Like you Need a Hole in the Head! a Defense of Trepanation

I recently wrote an article for Renaissance Magazine about the Brighter Side of Medieval Surgery, because, yes, there is one. If you’re not a subscriber, you can find the ‘zine at many bookstores, or on their website at But here, I’d like to take a closer look at one of the topics covered in more detail, that of trepanation, the practice of cutting a hole in the skull of the patient.

An illustration of a trepanation in progress, from Hieronymous Bosch (1450-1516)

An illustration of a trepanation in progress, from Hieronymous Bosch (1450-1516)

One of the misconceptions that moderns have about this surgery is that the primary use was to “let out evil spirits,” that it was a misguided and dangerous act, likely perpetrated against persons with mental illness or migraine headaches. Here is another example of the failure to recognize the granularity of history. There are suggestions from ancient artworks that such a goal might have been behind some number of prehistoric trepanations. Interestingly, evidence from graveyards suggests that about 75% of persons who underwent the surgery in prehistoric Mesoamerica survived (the bone has had a chance to heal).

Statistics from 14th century cemeteries have similar results. But were they performing the surgery for the same reason? Both Mesoamerican combat, featuring cudgels, and medieval combat, featuring flails, hammers, axes and falls from horses, have a pretty high level of cranial injuries. The one area where modern practice for a long time encouraged trepanation (and depending on the injury still does) is that of compressed skull fracture, where the skull is pierced and instruments use to elevate the broken bone to relieve pressure on the brain. Ambriose Pare, in his Apologie and Treatise, describes just such a recovery when he treated a knight struck by cannon shot who lay for 14 days “without saying a word” after vomiting and convulsions, until the trepanation was performed. As to the frequency of the operation, Pare says that, after the assault of Rouen, 1562, he performed eight or nine to relieve those who had been struck by stones during the siege.

And in the earlier Chirurgia Magna, Guy de Chauliac presents several pages of descriptions of head injuries, with reference to similar lists by earlier surgeons, and discusses how to treat them, including admonitions against cutting if it’s not necessary, and reference to the caution required to interact with the dura mater protecting the brain. He does caution against performing the operation at the full moon, interestingly because “the brain is puffed up against the dura mater.” So he gives an astrological explanation to the underlying concern about swelling which requires this level of intervention to begin with.

Most of the historical medical texts I have here in my office cite trepanation only in regards to the treatment of head injuries. There are numerous references on-line to the idea that it was used to treat mental illness, but the citations for these lack documentary evidence and are based on theories applied when the skulls do not appear to have suffered trauma as from an injury. (here is one nice article describing the history of research on trepaned skulls from archaeological sites) So I’m starting to wonder about the persistence of the notion among laymen that the primary use of trepanation was for non-medical purposes. If you know of articles or evidence relating to such uses, please pass them along!

Certainly, there are people today who believe that trepanation could open new levels of consciousness, including those who go so far as to advocate or attempt self-trepanation. I will not give them the authority of linking to their material, but if you are curious, a simple google search will suffice.

As an aside, you will also see the term “trephination” used to describe this operation. The trephine was a specific tool for cranial surgery developed during the middle 1500’s to reduce the likelihood of accidental penetration of the brain by allowing a one-handed use, and by introducing a sort of truncated cone-shaped circular drill so that the opening in the bone widened outward.

About E. C. Ambrose

I spend as much time in my office as I possibly can--thinking up terrible things to do to people who don't exist.
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1 Response to Like you Need a Hole in the Head! a Defense of Trepanation

  1. Pingback: Book Launch day, Elisha Rex! | E. C. Ambrose

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