It’s hard to imagine doctors performing something as invasive and delicate as brain surgery without sophisticated modern medicine, yet historians have proven time and again that the procedure’s roots trace back thousands of years. Some even believe neurosurgery to be the oldest medical “specialty” of all time.
Ancient Egyptian papyri, for instance, have been excavated and read to describe things like suturing skulls and the concept of cerebrospinal fluid. They’ve even been shown to hold outlines of complex neurosurgical operations.
And on Wednesday in the journal PLOS ONE, a team of historians announced evidence of a specific type of brain surgery, known as angular notched trephination, performed on a man who lived in Israel more than 3,000 years ago.
In itself, this information is mind-boggling. The 15th century BC was way before the invention of morphine or antibiotics — and you can completely forget about vital monitors, general anesthesia and classical operating rooms. (Though you might feel a little better knowing that sometimes modern brain surgery is done without general anesthesia too.)
But most importantly, knowing about this ancient surgery could help in our quest to uncover a rich timeline of how medicine has advanced since the dawn of human existence.
“We have evidence that trephination has been this universal, widespread type of surgery for thousands of years,” Rachel Kalisher, a doctoral candidate at Brown University and leader of the crew’s analysis, said in a statement. “But in the Near East, we don’t see it so often. There are only about a dozen examples of trephination in this entire region.”
“In antiquity, there was a lot more tolerance and a lot more care than people might think,” Kalisher continued. “We have evidence literally from the time of Neanderthals that people have provided care for one another, even in challenging circumstances. I’m not trying to say it was all kumbaya — there were sex- and class-based divisions. But in the past, people were still people.”
What is trephination?
As you’d expect, there were some major differences between brain surgery happening now and within the Neolithic Period of 10,000 BC, for instance.
Most notably, long ago, a routine way of approaching cranial procedures was with a mechanism called “trephination.”
Simply, trephination refers to cutting a hole in the skull with a drill — which might’ve been a stone tool in the olden days — to treat head injuries or ease pain. The name is derived from the ancient Greek word “trypanon,” which translates to “borer” or “auger.”
But back then, the drilled hole was expected to be the remedy, and was therefore permanent. This is precisely why scientists were able to see such clear-cut evidence of trephination in their 15th century subject. Today, the closest thing we have to trephination is a craniotomy. However, in contrast to ancient trephination, doctors who perform craniotomies work to replace the drilled piece of skull as soon as possible.
In general, craniotomies are considered rare because of how risky they are. They’re typically performed to treat aneurysms, remove brain tumors or relieve pressure in the brain for other reasons. If you’re a Grey’s Anatomy fan, you’ve definitely seen at least one dramatized craniotomy by now. Probably dozens.
The big question
One of two skeletons — buried alongside fine pottery and other valuable possessions beneath an elite residence in Tel Megiddo, Israel — had a square hole approximately 30 millimeters in the frontal bone of the skull.
The square shape is interesting because, per the researchers, we still don’t know why some trephination remains are triangular while others are square and still others are circular. Presumably, these individuals were brothers, but one is thought to have died young, in his teens or early 20s. The other likely passed sometime between his 20s and 40s.
“You have to be in a pretty dire place to have a hole cut in your head,” Kalisher said. “I’m interested in what we can learn from looking across the scientific literature at every example of trephination in antiquity, comparing and contrasting the circumstances of each person who had the surgery done.”
To that end, the fact that a high-status individual in the 15th century needed such an invasive procedure is intriguing. Back then, for instance, if you were elite, you probably didn’t have to work as much, had access to nutritious food and could be treated by the best possible medical professionals.
Therefore, you’d probably be able to survive a severe illness longer than a non-elite person.
So, the team wondered, what would’ve compelled one of these rich brothers to have a terrifying trephination experience? Upon further analysis, the team came up with some possible answers.
For example, the researchers observed several skeletal anomalies in the brothers’ remains that led them to believe the duo could’ve had a sort of iron deficiency anemia that might’ve impacted their development from childhood. The older brother also had a cranial suture and an extra molar in one corner of his mouth, which Kalisher connects to a congenital syndrome such as Cleidocranial dysplasia. People who have this rare condition possess differently formed, more fragile bones.
Moreover, as Kalisher explains, a third of one skeleton and half of the other shows signs of porosity, lesions and inflammation in the membrane covering the bones, which suggests that the brothers’ ultimate demise was probably due to an infectious disease such as tuberculosis or leprosy.
“Leprosy can spread within family units, not just because of the close proximity but also because your susceptibility to the disease is influenced by your genetic landscape,” Kalisher said. “At the same time, leprosy is hard to identify because it affects the bones in stages, which might not happen in the same order or with the same severity for everyone.”
A deeper investigation is needed to totally decode what happened to these two unlucky brothers. But one thing is for certain, as Kalisher notes. If the angular notched trephination was meant to keep the boy alive, it didn’t work.
Within days, hours or perhaps even minutes of the surgery, the team concluded, the patient died.