Trephination: A treatment you need like a hole in the head.
Just gotta let the ol' brain demons breathe a little.
The last several weeks, I’ve been plagued by near-constant headaches. Don’t worry, I have an appointment (in two months because free-market Western medicine is really great) and I’m sure it’s like, allergies or something. I just take Tylenol every day and hope that my organs don’t quit. It’s fine.
But I can honestly share that when your head hurts, just about everything else hurts, too - and hoo boy does it make you feel crazy.
So when I was reading about antiquated treatments for mental illness, the practice of trephination - literally just drilling a hole in the skull - I wasn’t so much surprised as I was…curious? Because honestly I can’t imagine anything that would help the various symptoms of my own conditions less than adding what must have been an absolutely monstrous headache.
And yet, this practice - which is different than a lobotomy, which we may or may not talk about at a later date but probably not because fuck that’s grim - was surprisingly common and has been practiced for thousands of years. Thousands! Which means entire generations lived and died thinking that it was a totally normal and functional treatment to drill a hole in a person’s dome.
But like…why? What did this treatment allegedly do and why did so many people think it worked? Let’s find out together!
Trephination is Old as Hell
According to a 2013 paper published in the journal Surgical Neurology International, trephination “is the oldest documented surgical procedure performed by man.”
From the paper:
“Trephined skulls have been found from the Old World of Europe and Asia to the New World, particularly Peru in South America, from the Neolithic age to the very dawn of history…We can speculate why this skull surgery was performed by shamans or witch doctors, but we cannot deny that a major reason may have been to alter human behavior – in a specialty, which in the mid 20thcentury came to be called psychosurgery.”
It seems that in the ancient world, the best thing healers of various stripes could figure to do when there was something wrong with the head was to go right to the source. Trephination was performed to alleviate headaches caused by extra blood (so many questions here), to get a look inside, and to release evil spirits or demons from the brain.
You know, it’s like bloodletting. But with demons. And the brain.
We can’t really know how effective these treatments were (I mean, we can because there is literally no way they were actually effective), though because there aren’t great records from 7,000 years ago and also it seems unlikely that the people performing the head-hole-making would be highly credible with regards to self-reporting. But we do know that some of these patients survived the procedure (?!?!) because there is evidence of healing on their recovered skulls.
One has to assume that the other common outcome was a patient who died which, like, problem solved. Plus, there just weren’t a lot of other options at the time. If someone was stark raving mad, what else could a healer/butcher/herbalist/barber do other than try to get the crazy out through a little peephole? Just like, give him some tea to drink? Please.
Cutting the Crazy Out
In the more modern era - like the Middle Ages moving forward - we see ample evidence of trephination, specifically around mental illness.
Again from SNI:
There are telltale works of art from this period that bridge the gap between descriptive art and fanciful surgery. For example, we find the famous oil painting by Hieronymus Bosch (c. 1488-1516) that depicts “The Extraction of the Stone of Madness.” Likewise, the triangular trephine instrument designed by Fabricius of Aquapendente (1537-1619) was subsequently used for opening and entering the skull; triangular trephines had already been modified for elevating depressed skull fractures. And thus, we find variations of the famous engraving by Peter Treveris (1525), illustrating surgical elevation of skull fractures, in many antiquarian medical textbooks.
That work of art, also called “The Cure of Folly,” looks like this:
Neat. My favorite part is how the doctor (?) is wearing a funnel on his head like the Tin Man.
This idea of removing the crazy part of the brain was pretty common in the Middle Ages and well into the Renaissance. After all, sometimes when someone was sick somewhere else - like in their stomach - something like an obstruction could be removed surgically and the person might live (though of course we are well before germ theory and the “surgical” conditions were not ideal).
That Hieronymus Bosch painting actually tells us a lot about trephination in the 1400 and 1500s because it comes with additional material. The title, which refers to the “stone of madness,” tells us that this is must have actually been a belief which had some wind behind it. If Bosch was making art about the process, it would have to be assumed that most people who saw it would have understood the process and the purpose of the hole-making.
Indeed, according to Jordi Vigué in Great Masters of Western Art, “there was a popular belief that a so-called "stone of madness" caused idiocy and dementia.” This hypothetical stone needed to be removed in order to cure a person.
And while this entire idea is…really something, it’s also a notion that might have been more heavily criticized than the royals and members of the court understood.
An Art UK story about the “stone of madness” notes that, in instances where this process if depicted in Western art, “usually the stone is referenced in the painting's title but is not visible in the image, suggesting it's a metaphorical object that describes madness, and that the painter is either playing a joke or commenting on the possibility that fantasy and delusion can sometimes spill over into reality.”
Either way, people definitely did have holes drilled into their head as a potential cure for mental illness, and they definitely were either killed in the process or permanently changed if they did survive. Not only does this entire thing sound massively painful, there’s also no way - knowing what we know about the brain now - that these individuals weren’t injured in the process.
Then again, we can’t be surprised. Folks living with mental illness have been marginalized since the dawn of time, often treated like freaks or monsters or, at the very least, simpletons who couldn’t feel pain and had no brain activity worth saving. So it’s not really that shocking that people - including members of the church and medical field - would feel perfectly comfortable whacking into their brain to have a little look under the hood. Worst case scenario, a loony has died. Best care scenario, you find the stone of madness and become a god among men. Seems like a decent trade in a society that viewed the mentally ill as subhuman, right?
Oh, There’s An Easier Way To Get In There?
Let’s be clear: Trephination did not go out of style because people suddenly started to have more empathy for people with mental illness. And it wasn’t because the stone of madness was either found or disproven. Instead, the skull drilling mostly stopped because there was a better understanding of the brain itself, thanks to Phineas Gage and the understanding of the brain’s lobes as distinct pieces of the overall cognitive puzzle.
The idea that there was a specific locus of insanity in the brain may have faded, but trephination or some version of it continued to be a therapeutic practice even after people finally figured out that you needed to wash your hands before surgery. However, the reasons for conducting the procedure changed, as well.
Charles Goss, who wrote the book A Hole In The Head, explains:
By the 18th 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 19th century trephining for epilepsy was confined to the treatment of traumatic epilepsy, that is, cases associated with known head injury.
Rather than preventative medicine, trephination was used (and still is sometimes) to treat active brain injuries.
However, doctors (and other folks who thought they were qualified) didn’t stop wanting to root around in people’s brains. Rather than going through the skull, which was challenging and also messy, they’d instead go in through the existing passage presented by the eye or the nose. This not only spared them from having to dig out the power tools, it also offered more direct access to the parts of the brain that they now believed (correctly) had the most to do with the personality.
Beginning in 1930s, your skull might have been spared, but your brain matter would definitely not.
Lobotomies - sans trephination - continued to be pretty common treatments well into the 1950s and 60s before they were banned in some countries and highly regulated in others, in part because they did not work and were reducing perfectly healthy human beings to shells of their former selves. Perhaps the most famous lobotomy patient is, of course, Rosemary Kennedy.
Kennedy, the sister of Bobby and John, showed signs of intellectual disabilities early in life. Her father arranged for her to undergo a lobotomy, which was an experimental operation that, at the time in 1941, was advertised as a kind of cure. It went horribly wrong - as basically all lobotomies do - and left her permanently disabled.
She was hidden away, both from the public and her family, for many years following the procedure. It was not until much later that the world learned about treatment and its impacts on her - and lobotomies were conducted in the United States, by her same doctor, for another 26 years before the procedure was finally stopped.
Like I said, this is a highly awful topic, but if you want to learn more, I recommend The Icepick Surgeon, which is a very good read and also a BUMMER. Another good book on the subject is Rosemary Kennedy’s biography called The Hidden Kennedy Daughter.
So there you have it - a historical arc of the barbarism of man against one another. And if we’re honest, a pretty good reminder of what happens when we let people promise us cures for things that we can actually just treat without, you know, completely destroying someone’s brains. Both trephination and lobotomy were popular treatments because they could “cure” craziness. But some of us are just crazy all the time and that’s OK. We don’t need to have our madness cut out. We just need to like, figure out other ways to exorcise the brain demons.