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Cranial trepanation in The Egyptian
La trepanación craneal en Sinuhé, el Egipcio
S. Collado-Vázqueza,
Corresponding author
susana.collado@urjc.es

Corresponding author.
, J.M. Carrillob
a Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Facultad de Ciencias de la Salud de la Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
b Departamento de Personalidad, Evaluación y Psicología Clínica, Facultad de Psicología de la Universidad Complutense de Madrid, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Since ancient times&#44; medicine has been defined as both a science and an art&#44; and as a sphere within which science&#44; culture&#44; and the humanities are not clearly delimited&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Many doctors have also been writers&#44; including Anton Chekhov&#44; Gregorio Mara&#241;&#243;n&#44; Pedro La&#237;n Entralgo&#44; and Juan Antonio Vallejo N&#225;gera&#46; In turn&#44; many writers have described medicine&#44; illness&#44; pain&#44; and death in such works as <span class="elsevierStyleItalic">Don Quixote</span> by Cervantes&#44; <span class="elsevierStyleItalic">The Death of Ivan Ilych</span> by Tolstoy&#44; <span class="elsevierStyleItalic">The Citadel</span> by Cronin&#44; <span class="elsevierStyleItalic">Rest Home</span> by Camilo Jos&#233; Cela&#44; and <span class="elsevierStyleItalic">The Plague</span> by Albert Camus&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The Egyptian</span>&#44; penned by Finnish author Mika Waltari&#44; is a powerful tale of the protagonist&#39;s medical career&#44; his learning process&#44; and the evolution from magical beliefs to a more scientific form of medicine&#46; This book refers to trepanning and indicates how the procedure was performed and what instruments were used&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Trepanning is a surgical procedure that has been practised since prehistoric times for head trauma&#44; post-traumatic epilepsy&#44; migraine&#44; and a host of neurological disorders&#46; However&#44; these operations also held magical significance in ancient times&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The purpose of this article is to examine Waltari&#39;s literary description of trepanation while offering a historical overview of this practice&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Procedure</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Cranial trepanation</span><p id="par0020" class="elsevierStylePara elsevierViewall">Palaeopathology studies have shed light on a surgical procedure that has been practised by numerous cultures since time immemorial&#58; trepanation&#46; This practice consists of removal of cranial bone slabs using an instrument called a trephine&#44; from the Greek word for &#8216;drill&#8217;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;10</span></a> Trepanning gives rise to many questions&#44; such as the purpose of the procedure&#44; whether it had precise indications&#44; if it was part of a ritual&#44; what were the most common complications&#44; and the survival rate&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Trepanning seems to have been prescribed as a treatment measure for headache&#44; mental illness&#44; epilepsy&#44; and most of all&#44; head trauma&#46; In the latter case&#44; the procedure was used to relieve pressure on the brain caused by fracture&#44; to remove bone shards&#44; or to drain haematomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;14&#44;15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The procedures and instruments varied according to the culture and the moment in history&#46; In general&#44; however&#44; the practitioner would detach the scalp&#44; perforate the cranium&#44; and clean the wound before covering it with a plate of precious metal and then applying a bandage&#46; Instruments employed included trephines&#44; knives&#44; tumis &#40;T-shaped knives&#41;&#44; saws&#44; chisels&#44; burins&#44; hammers&#44; sharp stones&#44; and forceps&#46; The operation lasted between 30 and 60<span class="elsevierStyleHsp" style=""></span>minutes in adults and about 10<span class="elsevierStyleHsp" style=""></span>minutes in children&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Prehistory</span><p id="par0035" class="elsevierStylePara elsevierViewall">Trepanned skulls from the Neolithic and Mesolithic periods&#44; some as much as 10<span class="elsevierStyleHsp" style=""></span>000 years old&#44; have been found in Japan&#44; the Iberian peninsula&#44; Germany&#44; Ukraine&#44; the Czech Republic&#44; Hungary&#44; France&#44; Syria&#44; Chile&#44; Mexico&#44; Peru&#44; and Bolivia&#46; Many of these skulls exhibit new bone formation along the edges of the orifice&#44; indicating that the subjects survived the intervention &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;16&#8211;19</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">It is believed that between 80&#37; and 90&#37; of the subjects may have survived and that many deaths were due to postoperative infection and not the operation itself&#46; These figures vary greatly depending on the historical moment&#44; geographical location&#44; and the technique employed&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;21</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In his study of more than 600 skulls&#44; Verano calculates a survival rate of about 78&#37;&#44; although he is not able to distinguish between short-term and long-term survival&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">According to La&#237;n Entralgo&#44; the purpose of trepanation would have been twofold&#58; firstly&#44; to surgically remove real or suspected accumulated material from the cranial cavity&#44; and secondly&#44; to magically release harmful presences that might have entered the body as the result of a curse&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Other authors support this assessment&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">According to Reverte Coma&#44; when primitive man removed a depressed bone fragment from the skull&#44; smoothed the edges of the skull fracture&#44; and removed necrotic tissue&#44; his actions were rational&#46; After repeating these actions many times&#44; ancient practitioners would have become experts with numerous cases of successful trepanation using different methods&#44; including grinding and drilling&#46; These techniques were used as therapy for head trauma&#44; headaches&#44; mental illness&#44; and epilepsy&#44; but although their use implied a certain degree of rationality in ancient cultures&#44; the process was also a magical act aiming to cure an illness caused by an evil spirit that had to be released&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">As many as 5 to 7 trepanations were performed on some skulls&#44; which exhibit burr hole sizes ranging from 1 to 10<span class="elsevierStyleHsp" style=""></span>cm&#46; In some cases&#44; we find signs that the patient survived&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;22</span></a> Skulls have also been found showing incomplete trepanation&#59; this was probably due to death of the patient during the procedure&#44; which was then halted&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Trepanned skulls most frequently belong to adult males&#44; the group most likely to suffer head trauma&#44; but others have been found from women and children under 12&#44; and in some cases as young as 2 or 3 years&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Ancient Egypt</span><p id="par0065" class="elsevierStylePara elsevierViewall">Babylonian and Egyptian inscriptions recommend trepanning in certain cases&#46; In other cases&#44; pronouncing invocations to expel the demons causing the disease would have been sufficient&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;14&#44;15</span></a> This provides an idea of how closely medical practice was linked to magical and religious concepts at the time&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;26&#44;27</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Some authors state that trepanation was not frequently performed in ancient Egypt&#46; Similarly&#44; the Edwin Smith Papyrus &#40;700 BCE&#41;&#44; a copy of a much older papyrus describing surgical techniques&#44; does not mention this type of procedure&#46; Elliot Smith&#44; a professor in Cairo&#44; studied some 15<span class="elsevierStyleHsp" style=""></span>000 Egyptian skulls and found no traces of trepanation&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;26&#44;28&#8211;31</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Scholars have found a few trepanned skulls from Ancient Egypt&#44; but their numbers are low compared to other cultures&#46; For example&#44; the Czech anthropologist Hrdlicka discovered an Egyptian skull with trepanation marks and reported his find to Egyptologist James Breasted&#46; The Qasr Al-Eini Museum of medicine&#44; a dependency of Cairo University&#44; conserves three trepanned skulls from the time of the pharaohs that show signs that the patients survived&#46; Radiographic and tomographic studies of a pre-Ptolemaic mummy with a trepanned skull showed clear signs of osteoblastic bone reaction along the edges of the orifice&#44; indicating that the patient survived&#46; Likewise&#44; the grand tomb of Maya and Merit in Saqqara also contained a skull with a burr hole in the occipital area and signs compatible with patient survival&#46; This operation was probably carried out to drain a subdural haematoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;26</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Greece and Rome</span><p id="par0080" class="elsevierStylePara elsevierViewall">Practitioners in ancient Greece and Rome used trepanning to treat convulsions&#44; especially those resulting from trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Hippocrates of Kos &#40;460&#8211;370 BCE&#41; was a pioneer in treating cranial lesions as we see in <span class="elsevierStyleItalic">On Injuries of the Head</span>&#46; Here&#44; he proposed a classification system for cranial fractures and indicated the cases in which trepanation might be indicated&#59; at a later point&#44; he improved that technique &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;28</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">In the 1st century&#44; Celsus &#40;25 BCE&#8211;50 CE&#41; described trepanations and instruments such as <span class="elsevierStyleItalic">terebras</span> and trephines&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Along with other Greco-Roman authors&#44; Galen &#40;129&#8211;200 CE&#41; described this practice and recommended it for cranial fractures to relieve pressure and decrease pain&#46; It was more controversial&#44; however&#44; as treatment for epilepsy&#44; headache&#44; or paralysis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Aretaeus of Cappadocia &#40;120&#8211;200 CE&#41; recommended trepanning in epilepsy cases when conservative treatment had failed&#46; In contrast&#44; Caelius Aurelianus &#40;400 CE&#41; criticised the practice of trepanning as harmful in some cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;33</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Few trepanned skulls from Imperial Rome have been discovered&#44; and this may have several explanations&#46; It is possible that surgery was only used on rare occasions when conservative treatment had failed&#46; Another explanation is that cremating corpses was a common practice in Rome&#44; and therefore few skeletons from that period remain&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Middle ages</span><p id="par0105" class="elsevierStylePara elsevierViewall">During the Mediaeval period&#44; trepanation was performed as therapy for head trauma and epilepsy &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; as well as for superstitious reasons as a means of ousting evil spirits&#46; Paintings depict these procedures&#44; such as <span class="elsevierStyleItalic">Cutting the Stone</span> by Hieronymus Bosch &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; It was believed that madness was caused by the formation of stones below the cranial surface&#44; and healers would make incisions in the head to extract them&#46; After the operation&#44; the healer would show bystanders a stone that he had palmed&#44; claiming that it had come from the patient&#39;s head&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Early modern period</span><p id="par0110" class="elsevierStylePara elsevierViewall">During the Renaissance&#44; craniotomy continued to be used to treat post-traumatic epilepsy by removing fragments of fractured bone without removing damaged brain tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Andreas Vesalius &#40;1514&#8211;1564&#41; performed several trepanations&#59; his patients included Don Carlos&#44; Prince of Asturias and Henri IV of France&#46; In the latter procedure&#44; he was assisted by French surgeon Ambroise Par&#233; &#40;1510&#8211;1592&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;35</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Andr&#233;s Alc&#225;zar &#40;1500&#8211;1584&#41; perfected the trepanation technique&#44; designed tools for the procedure&#44; and wrote one of his century&#39;s best studies on the use of the technique&#58; <span class="elsevierStyleItalic">Chirurgiae libri sex</span>&#44; published in 1575&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In 1600&#44; William Harvey recommended trepanation as treatment for migraines<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> and Finger mentions that Duretus&#44; also in 1600&#44; cured an epileptic child by removing a broken bone that exerted pressure on the brain&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Contemporary period</span><p id="par0130" class="elsevierStylePara elsevierViewall">Trepanations continued to be performed&#44; and researchers perfected both techniques and tools&#46; For example&#44; in 1828&#44; Dr Benjamin Dudley of Kentucky developed a trepanation technique for treating traumatic epilepsy&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> At the time&#44; trepanning was performed in cases of epilepsy&#44; head trauma&#44; brain cysts&#44; and brain tumours&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Early palaeopathology studies of trepanation</span><p id="par0135" class="elsevierStylePara elsevierViewall">Rivet states that the first early trepanned skull was found by Montfaucon in Cocherel in 1685&#59; the first detailed case of a trepanned skull was presented by Jean-Denis Barbi&#233; du Bocage in 1816&#46; A body of knowledge about trepanning began to accumulate in 1839 when Morton published <span class="elsevierStyleItalic">Crania Americana</span>&#46; The book included an image of a trepanned skull from Peru which Lehmann-Nitsche later examined&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;39</span></a> Interest in this practice grew when anthropologist Ephraim George Squier returned from Peru with a prehistoric trepanned skull&#46; The skull was studied and presented to the Anthropological Society of Paris 2 years later by Paul Broca&#44; who affirmed that the patient had survived for at least several weeks after the operation&#46; Subsequent discoveries of other trepanned skulls awakened the interest of doctors&#44; historians&#44; and anthropologists&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Sinuhe the Egyptian</span><p id="par0140" class="elsevierStylePara elsevierViewall">Mika Waltari &#40;1908&#8211;1979&#41; wrote his novel <span class="elsevierStyleItalic">The Egyptian</span> in 1945&#44; after having spent 10 years studying Egyptian culture&#46; The author demonstrated his craftsmanship and talent for blending the documented history of ancient Egypt with popular stories and legends&#46; For example&#44; he draws from <span class="elsevierStyleItalic">The Story of Sinuhe</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> the tale of a government official in the age of Senusret I &#40;1956&#8211;1911 BCE in the Twelfth dynasty of the Middle Kingdom&#41;&#46; So as not to be implicated in a conspiracy he accidentally discovered&#44; and which would prove fatal to Amenemhat I&#44; he fled to Palestine&#44; where he remained until his old age&#46; In addition to using the same name for his protagonist&#44; Waltari draws on other parallels&#44; such as telling his story in first person&#44; including the tale of the flight of Sinuhe&#44; and describing the conspiracies in which he found himself embroiled&#46; According to Waltari&#39;s version&#44; these conspiracies were due to religious reforms introduced by Akhenaten&#44; the tenth pharaoh of the Eighteenth dynasty&#44; who ruled from 1353 to 1336 BCE&#46; Waltari&#39;s novel includes several references to the ancient Egyptian story&#44; for example&#44; when the mother chooses the name of her adopted son based on legendary history&#44; and when she related the adventures of Sinuhe to her son&#46; <span class="elsevierStyleItalic">The Story of Sinuhe</span>&#44; dating from the 14th century BCE&#44; is known thanks to two of the Berlin papyri&#44; 10499 &#40;B&#41; and 3022 &#40;R&#41; discovered in 1863 by the Egyptologist Chabas&#46; We also observe similarities to certain passages of the Old Testament&#44; specifically&#44; the story of Moses&#46; Like that Biblical figure&#44; Sinuhe was abandoned in the Nile in a basket&#44; and his flight may be compared to Moses&#8217; exodus in search of the Promised Land&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Another story from which the Finnish author probably drew material was the saga of Tabubu&#46; This story written in the time of the Ptolomaic dynasty tells of the nightmares with which Tabubu&#44; priestess of the cat-goddess Bastet&#44; tormented the son of Ramesses II&#46; In <span class="elsevierStyleItalic">The Egyptian</span>&#44; Tabubu became the devious Nefernefernefer&#44; the wicked woman who seizes all of Sinuhe&#39;s worldly goods&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The author also draws from <span class="elsevierStyleItalic">The Satire of the Trades</span>&#44; also called <span class="elsevierStyleItalic">The Instruction of Dua-Kheti</span> &#40;2400 BCE&#41;&#44; as we gather from a dialogue between the protagonist and the scribe Horemheb on the importance of the scribe&#39;s profession&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In the late 19th century&#44; 380 clay tablets were found in Tell el-Amarna&#59; foreign governors of Canaan&#44; Mittani&#44; Assyria&#44; and Babylon had written them to Amenhotep III and IV&#44; and these pharaohs appear in Waltari&#39;s novel&#46; Considering the author&#39;s interest in Akhenaten&#44; it is very likely that he would have analysed the Amarna letters for background information&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In 1941&#44; a few years before Waltari published his novel&#44; Egyptian writer and Nobel Prize winner Naguib Mahfuz &#40;1911&#8211;2006&#41;&#44; wrote <span class="elsevierStyleItalic">Awdat Sinuhi</span> &#40;<span class="elsevierStyleItalic">The Story of Sinuhe</span>&#41;&#46; This novella is directly based on ancient texts&#44; but it also takes the liberty of including love stories that do not appear in the originals&#44; and Mika Waltari would do the same in his version&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The Egyptian</span> was Waltari&#39;s first historical novel and his most successful book&#46; It is structured in 15 chapters narrated in first person by Sinuhe&#44; the royal doctor who has been exiled since the death of Amenhotep IV &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Throughout the story&#44; Sinuhe&#39;s concept of medicine evolves from a magical and religious view to a more rational and empirical view thanks to his experience and powers of observation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The setting is Ancient Egypt&#44; during the reign of Amenhotep IV who changed his name to Akhenaten and created a religious schism by introducing worship of Aten as a sole deity&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Waltari had already developed an interest in this pharaoh&#44; as shown by his play that premiered in Helsinki in 1938&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">His original novel&#44; <span class="elsevierStyleItalic">Sinuhe egypti&#228;ien</span>&#44; was published in Finnish in 1945&#46; It would go on to be translated into different languages and published in many countries&#46; In Spain&#44; editor Jos&#233; Jan&#233;s published the novel&#44; translated by Manuel Bosch Barrett&#44; in 1950&#46; This translation was used in all subsequent editions of the book released by Plaza y Jan&#233;s &#40;1963&#44; 1966&#44; 1971&#44; 1981&#44; 1995&#41;&#44; GP &#40;1959&#41;&#44; C&#237;rculo de Lectores &#40;1965&#44; 1991&#41;&#44; RBA editores &#40;1993&#41;&#44; Debolsillo &#40;2000&#44; 2009&#41;&#44; and other publishers&#46; We use the same translation for our analysis of trepanation in the Spanish version of <span class="elsevierStyleItalic">The Egyptian</span>&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Trepanation in <span class="elsevierStyleItalic">The Egyptian</span></span><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The Egyptian</span> is a work of historical fiction and its author made no claims of scientific&#44; historical&#44; or medical accuracy&#46; As mentioned before&#44; Waltari researched this topic extensively&#44; and by intertwining history&#44; legend&#44; and his own imagination&#44; he presented a plausible recreation of life in ancient Egypt with some artistic license&#46; For example&#44; he refers frequently to trepanation&#44; when it seems that trepanning was only rarely practised in Egypt&#46; It is likely that the author would have read a Greco-Roman or mediaeval text on trepanation&#44; given that the technique and instruments were correctly and minutely described&#46; Similarly&#44; during his research sessions&#44; he may have read palaeopathology studies on this neurosurgical procedure that so fascinated him&#46; Since the practice had been carried out in so many populations and cultures since prehistory&#44; he decided to include it in his tale of ancient Egypt&#44; even though the Egyptians almost never employed the technique and no studies point to ritual trepanation in dying pharaohs as described by the author&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">On several occasions&#44; <span class="elsevierStyleItalic">The Egyptian</span> mentions the figure of the trepanner and provides vivid descriptions of the trepanning process&#44; the reasons why it was performed&#44; and the instruments used&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Sinuhe&#39;s father Senmut tells his children about his friend Ptahor&#44; the royal trepanner&#44; who he says has saved many lives&#46; Later in the story&#44; Sinuhe&#44; now a trepanner himself&#44; tells a patient that only 1&#37; of those undergoing the procedure will survive&#46; This figure does not match his father&#39;s assertions that Ptahor has used trepanning to save many lives&#46; Furthermore&#44; in the trepanations described in the book&#44; the surviving patients considerably exceed that tiny percentage&#46; Likewise&#44; the literature we consulted indicates that many trepanned skulls show signs of survival after the operation&#44; and it is believed that some 80&#37; to 90&#37; of the patients may have survived&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Speaking of his friend Ptahor&#44; Senmut says&#44; &#8220;he releases evil spirits that drive men to madness&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> This sentence supports the magical and religious concept of illness that was attributed to malignant forces&#46; Sinuhe witnesses several interventions and he will perform others himself&#46; The multiple mentions of trepanation are surprising given that the practice was uncommon in Egypt&#59; however&#44; it is possible that the number of operations described in the novel represent only a small percentage of the total patients attended&#46; On the other hand&#44; on one occasion&#44; when Sinuhe is studying in the House of Life&#44; he states that he rarely sees the royal trepanner since trepanation is seldom performed&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The novel describes the following instruments&#58; trephines or bores&#44; flint knives&#44; saws&#44; forceps&#44; and an ebony-handled hammer&#46; It stresses the cleansing process that takes place before surgery&#44; during which the surgeon washes himself and the instruments are purified and passed under a flame&#46; This process may have been completed for reasons of hygiene and asepsis&#44; or as a ritual&#46; The book also describes patients being given a drug mixed with narcotics to send them to sleep and alleviate the pain&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The first of the patients treated by Ptahor is an old man with a low probability of surviving the procedure&#46; The practitioner completes the trepanation merely to practice his technique&#46; The second patient is a strong young slave who was struck in the head with a stone during a brawl&#46; He can neither speak nor move his limbs&#46; In both cases&#44; the trepanner&#39;s technique is carefully described&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">&#8220;My task was to shave the heads of both patients with the keenest of razors&#46; Then the heads were cleaned and washed once more&#44; the scalps massaged with a numbing salve&#44; and Ptahor was ready for his work&#46; First he made an incision in the scalp of the old man and pushed the edges back regardless of the copious flow of blood&#46; Then with swift movements he bored a hole in the bared skull with a large tubular bore and lifted out the circle of bone&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> After finding that there was nothing wrong with the patient&#39;s head&#44; he replaced the extracted piece of bone&#44; sutured the wound&#44; and bandaged his head&#46; The old man died some time later&#46; The outcome of the procedure was very different in the case of the healthy young slave&#46; He was given drugs and bound firmly&#44; and his head was placed in a special vice so that he could not move it during the operation&#46; The trepanner incised the scalp and stopped the profuse flow of blood&#44; which he had not bothered to do in the case of the dying old man because he was not expected to survive and was only used as a practice case&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">&#8220;The veins at the edges of the incision were cauterized and the blood stopped by special medicaments&#8230; When Ptahor had cleansed the outside of the skull&#44; he pointed out to us the place where the bone had been crushed in&#46; By means of bore&#44; saw&#44; and forceps he removed a piece of skull as large as the palm of one&#39;s hand and then he showed us how clotted blood had gathered among the white convolutions of the brain&#46; With infinite care he removed the blood bit by bit and freed a bone splinter that had been forced into the brain substance&#8230; Next Ptahor closed the opening with a plate of silver that had been prepared meanwhile to correspond in shape to the piece of bone that had been removed and fixed it firmly in position with tiny clips&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">After completing the operation&#44; he asked his helpers to wake the patient&#44; who was nearly unconscious&#59; they untied him&#44; trickled wine down his throat&#44; and gave him strong drugs to inhale in order to wake him&#46; Soon he was sitting up and cursing&#44; even though he had been unable to speak and move shortly before&#46; Ptahor explained to Sinuhe that the splintered bit of bone and the pooled blood had caused the patient&#39;s symptoms&#44; which disappeared after both had been removed&#46; He predicted that the patient would recover if he were able to survive the first 3 days&#44; and that in a mere 2 weeks he would be able to settle the score with the man who had broken his skull&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Sinuhe would go on to perform several trepanations&#59; during one intervention&#44; the patient did not lose consciousness and reported that he felt better as soon as the doctor removed the bone fragment&#44; which ended his terrible headache and the disturbing and continuous noises in his ears&#46; He also operated on another 2 patients who survived&#44; and he performed the intervention 3 times in the House of Life once he had become the royal trepanner&#46; The first patient was in poor condition and died&#46; The second patient was a man who had fallen from a roof 2 years before and sustained no apparent injury&#46; However&#44; he had experienced seizures ever since his accident&#44; especially when he had been drinking alcohol&#58; &#8220;He&#8230;merely shouted in a furious voice&#44; kicked&#44; and bit his tongue&#44; and could not contain his water&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> When the doctor had opened his skull&#44; he found quantities of old blood in many locations&#44; and despite his efforts to cleanse it&#44; the patient died 3 days later&#46; The third patient was described as &#8220;a young boy &#91;whose&#93; head was beaten in&#8230; I&#8230;removed the splinters of bone from his brain and covered the hole with a plate of purified silver&#46; He recovered and was still alive when I left Thebes 2 weeks later&#44; although he found difficulty in moving his arms and could feel nothing when the hands and the soles of his feet were tickled with a feather&#46; I believed that in time he would be completely cured&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Some of the trepanations described in <span class="elsevierStyleItalic">The Egyptian</span> only served as a means of practising the technique&#59; in addition&#44; ritual trepanning was performed on the pharaoh&#46; The reason for the operation is not given in some cases&#44; but the rest were performed to treat head trauma with or without skull fracture&#44; and post-traumatic epilepsy in one case&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Although Sinuhe informs a patient that the probability of surviving trepanation was very low at about 1&#37;&#44; when he thinks back on his life and his profession he recalls his success in these interventions&#58; &#8220;&#8230;at this time I tended many sick people&#46; Of the patients whose skulls I opened only three died so that may reputation as a skull surgeon stood high&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0235" class="elsevierStylePara elsevierViewall">Trepanning is a surgical practice that has been used since prehistoric times to treat head trauma&#44; epilepsy&#44; headaches&#44; and mental illness&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">In his novel <span class="elsevierStyleItalic">The Egyptian</span>&#44; Mika Waltari displays an accurate knowledge of techniques used in trepanation&#46; His understanding is largely based on his extensive research&#44; although the sources he used as his references probably reflected practices from areas other than Egypt&#59; palaeopathology studies indicate that trepanning was rarely practised in that area&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Mika Waltari&#39;s novel provides a good example of the historical&#44; scientific&#44; literary&#44; and humanist value contained in some books that link medicine to literature&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Early palaeopathology studies of trepanation"
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              "identificador" => "sec0055"
              "titulo" => "Sinuhe the Egyptian"
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              "identificador" => "sec0060"
              "titulo" => "Trepanation in The Egyptian"
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            2 => "History of neurology"
            3 => "Medicine and literature"
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            0 => "Antiguo Egipto"
            1 => "Cirug&#237;a"
            2 => "Historia de la neurolog&#237;a"
            3 => "Medicina y literatura"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Medicine and literature have been linked from ancient times&#59; proof of this shown by the many doctors who have made contributions to literature and the many writers who have described medical activities and illnesses in their works&#46; An example is <span class="elsevierStyleItalic">The Egyptian</span>&#44; the book by Mika Waltari that provides a masterly narration of the protagonist&#39;s medical activity and describes the trepanation technique&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Development</span><p id="spar7065" class="elsevierStyleSimplePara elsevierViewall">The present work begins with the analysis of trepanations since prehistory and illustrates the practice of the trepanation in <span class="elsevierStyleItalic">The Egyptian</span>&#46; The book mentions trepanation frequently and illustrates how to practice it and which instruments are required to perform it&#46; Trepanation is one of the oldest surgical interventions carried out as treatment for cranial trauma and neurological diseases&#44; but it also had the magical and religious purpose of expelling the evil spirits which caused the mental illness&#44; epilepsy&#44; or migraine symptoms&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar8065" class="elsevierStyleSimplePara elsevierViewall">Trepanation is a surgical practice that has been carried out since prehistory to treat post-traumatic epilepsy&#44; migraine&#44; and psychiatric illness&#46; <span class="elsevierStyleItalic">The Egyptian</span> is a book that illustrates the trepan&#44; the trepanation technique&#44; and the required set of instruments in full detail&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0030">Introducci&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La Medicina y la Literatura han estado unidas desde antiguo&#44; prueba de ello es que muchos m&#233;dicos se han dedicado a la Literatura y muchos escritores han plasmado en sus obras la actividad m&#233;dica y la enfermedad&#46; Un ejemplo es la obra <span class="elsevierStyleItalic">Sinuh&#233;&#44; el egipcio</span> de Mika Waltari&#44; que narra magistralmente la actividad m&#233;dica del protagonista y describe la t&#233;cnica de trepanaci&#243;n&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0035">Desarrollo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El presente trabajo comienza con el an&#225;lisis de las trepanaciones desde la Prehistoria y se ilustra la pr&#225;ctica de la trepanaci&#243;n en <span class="elsevierStyleItalic">Sinuh&#233;&#44; el egipcio</span>&#46; En esta obra se hace referencia en m&#250;ltiples ocasiones a la trepanaci&#243;n y se detalla la forma de practicarla y el instrumental necesario&#46; La trepanaci&#243;n es una de las intervenciones quir&#250;rgicas m&#225;s antiguas llevada a cabo con fines terap&#233;uticos en traumatismos craneales y patolog&#237;as neurol&#243;gicas&#44; pero tambi&#233;n con una finalidad m&#225;gico-religiosa&#44; para expulsar los esp&#237;ritus malignos causantes de enfermedades mentales o de los s&#237;ntomas de epilepsias y migra&#241;as&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La trepanaci&#243;n es una pr&#225;ctica quir&#250;rgica realizada desde la Prehistoria en traumatismos craneales&#44; epilepsias&#44; cefaleas y enfermedades psiqui&#225;tricas&#46; En la novela <span class="elsevierStyleItalic">Sinuh&#233;&#44; el egipcio</span> se describe con detalle la figura del trepanador&#44; la t&#233;cnica de trepanaci&#243;n y el instrumental necesario&#46;</p>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos