the society, except of course for those amputations performed for punitive reasons. The rationale of the social reintegration of amputees was not so strong in ancient times, the Roman or Byzantine period, or at least there is no strong evidence to support it. Certainly the development of Prosthetology followed the rapid evolution of surgical techniques of amputation during the second half of the Middle Ages, the Renaissance and the modern era as a result of the evolution of technology, accomplished a revolution. But it would be remiss not to point out that the evolution of the basic need of Prosthetology emerged through the wars that took place in human history from the 16th century onwards, but especially in the modern era in the 19th and 20th century. So the fact these wars, especially those occurred during the last centuries, resulted in a significant number amputees and the fact that the modern organization of the societies in states which included into their tasks to offer care to citizens, contributed enormously in the development of Prosthetology.Amputations in the field of battle represent a unique patient population, given the complexity and the extensive nature of the injuries. The wounds are usually contaminated by dirt, bacteria and fragments of bullets, shells and mines. Thus, they constitute a real challenge to physicians who must deal with not only the surgical treatment and rehabilitation but also with the psychological and emotional consequences. Amputations in the battlefields are associated with increased chances of developing secondary complications such as infections, heterotopic ossification, venous thrombosis, which require the constant vigilance of doctors and close monitoring of incidents.Also, advances in anesthesia with administration of new substances that provide effective anesthesia during surgery and analgesia in the postoperative period, and the progress made in fighting infections with antiseptics and the discovery of antibiotics have all contributed to make the amputation these days a safe and painless procedure. Moreover, such patients develop severe mental illnesses and the control of both somatic pain and psychological imbalance are important elements of the treatment. The patient eventually has to play an active role in all phases of rehabilitation. The harmonious collaboration of physicians from various disciplines such as general, orthopedic, vascular and plastic surgeons and psychiatrists, along with paramedical practicians such as nurses, social workers, physiotherapists and occupational therapists and prosthetologists remains the key element for a faster and more effective rehabilitation. The rapid development of technology in the field of prosthetics in recent years, gave the opportunity to many amputees in war or not, to receive prosthetic limbs, and reintegrate into society more smoothly than before. Finally, in the modern history of humanity in some states amputations are still performed unfortunately as punishment of crimes although this practice has been condemned by international bodies as unacceptable and incompatible with the culture that should underpin modern societies. The dissemination of the cultural heritage of peoples in combination with education and relinquishment of theocratic fanaticism is the only hope for the disappearance of this phenomenon.The aim of the thesis was to present the progress of surgical techniques for lower limb amputation as well as the development of prosthetics and the contribution of anaesthesia in the treatment of pain and antisepsis to drastically reduce infections. Additionally, essential goal of this work was to highlight the way in which the surgical amputation was influenced from the progress of the knowledge of the human body and from the social and economic conditions prevailing in the medical world at various times.For this reason various primary and secondary sources relating to amputation in different periods were used to collect the data. Then the data is presented and critically evaluated in certain historical periods. Amputation of the lower limbs is perhaps the oldest medical intervention in the history of medicine carried out often in the pre-Hippocratic period and in various populations and cultures for reasons that were not always related to the treatment of an illness. Amputations continued in Roman and in the Byzantine periods mainly performed for traumatic injuries, especially in the war, or as a punishment of those acting against the state power or committed to criminal actions. Only by the second half of Middle Ages onwards and on the Renaissance the technique of amputation has been subjected to major changes in both the technique to give better stump, and the way of vessel ligation, as well as in the rapid management of patients requiring amputation, especially the wounded on the battlefield. It is particularly important to recognize that the evolution of amputation at every stage of history was intertwined with the wars. Besides the wars and medical reasons, unfortunately in modern history amputations are still performed unfortunately as punishment of crimes in some countries. The rationale of the social reintegration of amputees was not so strong in ancient times, the Roman or Byzantine period, or at least there is no strong evidence to support it. The rapid evolution of Prosthetology followed the surgical evolution of amputation but, the turning point for the basic need of Prosthetology emerged through the wars, especially in the modern era in the 19th and 20th centuries. Also, advances in anaesthesia with administration of new substances that provide effective anesthesia during surgery and analgesia in the postoperative period, and the progress made in fighting infections with antiseptics and the discovery of antibiotics have all contributed to make the amputation these days a safe and painless procedure. The harmonious collaboration of physicians from various disciplines and the rapid development of technology in the field of prosthetics in recent years, gave the opportunity to many amputees in war or not, to receive prosthetic limbs, and reintegrate into society more smoothly than before.

Η παρούσα διατριβή αποπειράται να προσεγγίσει τις ιατρικές, ιστορικές, νομικές και κοινωνικές πτυχές της εξέλιξης του ακρωτηριασμού από την αρχαιότητα μέχρι και σήμερα. Στη προσπάθεια αυτή, αναδεικνύεται η συμπόρευση της χειρουργικής επιστήμης με την τέχνη της προσθετικής. Παράλληλα επιχειρείται η αποτύπωση της συνεισφοράς της αναισθησίας στην αντιμετώπιση του άλγους των ακρωτηριασθέντων ασθενών, καθώς και της αντισηψίας στην δραστική μείωση των λοιμώξεων. Ο ακρωτηριασμός παρουσιάζεται και ως ποινή σε παλαιότερες εποχές και στις σύγχρονες κοινωνίες.Στόχος είναι να διερευνηθούν οι πραγματικές δυσκολίες που αντιμετωπίζουν οι ακρωτηριασθέντες και να παρουσιαστεί ο ακρωτηριασμός ως η αρχή μιας μακράς διαδικασίας, όπου ο ακρωτηριασθείς καλείται να θωρακισθεί ψυχολογικά, να βοηθηθεί με τη συνδρομή της τεχνολογίας, προκειμένου να επανενταχθεί ομαλά στο κοινωνικό σύνολο.Τέλος, η παρούσα διατριβή αποσκοπεί στο να εξάγει χρήσιμα συμπεράσματα και να δώσει ένα έναυσμα για μια περαιτέρω συζήτηση μεταξύ όλων των εμπλεκομένων κοινωνικών φορέων του τόπου και της ακαδημαϊκής και εκπαιδευτικής κοινότητας, παρά στο να επιβάλλει συγκεκριμένες απόψεις.Σκοπός της διατριβής ήταν να παρουσιάσει την πρόοδο των χειρουργικών τεχνικών του ακρωτηριασμού των κάτω μελών, καθώς και την ανάπτυξη της προσθετικής και της συμβολής της αναισθησίας και της αντισηψίας. Επιπλέον, βασικός στόχο αυτής της εργασίας ήταν να αναδείξει τον τρόπο με τον οποίο η χειρουργική του ακρωτηριασμού επηρεάστηκε από την εξέλιξη της γνώσης του ανθρώπινου σώματος και από τις κοινωνικές και οικονομικές συνθήκες που επικρατούσαν σε διάφορες χρονικές περιόδους.Για το λόγο αυτό, διάφορες πρωτογενείς και δευτερογενείς πηγές που σχετίζονται με ακρωτηριασμό σε διαφορετικές περιόδους χρησιμοποιήθηκαν για τη συλλογή των δεδομένων. Στη συνέχεια, τα στοιχεία παρουσιάζονται και αξιολογούνται ανά ορισμένη χρονική περίοδο.Ο ακρωτηριασμός των κάτω μελών είναι ίσως η παλαιότερη ιατρική παρέμβαση στην ιστορία της ιατρικής ακόμα από την προ-Ιπποκράτειο περίοδο και σε διάφορους πληθυσμούς και πολιτισμούς, για λόγους που δεν σχετίζονταν πάντοτε με τη θεραπεία μιας ασθένειας. Ακρωτηριασμοί συνέχισαν να γίνονται στη ρωμαϊκή και στη βυζαντινή περίοδο είτε για τραυματικές κακώσεις, ιδιαίτερα στον πόλεμο, είτε ως τιμωρία ενεργειών κατά της κρατικής εξουσίας ή για εγκληματικές ενέργειες. Μόνο από το δεύτερο μισό του Μεσαίωνα και στην Αναγέννηση η τεχνική του ακρωτηριασμού εξελίχθηκε τόσο στην τεχνική για να προκύψει καλύτερο κολόβωμα όσο και στην ταχεία διαχείριση των ασθενών που χρειάζονται ακρωτηριασμό , ιδιαίτερα τους τραυματίες στο πεδίο της μάχης. Είναι ιδιαίτερα σημαντικό να αναγνωρίσουμε ότι η εξέλιξη του ακρωτηριασμού σε κάθε στάδιο της ιστορίας ήταν συνυφασμένη με τους πολέμους. Δυστυχώς, στη σύγχρονη ιστορία ακρωτηριασμοί εξακολουθούν να πραγματοποιούνται ως τιμωρία για εγκλήματα σε ορισμένες χώρες.Η λογική της κοινωνικής επανένταξης των ακρωτηριασμένων δεν ήταν τόσο ισχυρή κατά την αρχαιότητα, τη ρωμαϊκή ή βυζαντινή περίοδο, ή τουλάχιστον δεν υπάρχουν ισχυρά αποδεικτικά στοιχεία. Η ραγδαία εξέλιξη της προσθετικής ακολούθησε την χειρουργική εξέλιξη του ακρωτηριασμού, αλλά το σημείο καμπής για την εξέλιξή της αναδύθηκε μέσα από τους πολέμους, ιδιαίτερα στη σύγχρονη εποχή τον 19ο και 20ο αιώνα.Επίσης, οι πρόοδος στην αναισθησία με τη χορήγηση νέων ουσιών που παρέχουν αποτελεσματική αναισθησία κατά τη διάρκεια χειρουργικής επέμβασης και αναλγησία κατά τη μετεγχειρητική περίοδο, καθώς και η πρόοδος που έχει σημειωθεί στην καταπολέμηση των λοιμώξεων με αντισηπτικά και την ανακάλυψη των αντιβιοτικών, συνέβαλαν στο να γίνει ο ακρωτηριασμός σήμερα μια ασφαλής και ανώδυνη διαδικασία. Σήμερα, η αρμονική συνεργασία των γιατρών από διάφορες ειδικότητες και η ταχεία ανάπτυξη της τεχνολογίας στον τομέα της προσθετικής έχουν συμβάλλει σημαντικά στην ομαλή επανένταξη των ακρωτηριασθέντων στο κοινωνικό σύνολο.