The historical practice of trepanation

by Marc Wilson / 15 September, 2012
If you’re squeamish, read no further about the ancient – and still sometimes advocated – art of trepanation.
Hieronymus Bosch’s 'The Extraction of the Stone of Madness'


Though psychology as a distinct discipline is typically considered to date back to 1879 when Wilhelm Wundt established the first psychology laboratory, its subject matter goes much further back. Our understanding of how people think and behave shapes how we deal with problems in how people think and behave, and a good example of this is the millennia-old practice of trepanation (or trephination) – making holes in the skull to alleviate psychological symptoms. In my psychology lectures on this for first-years, I show some skulls that have been holed, some square and raggedly saw-toothed at the edges, some rounder and smoother. Importantly, the smooth-edged holes indicate the patients must have lived long enough for the bone to at least
start to heal.

Around 800 trepanned skulls have been dug up, and from all over the globe. From these, it appears survival rates were around 90%, indicating the practitioners responsible were pretty good at what they did. A variety of techniques were practised, but the most common involved gradually scraping away at the skull until the dura mater, the membrane that encloses the brain and spine, was exposed. Why would anyone do such a thing? Well, if you believe that the symptoms we identify with depression, anxiety or schizophrenia are caused by evil spirits taking up residence in our noggin, then doesn’t it also make sense to let them out? At least that’s the story I tell, and it’s a common one in introductory psychology textbooks. In truth, it seems we can’t be sure that trepanation was always conducted for this reason. Hippocrates, the “father” of medicine, wrote of trepanation as a procedure for dealing with various types of head trauma – that head injuries caused a build-up of blood that could go bad and should therefore be released.

Paul Broca, famous in neurological circles for identifying in the mid-1800s a key area of the brain associated with speech production, is also credited with playing a part in the “discovery” of trepanation in historic skulls. He speculated initially that the procedure might have served some ritual purpose (bits of skull have been attributed powerful totemic significance), and later speculated the procedure might have been used to treat epilepsy. Hippocrates aside, there are few records to explain the rationale for trepanation among many of the “non literate” and now “dead” cultures that practised it. But these people were uncivilised, right? Surely, these days we need a hole in the head like, well, we need a hole in the head. Not so fast.

First, to characterise this historical practice as irrational is unfair because (where we know the reasoning) it was entirely consistent with the theories of mind and behaviour dominant at the time. Second, trepanation-like surgery is currently used (for example, after head trauma) to relieve swelling that could lead to more serious consequences. Third, you don’t have to do much googling to find people advocating for elective (and freely available) trepanation on the grounds that it is a path to enlightenment and general psychological good health. The International Trepanation Advocacy Group has argued for some time that trepanation has benefits and has even collaborated on research projects testing the underlying theory that trepanation can improve psychological performance by increasing cerebral blood flow. As of 2010, this research has shown that blood flow can indeed increase following trepanation. But call me a sceptic – this doesn’t automatically mean the procedure will be beneficial.
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