A Hole in the Head: A History of Trepanation | Hacker News Reader

A Hole in the Head: A History of Trepanation

thereader.mitpress.mit.edu

63 pointsfortran7746 comments

> let blood by perforating with a small trepan

Trepanation makes really good sense for epidural hematomas.

Epidural hematomas are bleeding that occurs between the skull and the dura which is the tough outer covering of the brain. This can happen from trauma. When that happens blood flows into the space between the dura and the skull and starts building up there. Eventually the pressure will build up and the blood will start pushing the brain. If this continues, the blood will build up enough to push the brain out through the base of the skull. This is called brain herniation, and is fatal.

Natasha Richardson, Tony award winning actress and Liam Neeson's wife, died several years ago from this type of bleed.

An epidural hematoma would be perfect to treat with a trepan. One of the big risks of trepanation is that you pierce or tear the dura during the operation, which will cause cerebro-spinal-fluid (the fluid around the brain and spine) to leak and can introduce bacteria that cause meningitis. With an epidural hematoma that is less likely, because the blood has built up under the skull and pushed the dura down, leaving a cushion of blood there. This makes it less likely for you to injure the dura.

The results likely would have been spectacular for the ancient practitioner. The patient would initially be increasingly sleepy their eyes would be fixed looking to one side. When the bone was cut out and removed, there would be a bunch of blood that drained out, and the patient would rapidly improve as the pressure on the brain was relieved.

Source: Trained in Neurosurgery

> When the skull was presented to a meeting of the New York Academy of Medicine, the audience refused to believe that anyone could have survived a trephining operation carried out by a Peruvian Indian. Aside from the racism characteristic of the time, the skepticism was fueled by the fact that in the very best hospitals of the day, the survival rate from trephining (and many other operations) rarely reached 10 percent, and thus the operation was viewed as one of the most perilous surgical procedures. The main reason for the low survival rate was the deadly infections then rampant in hospitals

The elephant in the room is that many cultures were far more advanced in their prevention and treatment of infectious diseases. The Incas figured out that certain fermented plants had health benefits, which we now know is because they contained bacteria which produced penicillin: https://en.wikipedia.org/wiki/Tocosh.

The Persians and Greeks similarly used fermented hay for their antibiotic properties, although they hadn't developed the microscope to understand why it worked.

How to make penicillin at home: https://www.primalsurvivor.net/make-penicillin-home/

I am continually amazed at how human beings can find a process that works without knowing the 'real' reason behind why it is effective.

This is exactly the scientific process! Observe results, reproduce conditions, and then figure out how it works later.

This is what happened when the cure for scurvy was discovered, it was eventually lost because it was not understood that ascorbic acid was the reason behind the curative powers of certain foods.

https://idlewords.com/2010/03/scott_and_scurvy.htm

More along the same lines:

Ancient African Cocktail: Beer and a Shot of Antibiotic https://www.livescience.com/11028-ancient-african-cocktail-b...

Ayahuasca is interesting in this respect. The effects require the co-ingestion of two different plants - one contains DMT which is usually metabolized too quickly to have a psychoactive effect. The other contains a MAOI that deactivates the enzyme which deactivates DMT, allowing it to have effect.

The MAOI plant does have some psychoactive effects alone - and increases the effects of many things, so that's probably how this was discovered, but still pretty amazing that people were able to figure this out through trial and error.

Interesting that this was a real technique. It sounds strange, but sometimes when I have a very bad headache I’ll keep imagining that a small hole would relieve the pressure.

It still is a real medical intervention used in some emergencies to relieve pressure in the skull

My spouse does this. Traumatic brain injuries often lead to swelling/fluid buildup, and if a serious TBI isn’t relieved by a drain or bone flap, the brain can herniate through the base of the skull.

If you are interested, I suggest watching Hamilton's Pharmacopeia S03E06 UltraLSD discusses trepanation with Amanda Feilding.

There is also a manga titled Homunculus about a man who gains a sixth sense after trepanation.

This article was absolutely boring. I need another trepanning article like I need a hole in my head.

Pun(s) intended.

What is incredible is that these procedures were done on people who lived for many years after them, by people whose supposed knowledge of medicine was dubious at best.

Being on the receiving end without general anesthesia also sounds pretty incredible: how many of us could take an hour of having a caveman scrape away at your skull with a flint, which is one of the documented methods mentioned?

I think the head wound itself would cause pain, but I'm not sure the bone scraping would cause more than some slight discomfort.

I think it's more the trauma of someone scraping at your head than anything. But, there's many ways of knocking someone out or making someone not feel or care about feeling it.

Makes you wonder which current medical procedures will be considered crazy in hindsight few decades from now.

Chemotherapy has to be high on the list. Amputation. ACL reconstruction. Gender reassignment surgery. Defibrillation.

Okay I’ll bite - what could replace gender reassignment surgery? We’re a long way off from Iain m banks style gender transitions…

Three possible options, some possibly far-fetched, but most likely not impossible at some point, that come to my mind?

* Non-surgical body modification (organ regrowth?).

* Brain treatment of dysphoria.

* Developmental treatment of the fetus to prevent body-brain mismatch.

Option 2 sounds like attack of the body snatchers. Whoever would be left in that body wouldn't be the same person who went into the procedure.

I can assure you that if some kind of brain treatment could remove my mental problems I'd jump on it. Making an unhappy person into a different one seems to be exactly the point.

Making a transgender person into a cisgender person is a bit different, though I wouldn't remove any of my mental problems either, so maybe it's a philosophical disagreement.

I'm not quite sure that's what you'd need to do; perhaps removing dysphoria would be enough.

The goal of transition is to reduce the things that otherwise make you uncomfortable, and that discomfort is called dysphoria. So having dysphoria and being transgender are more or less synonymous.

From what I understood, clinical dysphoria is not always present in transgendered individuals.

Maybe not "a few decades" out (though, who knows?) but I'd really hope medicine will at some point be able to offer less traumatic and more effective options than reassignment surgery. Same with people with missing limbs, disfiguration, body image issues. There shouldn't be any fundamental obstacle in having things grow into other shapes and forms or just grow back, though the engineering challenges are probably enormous and brutal.

What do you gain from taking shots at people who aren’t a threat to you?

You mean football players with a reconstructed ACL? Because those listed are all very unpleasant medical procedures that should be replaced with less painful, more efficient alternatives.

Tommy John surgery, maybe?

The impression I got from this article was not that trepanation is to be considered crazy at all. We still do it, and for mostly the exact same reasons that Galen gave for it

I hope the way we surgically treat cancer by cutting it out and hoping we got enough margin will be viewed by future generations as primitive. I’m hopeful medicine will eventually advance to the point where cancers can be treated (or, fingers crossed, cured) with a pill, or perhaps even prevented altogether.

Kinda doubt that. For example, stitching the wound's edges together is pretty damn primitive if you ask me but it's not going away anytime soon. And so is excision: if there is a part of body you'd like to be absent, then cutting it away is a pretty obvious, straightforward and reliable way to achieve that.

"Doctor, my ear hurts, and the surgeon told me that he'd have to cut it off" — "Ah, those surgeons, they only know how to cut things off. Here, take this pill, and your ear will drop off on its own".

Reminds me of one of my favourite Star Trek scenes: https://www.youtube.com/watch?v=1i3gp_aN1cs

"My god, what is this, the Dark Ages?"

"Sounds like the goddamned Spanish Inquisition."

The coarseness of pharmacological dosing:

Right now, if the average effective dose is 10mg, doc just gives you 10mg. Often pharmacies can only provide multiples of this. People can have very dramatic differences in drug metabolism and tolerance, so this 'one size fits all' attitude is very coarse.

I think it would be much better for certain medications, particularly ones that are taken over longer periods of time, to be titrated more carefully:

- First dose should be <= 1/10th effective dose to check for hypersensitivity or allergies

- Early doses should gradually titrate up - patient has no tolerance, and so early doses will have more effect. Titration should watch for both whether therapeutic effect is being achieved and whether side effects occur.

- If therapeutic effect is achieved, stop increasing the dose. Possibly slowly reduce the dose until therapeutic effects are insufficient and then step up a little but in order to minimize side effects.

- If side effects are too severe and no therapeutic effects are found, look for another drug.

* This could be counterproductive for certain medications, like antibiotics or drugs with atypical dose response curves

I think the main hurdle is that custom-dosing medications is expensive to do currently. Also requires an ability to quickly detect and react to whether therapeutic or side effects are occurring, which is also expensive and has patient compliance issues.

When I hear the word trepanation: https://www.metal-archives.com/images/3/5/4/0/3540364223_log...

For me it's this: https://scaphism.bandcamp.com/track/trepenate-the-undesired

With bonus spelling mistake and a Ghostbusters reference.

Makes me think of:

https://web.archive.org/web/20010406062920/http://crank.com/...

Issue #2 and a follow-up in Issue #4.

Trepanning always reminds me of His Dark Materials.

Adrian Selby's book Brother Red[1] contains a race of people, the Oskoro and Ososi, who appear to undertake trepanning and then plant things in their heads. At least that's how I imagined it!

[1] https://www.adrianselby.com/brother-red-2020-orbit/

Sawbones podcast always signs off with “don’t drill a hole in your head.” Seems like a decent suggestion.

https://maximumfun.org/transcripts/sawbones/transcript-sawbo...

Thanks for sharing, I found a lot of interesting information here. A really good post.

https://www.myaarpmedicare.guru/

Highly recommend the book Bore Hole, a memoir revolving around recreational trepanation

Fascinating Wikipedia rabbit-hole, although I laughed out loud at the oddity of this sentence [0]:

>Feilding learned about the ancient practice of trepanation from Bart Huges, whom she met in 1966, and who published a scroll on the topic.

Curious as to the details of scrolls as a modern publishing medium. The source link is broken, so I guess I'll never know.

[0] https://en.wikipedia.org/wiki/Amanda_Feilding#Trepanation

Some pictures of this scroll are viewable in Hamilton's Pharmacopeia S03E06 Ultra LSD episode:

- https://youtu.be/7N4VoqeuK3s?t=433

- https://youtu.be/7N4VoqeuK3s?t=987

There are also more details and NSFW pictures about Feilding trepanation in this episode.

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