A Hole in the Head Read online

  By Galen’s time (129–199) trephining was in standard use in treating skull fracture for relieving pressure, for gaining access to remove skull fragments that threatened the dura, and, as in Hippocratic medicine, for drainage. Galen discussed the techniques and instruments in detail and advocated practicing on animals, especially the Barbary “ape” (Macaca sylvana). He was well aware of avoiding damage or pressure on the dura and indeed carried out experiments on the effect of pressing on the dura in animals.18

  TREPANATION IN ANCIENT CHINA

  The possibility that trepanation was practiced in ancient China is suggested by the following story about Cao Cao and Hua Tua, from a historical novel attributed to Luo Guanzhong, written in the Ming dynasty (1368–1644) and set in 168–280 at the end of the Later Han dynasty. Cao Cao was commander of the Han forces and posthumously Emperor of the Wei dynasty, and Hua Tuo was (and still is) a famous physician of the time.

  Cao Cao screamed and awoke, his head throbbing unbearably. Physicians were sought, but none could bring relief. The court officials were depressed. Hua Xin submitted a proposal: “Your highness knows of the marvelous physician Hua Tuo? . . . Your highness should call for him.” . . .

  Hua Tuo was speedily summoned and ordered to examine the ailing king. “Your Highness’s severe headaches are due to a humor that is active. The root cause is in the skull, where trapped air and fluids are building up. Medicine won’t do any good. The method I would advise is this: after general anesthesia I will open your skull with a cleaver and remove the excess matter, only then can the root cause be removed.” “Are you trying to kill me?” Cao Cao protested angrily . . . [and] . . . ordered Hua Tuo imprisoned and interrogated.

  Ten days later Hua Tuo died . . . his medical text was lost upon his death.19

  WESTERN MEDICINE

  From the Renaissance until the beginning of the nineteenth century trephining was widely advocated and practiced for the treatment of head wounds.20 The most common use was in the treatment of depressed fractures and penetrating head wounds. However, because of the high incidence of mortality particularly when the dura was penetrated, there was considerable debate in the medical literature throughout this long span about if and when to trephine.21 Besides trephining in cases of skull fracture, the Hippocratic practice of “prophylactic trephination” in the absence of fracture after head injury continued to persist. For example, in the 1800’s Cornish miners “insisted on having their skulls bored” after head injuries, even when there was no sign of fracture.22

  Until the early nineteenth century trephination was done in the home (figures 1.4 and 1.5). However, when the operation was moved to hospitals, the mortality was so high that trephination for any reason including treatment of fractures and other head injury declined precipitously.23 The practice was so dangerous the first requirement for the operation was said to be “that the wound surgeon himself must have fallen on his head.”24 Or as Sir Astley Cooper put it in 1839, “If you were to trephine you ought to be trephined in turn.”25 It was against this background that the discovery of Neolithic trephining was so unbelievable to the American and French medical communities in the middle of the nineteenth century. Eventually, the introduction of modern antisepsis and prophylaxis of infection at the end of the nineteenth century, as well as an increased understanding of the importance of intracerebral pressure in head injury, allowed trephination to return as a common procedure in the management of head trauma.26

  In modern neurosurgical practice, trephining is still an important procedure but it is no longer viewed as therapeutic in itself. It may be used for exploratory diagnosis, for relieving intracerebral pressure (as from an epidural or subdural hematoma), for debridement of a penetrating wound, and to gain access to the dura and thence the brain itself (for example, to provide a port through which a stereotactic probe can be introduced into the brain.)

  EPILEPSY AND MENTAL DISEASE

  In the European medical tradition, in addition to its use in treating head injury, trephining has been an important therapy for two other conditions, epilepsy and mental illness.

  Figure 1.4

  A sixteenth-century woodcut of a trephination in the home. Note the man warming a cloth dressing, the woman praying, and the cat catching a rat (Dagi, 1997).

  Figure 1.5

  Trepanation scene from Diderot’s encyclopedia (Diderot and D’Alembert, 1761) Used with kind permission of the Princeton University Rare Books Collection, Princeton, New Jersey.

  The tradition of trephining as a treatment for epilepsy begins as early as Aretaeus the Cappadocian (ca. 150), one of the most famous Greek clinicians, and lasted into the eighteenth century. The thirteenth-century surgical text Quattuor magistri recommended opening the skulls of epileptics “that the humors and air may go out and evaporate.”27 However, by the seventeenth century trephination for epilepsy was beginning to be viewed as an extreme measure, as in Riverius, The Practice of Physick (1655):

  If all means fail the last remedy is to open the fore part of the Skul with a Trepan, at distance from the sutures, that the evil air may breath out. By this means many desperate Epilepsies have been cured, and it may be safely done if the Chyrurgeon be skilful.28

  By the eighteenth century the incidence of trephining for epilepsy had declined and its rationale changed. Now rather than the idea of allowing an exit for evil vapors and humors, the purpose was to remove some localized pathology. By the nineteenth century trephining for epilepsy was confined to the treatment of traumatic epilepsy, that is, cases associated with known head injury.29

  Another use of trephining was as a treatment for mental disease. In his Practica Chirurgiae, Roger of Parma (ca. 1170) wrote:

  For mania or melancholy a cruciate incision is made in the top of the head and the cranium is penetrated, to permit the noxious material to exhale to the outside. The patient is held in chains and the wound is treated, as above, under treatment of wounds.30

  Robert Burton, in his Anatomy of Melancholy (1652), also advocated boring a cranial hole for madness, as did the great Oxford neuroanatomist and physician Thomas Willis (1621–1675). (See chapter 5.)

  Probably the most famous depictions of apparent trephining for mental disease are in early Flemish Renaissance painting. Thus, Hieronymus Bosch’s (1450–1515) The Cure for Madness (or Folly), also known as The Stone Operation (figure 5.1) shows a surgical incision being made in the scalp. The inscription has been translated in part “Master, dig out the stones of folly.”31 There are similar depictions of the removal of stones from the head by Peter Bruegel, Jan Steen, Pieter Huys, and other artists of the time (figures 5.2, 5.3, and 5.4). The interpretations of these paintings by art historians and their relation to the medical practice of the times are discussed in chapter 5.

  By the eighteenth century, “most reputable and enlightened surgeons gave up the practice of . . . [trephination] . . . for psychiatric aberrations or headache without evidence of trauma. Thus, . . . the skull was never to be trephined for ‘internal disorders of the head.”’32

  TREPHINING IN AFRICA

  Herodotus describes the Libyans as cauterizing the heads of their children to “prevent them being plagued in their afterlives by a flow of rheum from the head.” And indeed, trephined skulls have been found among the people he was probably writing about, the Tuareg nomads.33

  A important source of information on the motivations for trephination is contemporary traditional practitioners and their patients. There are literally hundreds of twentieth-century accounts of trephination, particularly in Oceanic and African cultures. Especially detailed and recent ones concern the Kisii of South Nyanza in Kenya and include photographs of the surgical instruments, practitioners, and patients; X-rays of the skulls of surviving patients; detailed interviews; and even a documentary film.34

  Trephining among the Kisii is carried out primarily for the relief of headache after some kind of head injury. According to Margetts, it is not done for “psychosis, epilepsy, dizziness or spiri
t possession.”35 The operation is carried out by general practitioners of medicine and takes a few hours. Restraint rather than anesthesia is used. The hole in the skull is usually made by scraping with a sharp knife with a curved tip to avoid injuring the dura. Various medicines are administered before, during, and after surgery but their nature does not seem to have been studied. Mortality, by one authority, is described as “low, perhaps 5 per cent.” The practitioners and patients seem to be quite satisfied with the results of the operation.36

  Although headache after head injury is the most prevalent reason given for trephining by contemporary practitioners of traditional medicine in Africa and elsewhere, other reasons are cited in the literature such as “to let out the evil spirits which were causing an intractable headache.”37

  TREPHINING ON THE INTERNET

  Today, the practice of trephining is not confined to surgical suites or traditional medicine men. It is advocated by the International Trepanation Advocacy Group as a means of enlightenment and enhanced consciousness. Their general idea is that when the skull sutures close in childhood it “inhibits brain pulsations causing a loss of dreams, imagination and intense perceptions.” Trephining a small hole, they say, “restores the intracranial pulse pressure which leads to a permanent increase of the brain-blood volume which leads to accelerated brain metabolism and more areas of the brain functioning simultaneously” and “increased originality, creativity and...testosterone level.”38 Beyond such “physiological” arguments, the group supports the practice by pointing out its ancient, widespread, and continuing presence in other cultures. This particular form of alternative medicine recently gained considerable if not entirely positive publicity: in November 1998 it was featured on ER, the television soap opera set in an emergency ward.

  Much of the defense for alternative medicine treatments is that they must work because they have been around for such a long time, an apparently attractive argument for the increasing popularity of five-thousand-plus-year-old Chinese traditional medical practices. However, the case of trephining suggests that just because a procedure is very old does not mean it is necessarily an effective one, at least for enhanced enlightenment and creativity.

  TREPANATION AS AN EMPIRICAL IF NOT A RATIONAL PROCEDURE

  The most common view of the prehistoric and the non-Western practice of trephining, especially in the absence of a depressed fracture, was that it represented some kind of “superstition,” “primitive thinking,” “magic,” or “exorcism.” Yet an examination of the reasons for the practice among the Hippocratic and early European doctors as well as among contemporary Kenyan practitioners suggests a different view. Trephining may have appeared, in these contexts and cultures, to have been an effective empirical approach to head injury and the headaches that often accompany them. Headaches after head injury often do feel like “a pounding” and “pressure” inside the head and thus the idea that a hole in the skull would relieve them is not necessarily magical or bizarre. Furthermore, epidural bleeding does sometimes accompany head injury, and in these cases trephining might have actually reduced intracranial pressure. Finally, the apparently excellent survival rate meant that the procedure, at least until it moved into a hospital setting, may have met the prime requirement of medicine, “do no harm.”

  POSTSCRIPT

  The first International Colloquium on Cranial Trepanation in Human History was held at the University of Birmingham in April 2000. Papers from this unique three-day meeting were published as Trepanation: History, Discovery, Theory,39 which provides the most complete review of the subject to date. A major achievement of the meeting was the demonstration that trepanation was widespread in many regions of Europe, Asia, Africa, Oceania, and the Americas in both preliterate and literate periods. The volume also contains illustrations of trephined skulls from many cultures and of the great variety of instruments used.

  Another interesting development was the return of E. L. Margetts to the Kisii of Kenya, whose trepanning practices he had studied 25 years earlier.40 He estimates that there may now be more than 100 surgeons carrying out the operation. Unlike in the past, they now use modern Western local anesthetics injected into the scalp prior to surgery. However, the reasons for the very low rate of infections still have not been studied systematically.

  Since my original article, there seems to have been an increase in Internet sites advocating trepanning and often self-trepanning for the treatment of, among other disorders, depression, chronic fatigue syndrome, and stress and to improve mental “energy and vigor.”41

  The British Medical Journal took these developments seriously enough to issue a warning of their dangers:

  Doctors have warned about the dangers of trepanning after the launch of several websites promoting the “do it yourself ” surgery and the case of a Gloucestershire woman who drilled a 2 cm diameter hole in her skull. Concern has been expressed about the growing interest in trepanning for several conditions, including depression and chronic fatigue syndrome. Concern is also growing about the increasing promotion of trepanning, including videos, T-shirts, and a virtual trepanning shopping mall on the internet.42

  Trepanning received widespread publicity when the surgeon Stephen Maturin carried out the procedure on a sailor in view of the assembled crew in the film Master and Commander: The Far Side of the World, based on the Patrick O’Brian naval novels about the Napoleonic Wars.43

  NOTES

  Earlier versions of this article were published in The Neuroscientist (5: 263–269 [1999], “A hole in the head”) and in Trepanation: History, Discovery, Theory (ed. R. Arnott, S. Finger, and C. U. M. Smith [Swets and Zeitlinger, 2003], “Trepanation from the Paleolithic to the Internet”). My motivation in choosing this subject was to start with the earliest evidence for knowledge of the brain among people other than the hunter and the cook.

  1. Squier, 1877. Squier was an engineer turned journalist with an interest in aboriginal culture. As a reward for helping the presidential campaign of Zachary Taylor he was appointed Charge d’Affaires to the “Republic of Central America,” which enabled him to travel extensively and write abut the region (Fernando and Finger, 2003).

  2. New York Academy of Medicine, 1865.

  3. Lisowski, 1967; Majno, 1975; Bakay, 1985.

  4. Schiller, 1992. Schiller claims that Broca was less racist than most of his contemporaries. This may help explain Broca’s readiness to accept the trephined skull as a result of skilled surgery by an Inca Indian.

  5. Schiller, 1992.

  6. Schiller, 1992; Sigerist, 1987.

  7. Schiller, 1992; Sigerist, 1987; Finger and Clower, 2003.

  8. Lisowski, 1967; Margetts, 1967; Saul and Saul, 1997.

  9. Lisowski, 1967; Saul and Saul, 1997.

  10. Schiller, 1992.

  11. Hippocrates, 1927.

  12. Wilkins, 1997; Thompson, 1938.

  13. Lisowski, 1967.

  14. Bakay, 1985; Wilkins, 1997; Woodall, 1639.

  15. Hippocrates, 1927; Rocca, 2003a. A more recent discussion of Hippocratic trephination is Dimopoulous et al., 2008.

  16. Hippocrates, 1927.

  17. Majno, 1975.

  18. Rocca, 2003a; Dimopoulous et al., 2008.

  19. Guanzhong, 1991; the real Hua Tuo (ca. 200) had “enduring fame” as a surgeon for using some type of general anesthesia in surgery, for medical gymnastics (Frolics of the Five Animals), and for his skill as an acupuncturist (Lu and Needham, 1980). From the Wei dynastic history, Lu and Needham (1980) give a different version of Hua Tuo’s interaction with the emperor than the one in Guanzhong’s novel, viz., the emperor suffered from migraine, mental disturbances, and dizziness, and Hua Tuo gave acupuncture at a point in the sole of the foot and he was immediately cured. Since Lu and Needham’s classic, Hua Tuo has become popular on Chinese medicine Internet sites, there are a number of remedies named after him, and there is even a translation of his supposed work Classic of the Central Viscera (Hua Tuo, 1993).

  20. Lisowski, 1
967; Bakay, 1985; Woodall, 1639; Goodrich, 1997; Dagi, 1997; Wehrli, 1939.

  21. Dagi, 1997.

  22. Rosen, 1939.

  23. Bakay, 1985.

  24. Majno, 1975.

  25. Flamm, 1997.

  26. Dagi, 1997.

  27. Aretaeus, 1856; Temkin, 1971.

  28. Temkin, 1971.

  29. Temkin, 1971.

  30. Valenstein, 1997.

  31. Cinotti, 1969.

  32. Mettler and Mettler, 1945.

  33. Margetts, 1967.

  34. Margetts, 1967; Grounds, 1958; Coxton, 1962.

  35. Margetts, 1967.

  36. Margetts, 1967; Grounds, 1958; Coxton, 1962.

  37. Margetts, 1967.

  38. This account and the quotes were derived from a Web site, www.Trepan.com, accessed in 1999, which no longer exists in its original form. Trepanation sites on the Internet seem to come and go.

  39. Arnott, Finger, and Smith, 2003. For some reason, the presentation at the meeting of a modern-day advocate of trepanning for “raising consciousness” was omitted from this volume of the papers from the meeting.

  40. Margetts, 1998.

  41. Oft-cited print accounts include that of Mitchell, 1999.

  42. Dobson, 2000.

  43. This incident is from O’Brian (1984).

  2

  HEART VERSUS BRAIN: GALEN AND THE SQUEALING PIG

  BACKGROUND

  Galen of Pergamon (129– ca. 213), “Prince of Physicians,” was the outstanding and most influential physician, anatomist, and experimental physiologist of classical antiquity. The following essay, “Galen and the Squealing Pig,” describes his most famous public physiological demonstration. Galen used this live demonstration to support the still disputed view that the brain, as opposed to the heart, controls thought and action. This new preface to the paper provides the background of the controversy over the role of the heart and the brain.