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Put a Hole in That Skull!
Trepanning, an operation whereby a hole is drilled into the skull, has a long history. But why did our ancestors drill holes in skulls?
If we were asked what we believed is the oldest medical procedure for which tangible proof exists, the answer, surprisingly, would be trepanning. The first skull which shows signs of this kind of surgery has been dated back several thousand years. The earliest examples with man-made holes in skulls come from the Neolithic. Although it is impossible to create a definitive timeline and identify the earliest trepanned skull that has been unearthed by archaeologists, the one discovered at a Neolithic site in Omdurman, Sudan, is likely to be among the oldest.
What is more, from an archaeological perspective, this period has turned out to be a source of a surprising number of trepanned skulls. There is a site in France where almost a third of all skulls from 6500BC – about 40 pieces – have signs of trepanning. Altogether, it appears that the procedure was used to varying degrees depending on the continent, and yet some estimates claim that as much as five percent of all well-preserved skulls from the Neolithic may have been trepanned.
As previously mentioned, early signs of skull surgery have been found outside of Europe as well. Among others, the practice was found in Pre-Columbian Indian cultures, and there are even illustrations of it from the post-colonial period, not only from Mesoamerica but the Andes as well. In the Andes, at a site once inhabited by the Paracas culture (800-100 BC), some trepanned skulls were found during grave excavations in the Ica valley. The practice was even more widespread in Central America, as evidenced by a series of skulls from between 950 and 1400, excavated at the sites of Oaxaca, Tilatongo, and Monte Albán. Trepanning was preformed not only on men but on women and children as well, and the survival rate is estimated to have been 70-80 percent.
The technique of trepanning was also employed by Ancient cultures. For example, the 4,000-year-old Edwin Smith Papyrus features the following sentence: “First, shave the patient’s head with a sharp, flat stone, while your assistant sharpens the other stones. If possible, get the patient drunk, then gather six strong men to hold him down while you cut the skin and put a hole in the skull. Perform this procedure quickly and disregard the patient’s cries. Use mud or tightly-applied tree bark to cover the hole.” As a final piece of advice, the text adds that hope is the best medicine.
In addition to the Egyptians, the Ancient Greeks were also interested in the brain. Hippocrates (born c. 460 BC) was the first who, while investigating head injuries, concluded that two hemispheres of the brain can work independently. As a result, he was a big proponent of trepanning, although he also saw that science would eventually come up with more efficient procedures. Galen, who lived in the 2nd century AD, defined the methodology of medical science for hundreds of years. While living in Rome he was given the opportunity to treat the gladiators of the Colosseum. He later summarized his findings, and copies of his manuscript were also preserved during the medieval period. He experimented with a range of herbal soporifics, including belladonna, jimsonweed, poppy seed, and mandrake.
Following in Galen’s footsteps, trepanning continued to be used in Europe during the Middle Ages. A wider variety of sleeping solutions came to be employed, and over the centuries the physicians of the time also became more experienced. The tools of the trade continued to develop too: For example, Hieronymus Bosch depicted a trepanning involving a skull clamp and a drill. It was probably the accumulated knowledge of centuries past that led to physicians paying special attention to using appropriately clean tools despite the circumstances of the period. They were also careful enough to cover the hole in the skull with a metal plate – or at least some kind of hat that had a harder object sown into it in the right place. Medieval physicians also figured out that, while cutting through the skin and the skull hurts quite a bit, the brain itself does not feel pain.
The procedure of trepanning was known almost all over Europe, even though it was presumably more rarely used than in earlier periods. In Spain, for example, the archaeological site near Soria yielded the remains of a 50-55-year-old man and a 45-50-year-old woman from the 13-14th century. The bone regrowth on the skull is a sign of healing, which indicates that the patients survived the procedure and went on to live several more years afterwards.
It should be noted, however, that Galen was not the only one responsible for the spread of trepanning in Europe. It was likely also used by the nomads of the steppes. Hungarian graves from the 10th century have also revealed a large number of trepanned skulls – their ratio is close to 10 percent. They are likely to have adopted the practice from the East, as it was also known in Asia, with proof including archaeological discoveries from Ancient China. The majority of Hungarian trepanning operations likely served a ritualistic purpose rather than a medical one, since there were cases of symbolic trepanning as well, in which the skull was not drilled all the way through and only the surface of the bone was carved off.
While people used to believe that the hole was meant to help cleanse patients of evil spirits, during the late medieval period this explanation was abandoned. Still, illnesses explained with demons, such as epilepsy, were sometimes treated by trepanning. The same was true for migraine, chronic headaches, and some psychological diseases.
While both the tools and the technology had become more advanced in the medieval period and the modern age, little was actually known about the nature of diseases. It was Louis Pasteur who discovered that the gangrene that followed various operations was the result of microorganisms. His innovations gave birth to antiseptic surgery, which greatly reduced the mortality rate among patients who had to be operated on. He used carbolic acid against bacteria and would clean his hands, instruments, and bandages as well. Pasteur also did away with the practice of performing surgery in his everyday attire, and in subsequent decades surgical clothing improved greatly.
Meanwhile, the 19th century also brought about a revolution in the substances used to put patients to sleep. This used to be a major problem in earlier centuries, and the advancement of technology allowed for experimentation with more and more solutions. Opiates had already replaced alcohol in earlier centuries, but none of them proved entirely appropriate for surgical purposes. There were experiments with laughing gas, diethyl ether, cocaine derivatives, morphine, and even hypnosis. They each produced a variety of problems. On the one hand, their dosage was impossible to calculate accurately, which often resulted in overdoses. The other issue was side effects, and there arose a need to avoid vomiting during and addiction after the procedure.
Thus, as the century went on, the field of professional anesthesiology slowly came into being, which collected, organized, and applied the lessons learned during operations. As a result, there was an increasingly better chance of having access to the right substances for each surgery, including ones involving the skull. That said, the workings of the brain were still relatively unknown, and sometimes after a procedure there were unexpected side effects despite an otherwise full recovery, including partial amnesia and considerable changes in personality.
The 20th century brought about major advancements in the field of medical science – partly thanks to the two world wars. As in previous centuries, the various head injuries on the battlefield provided an opportunity to analyze the result of trauma and to map the human brain. The increase in wartime spending usually brought with it larger budgets for the military for medical purposes. The 1920s gave birth to the science of neurology, which made it possible to identify what processes the various larger parts of the brain are responsible for.
Moreover, technological development has made it possible for the brain to be examined with non-invasive procedures. The first breakthrough was the invention of the x-ray, which allowed for the observation of the skull’s bone structure and potential injuries before an operation. The first electroencephalography was created by Austrian physiologist Hans Berger in 1929, whereby he made it possible to survey the brain’s electric impulses and use the resulting information to draw conclusions regarding potential defects. Roughly at the same time the technique of cerebral angiography was born, which offered a “look” into the veins of the brain via a contrast agent injected into the blood stream.
The 20th century saw several other inventions added to the toolset of medical procedures performed on the skull, including MRI and the PET scan, which also contributed to the spread of non-invasive inquiries. There are also current promises of widely-applicable methods such as laser treatment without opening up the skull and operations performed by robots. It seems that the constant advancement of the earliest medical procedures is not about to come to an end, despite having come a very long way since the first attempt at trepanning.
These days when we talk about brain surgery we usually think of an operating room outfitted with sophisticated instruments, as well as a long and expensive procedure. The concept of performing surgery on a human brain has become intertwined with modernity. However, as surprising as it may seem, people from ages long past also performed surgery on the skull, despite not having access to the tools that by now have made the task much safer. Below is the history of trepanning: an operation whereby a hole is drilled into the skull.
Did you know?
In 1965, Dutch librarian Hugo Bart Huges drilled a hole in his skull in the belief that trepanation would enhance his brain functions.
Archeological evidence shows that trepanation was quite a common practice in the society of pagan Hungarians. More than 10 per cent of the skulls that date back to the pre-Christian era of Hungary had the signs of trepanation.
Trepanation was also frequently performed in the pre-Columbian civilizations established in the Andes. It is estimated that more than 70 per cent of the patients had a successful operation.