How the oldest surgical procedure in the world has evolved over the centuries.
Modern neuroscience is so famously and fascinatingly complex that it has inspired its own idioms—"it's not brain surgery," for example. This phrase plays off the idea that neurosurgery requires extremely sharp wits and manual dexterity, a stereotype that is expertly parodied by this sketch from That Mitchell & Webb Look."Brain Surgeon." Credit: BBC
This connotation makes sense from our 21st century vantage point, given that exotic concepts like brain implants, neural probes, and thought-enhancing smart drugs are casually bandied about in scientific circles.
But you only need to look back a few centuries before realizing that brain surgeons weren't always so sophisticated and precise on the operating table. In fact, for millennia, the most advanced neurosurgical technique available was straight-up drilling into a patient's head, which was seen as a solution to all kinds of mental problems.
This practice is known as trepanation, and according to neuroscientist Charles G. Gross, it is the oldest known surgical procedure, dating back at least 8,000 years. Trepanning also appears to have been an unusually expansive, cross-cultural technique, practiced by ancient peoples ranging from Mesoamerica to Europe to Asia.
We know this because trepanned skulls have been recovered from a variety of burial sites around the world. These wounds are distinguished from other head traumas by their shape, position on the skull, and post-trauma evidence of re-healing.
It's difficult to speculate on what kind of role trepanation played in these preliterate societies, though its sheer ubiquity suggests the procedure was employed in response to a wide variety of different ailments. In addition to treating traumatic head wounds and mental illnesses, archeologists and historians have suggested that may also have been conducted for religious purposes, such as exorcising demons from a supposedly possessed mind.
The tools used in these early operations ran the gamut from sharp pointed rocks to carved obsidian blades. With the advent of metalworking in the Bronze Age, fine-tuned saws and scalpels were used instead, while some cultures developed a technique of scraping down the skull with glass.
But despite these diverse archeological roots, it wasn't until around 400 BCE, when Hippocrates compiled the treatise On Wounds of the Head, that trepanation was first addressed with any level of detail in writing. Even then, the account is somewhat garbled.
"[Hippocrates] could not explain clearly, in the pathological terms used in his time, why routine early trepanning was beneficial," said neurosurgeon Graham Martin in the Journal of Clinical Neuroscience.
"His technique was hesitant, suggesting he himself had never done the routine early trepanning he advocated, and he had not yet realised that his policy would be unacceptable to most Greek patients," Martin continued. "It is suggested that he might have learnt trepanning on a brief trip to Marseilles, where the Gauls had already trepanned for 1,500 years."
Inexperienced though he may have been, Hippocrates certainly understood the need for precision in brain surgery, and advocated proceeding with trepanation only with the utmost care. Furthermore, his treatise cemented the idea that boring a hole in a patient's head was the best way to relieve pent-up pressure caused by blood, madness, demons, or whatever else a physician diagnosed as the underlying problem of an ailment.
There are some exceptions to that rule, however. For example, trepanation was widely practised in Mesoamerica as a therapeutic treatment for headaches, and other brain diseases. But it may also have involved a ritual element as well. It was so popular in the pre-Columbian Zapotec settlement of Monte Albán, for example, that patients occasionally got the procedure done multiple times, as if they were casually filling up a cranial punchcard.
We don't know why these people had their heads repeatedly punctured, or even if it was voluntary. Perhaps Monte Albán was home to a mad scientist who was experimenting with novel brain surgeries, or perhaps these holes are the fallout of initiation rites, or indications of rank or status. With only archeological artifacts to guide us, it's difficult to root out the underlying reasons for such invasive operations.
Fortunately, by the time the 15th century rolled around, trepanation was scrupulously documented by many Renaissance painters in Europe, whose work exposes all kinds of bizarre beliefs about the procedure's ability to supernaturally cure mental problems.
For example, some physicians at this time believed that neurological and psychological conditions were caused by a magical "stone of madness" or "stone of folly" that needed to be extracted from the patient's brain before it corrupted the entire organ.
This weird theory inspired some incredible fine art depictions of trepanation, epitomized by Hieronymus Bosch's fantastically bizarre painting "The Extraction of the Stone of Madness."
Though this notion of an implanted stone of madness turned out to be a brief fad in trepanation's history, the diversity of paintings inspired by it suggests that the theory definitely captured the public imagination.
Fortunately, neurosurgery has matured a lot since the Renaissance, and accordingly, trepanation has been edged out by less hamfisted methods. It is still occasionally used by neurosurgeons as an emergency treatment for hemorrhages, but in this context, it is usually called a craniotomy—a rebrand that distinguishes the traditional burr-hole procedure from its variant in modern medicine.
Interestingly enough, however, trepanation hasn't been excised from public culture, despite the fact that doctors have largely phased it out of practice. Since the mid-20th century, there has been a steady rise in self-inflicted trepanations, inspired partly by a Dutch librarian named Bart Huges, who drilled a hole into his head with a dental tool on January 9, 1965. He claimed the process was painless.
Huges was a big advocate of using mind-altering psychedelics to expand one's consciousness, and he believed that trepanation was basically a one-way ticket to a perma-high. It should come as no surprise that he handcrafted a codex-style scroll called "Homo Sapiens Correctus," in which he argued that trepanation increased the brain's circulatory metabolism, thus curing depression and other psychological conditions.
Huges cultivated a small number of skull-drilling disciples, including filmmaker Amanda Feilding (Huges and Feilding were also romantically involved for a while). Feilding documented her own self-performed trepanation in her 1970 film "Heartbeat in the Brain," and she later ran for Parliament on a pro-trepanation platform (where do the current primary candidates stand on that issue?).Excerpt from the documentary "A Hole in the Head" about self-performed trepanation. Credit: A Hole in the Head
She also performed the surgery on her long-time partner Joey Mellen, with whom, I feel it is important to mention, she has two sons named Rock Basil and Cosmo Birdie. In a 2013 VICE interview, she restated her faith in the underlying benefits of trepanation, though she was open-minded—pun intended—to the idea that trepanation might be a placebo.
"[Trepanation] is still a hypothesis, one which isn't provable at the moment because I don't think we have the instrumentation to fully investigate it yet," Feilding told Joseph Cox. "The research we did on trepanation, which was only done on about 15 people, is not nearly enough to make any concrete scientific claims. We need more research with more people."
There you have it. You can help Feilding and her small trepanated community usher in a 21st century revival of this ancient neurosurgical practice (provided you don't mind performing a little bit of DIY skull-drilling, of course). After all, it's not rocket science—just brain surgery.
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