Hippocrates, Galen, and the Uses of Trepanation in the Ancient Classical World

Symeon Missios, M.D.

Disclosures

Neurosurg Focus. 2007;23(1):E11 

In This Article

Abstract and Introduction

Abstract

Trepanation (αν´ατρησιζ) is the process by which a hole is drilled into the skull, exposing the intracranial contents for either medical or mystical purposes. It represents one of the oldest surgical procedures, and its practice was widespread in many ancient cultures and several parts of the world. Trepanation was used in ancient Greece and Rome, as described in several ancient texts. Hippocrates and Galen are two of the most prominent ancient Greek medical writers, and their works have influenced the evolution of medicine and neurosurgery across the centuries. The purpose of this paper is to examine Hippocrates' and Galen's written accounts of the technique and use of trepanation in the ancient Greek and Roman world. Examination of those records reveals the ancient knowledge of neurological anatomy, physiology, and therapeutics, and illustrates the state and evolution of neurosurgery in the classical world.

Introduction

Trepanation (αν´ατρησιζ) is the process by which a hole is drilled into the skull, exposing the intracranial contents for both medical and mystical purposes. The word originates from the Greek "τρ´υπανον," which means drill, bore, or auger.[1] It represents one of the oldest surgical interventions, and was certainly the first neurosurgical procedure performed by humans. The procedure itself dates back to the Mesolithic era, before the development of written language and use of metal instruments, perhaps as far back as 10,000 BC. Its practice was widespread among the continents, and evidence of trepanation has been discovered in Mesoamerica, South America, Africa, Asia, and Europe.[1,17,21]

Despite its origin in the Mesolithic era, prior to the beginning of civilization and any formal scientific—let alone medical—thinking, trepanation has been widely adopted by numerous cultures and has been refined throughout the ages. The technique evolved from the use of sharpened stones and scraping of the skull to the use of initially wooden and then metal trepans. Later, in Medieval Europe, came the use of increasingly elaborate and more sophisticated apparatuses for the less painful and safer drilling of the skull and the protection of its contents. The practice of trepanation itself also evolved from its likely ritualistic and mystical content in the primitive cultures of Africa and pre-Columbian Mesoamerica to its use by the Egyptians, Greeks, and Romans, who identified its potential therapeutic purpose, recorded their findings, and produced complicated instructions for its performance.[11] Trepanation continued to be practiced throughout Medieval Europe, based on instructions and principles of Hippocrates and Galen, until further advances in anatomy and science allowed the development of more sophisticated surgical procedures.

It is likely that the Egyptians were aware of the procedure, but they did not practice it on a regular basis. The primary written source of ancient Egyptian medical knowledge and surgical experience, the Edwin Smith Papyrus— the world's earliest known medical document, written around the 17th century BC—describes 48 battlefield injury cases, including cases of head and spine trauma. It contains the first descriptions of the cranial sutures, meninges, and cerebrospinal fluid. Imhotep, the founder of Egyptian medicine, is credited as the author of the text, although current thought is that the papyrus received contributions from multiple authors.[1,9,19] It is important to note that the papyrus offered rational treatments for most of its cases in a culture in which medicine, magic, and superstition were inseparable. Nevertheless, the text does not offer specific surgical recommendations for the management of head injury by trepanation or information about the practice of neurosurgery in ancient Egypt.[1]

The description, use, and codification of trepanation began in Greece during the fifth century BC. Hippocrates, in his work On Injuries of the Head, described the different types of skull fractures and provided specific instructions as well as warnings about the use, and the dangers, of trepanation.[20,32] The Hippocratic teachings, largely based on observation and clinical examination, were elaborated during the Roman period by Galen, who contributed his knowledge of anatomy through his experimentation and dissections. The work of Hippocrates and Galen on the use and technique of trepanation guided its application and practice not only during the classical period but also through the Medieval era to the Renaissance.

The purpose of this paper is to present Hippocrates' and Galen's records on trepanation and to explore their teachings of its proper use, its potential dangers, and the techniques and tools employed. Their ancient descriptions of trepanation reflect the then-existing knowledge of brain anatomy and physiology, and their teachings survived through the Medieval period and influenced subsequent European scientific thinking and practice. The evolution of trepanation through its transition from ritual to a surgical procedure with therapeutic benefit parallels the evolution of ancient neurosurgery through the classical period.

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