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The myth of trepanning for migraine, and how it started.

This is an article I wrote for The Conversation UK in response to a question that I have often been asked when I’ve talked about my book project, and after a hunt through the literature for the origins of this common story (original post here).

Trepanation is the technique of removing bone from the skull by scraping, sawing, drilling or chiselling, and it is often stated to be one of the most ancient treatments for migraine.

The word trepanation comes from the Greek trypanon, meaning a borer. The earliest known trepanned skulls date from around 10,000 BCE, and come from North Africa. There are trepanation accounts in the Hippocratic texts (5th century BCE), when it was used in cases of fracture, epilepsy or paralysis, and in the second century CE Galen wrote of his experiments with trepanation on animals in his clinical studies.

But the reasons for trepanning remain largely unknown. While the famous 17th-century physician William Harvey may have suggested that the procedure was used for migraines, recent authors have acknowledged that there is little evidence to suggest this. So where did this persistent idea come from?

Migraines and fairies

Inca skull showing trepanning. © Wellcome Collection

The real source of the myth seems to have come much later. In 1902, the Journal of Mental Science published a lecture by Sir Thomas Lauder Brunton, a London physician well-known for his work on pharmacology and ideas about migraine pathology. The lecture mixed neurological theory and armchair anthropology, and ranged over subjects including premonitions, telepathy, hypnotism, hallucinations, and epileptic and migrainous aura. In one notable passage, Brunton proposed that visions of fairies and the sound of their jingling bells were “nothing more” than the zigzags of migraine aura, and the aural results of nerve centre stimulation.

Brunton proposed that openings bored into ancient Stone Age skulls during life had been made to cure migraine. His suggestion followed considerable excitement during the 1870s when the French physician and anthropologist Paul Broca claimed that ancient skulls discovered in Peru and France had not only been opened surgically during life in order to release evil spirits, but that the patients had survived. To Brunton, it seemed obvious that the holes would have been made at the request of migraine sufferers in order to “let the headache out”. He wrote:

For when the pain of headache becomes almost unbearably severe, an instinctive desire sometimes arises either to strike the place violently in the hope of relieving the pain, or to wish that some operation could be done to remove the pain.

The French surgeon Just Lucas-Champonnière had claimed in 1878 that some South Sea islanders still performed a similar procedure but, essentially, Brunton’s ideas about trepanning were as imaginative as his thoughts on fairies.

Nevertheless, the theory gained traction. In 1913, the world-famous American physician William Osler repeated that trepanation operations had been used “for epilepsy, infantile convulsions, headache and various cerebral diseases believed to be caused by confined demons”. By 1931, T Wilson Parry (who was partial to the odd experiment of his own) reasoned in The Lancet that as the large numbers of trepanned skulls found throughout France could not all be accounted for by epilepsy, the procedure must also have been used to cast out “other devils”. He proposed that this included disorders with “exasperating” head symptoms such as migraine, giddiness, “and distracting noises of the head”.

A ‘burr hole’

If Victorian theories about ancient trepanation for migraine were largely speculative, there is evidence of cutting holes in skulls for migraine somewhat closer to home. In 1936, Alfred Goltman, a physician from Tennessee, observed something strange about a woman with migraine that he was treating for allergies.

In the left frontal region of her skull, the woman had a depression, an inch in diameter, with a marked concentration of blood vessels. Four years earlier, she had been admitted to the care of Dr Raphael Eustace Semmes, the first neurosurgeon in Memphis, who had trained under Harvey Cushing, the American “father” of modern neurosurgery. Semmes had drilled a small circular opening known as a “burr hole” during one of the woman’s severe headaches, while she was under local anaesthetic. As he opened the thick membrane surrounding the brain, “a quantity of fluid escaped under increased pressure”. There was no evidence of a tumour.

This now seems a troubling era in experimental interventionist neurosurgery. Between the 1890s and the 1920s, some surgeons believed that brain surgery could “cure” inherited criminal tendencies. Children referred by juvenile courts were operated on in an attempt to release “pressure on the brain”, a procedure with a mortality rate of up to 42%. By the 1930s, frontal lobotomy was emerging as a treatment for mental illness.

Semmes’ patient survived the surgery, but her migraine headaches did not stop. Goltman noticed that during her headaches the depression left by the surgery began to fill up. As the migraine attack ended, the swelling would recede. Goltman’s observations helped influence the widespread acceptance of a theory that would dominate understanding of migraine until the 1970s: that the origin of migraine headache must be vascular, characterised by dilation of the blood vessels during the attack.

While we now see migraine as neurological, much still remains to be discovered about its causes and mechanisms in the brain. In some ways, trepanning does seem a logical response to the intense pain of migraine. As Andrew Levy notes in his memoir: “The migraining head wants to be cut open; it longs to be cut open.” This does not, of course, mean that it should be.

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Migraines were taken more seriously in medieval times – where did we go wrong?

This is a piece I wrote for The Conversation (08/09/2016) and which was subsequently republished in the Independent (17/09/2016). It is reproduced here under the terms of the Creative Commons Attribution No Derivatives license.

Katherine Foxhall, University of Leicester

Have you ever experienced a migraine? If so, perhaps you recognise this:

It feels as if there is hammering and pounding in the head. Sound or talking is unbearable, as is light or glare. The pain arises from hot, choleric fumes, together with windiness. And so one feels piercing, burning and ringing.

Such a precise explanation of the pain and disorientation experienced during a migraine might have been written yesterday. In fact, it comes from an encyclopedia, compiled by the Franciscan monk Bartholomaeus Anglicus (Bartholomew the Englishman), in the 13th century.

There aren’t many ailments that have maintained so clear a course over so many centuries. And what’s more, looking at the history of migraines reveals that the ailment was actually taken more seriously in the past, something we can learn a lot from today.

Hemicrania deciphered

We can pinpoint the beginning of the history of migraine as a named disorder to Galen (c. 129 – c. 216/17 CE), the most famous philosopher and physician in the Roman Empire. Galen set migraine, or hemicrania as he termed it, apart from other types of headache: as a painful disorder affecting only half the head, caused by the ascent of vapours from the stomach that were excessive, too hot, or too cold.

The 12th-century text of Causae et Curae, which scholars generally accept as the work of the the celebrated German abbess Hildegard of Bingen (1098-1179), gave a compelling explanation of why migraine seized only half the brain at a time: this was a bodily force so powerful, that if it seized the whole head, the pain would be unendurable.

An 18th-century portrait of Galen.

Although Galen’s writings were lost with the fall of the Roman Empire, Galen’s term, hemicrania, persisted, being adapted and adopted into various languages over the centuries. For example, in Middle English, we find emigranea and in medieval Wales the term migran. William Dunbar, writing in Middle Scots, used the term magryme in his poem describing the physical pain of migraine as being like an arrow piercing his brow, a pain so bad that he couldn’t look at the light. Dunbar also captured the migraine aftermath, the “postdrome” that came with the new morning, when he sat down to write but was unable to find any words. His head “dulled in dullness”, his body was unrefreshed, his spirit asleep.

Throughout the 16th and 17th centuries, a wealth of remedies in manuscript and printed recipe collections suggest a sophisticated general knowledge about this disorder. For example, Jane Jackson’s recipe book, dating from 1642, gives six separate recipes for “Migrim in the Head”, requiring various amounts of effort to produce. The simpler remedies could be made in a few minutes from common garden ingredients (mix houseleek and earthworms with flour, spread it on a cloth and bind to the forehead), but the most complex concoction required equipment, planning and financial outlay to produce a medicine that would last 20 years.

As well as taking migraine seriously, Jackson’s recipe book suggests that people of the 17th century appreciated that migraine could occur on a spectrum, from the occasional acute attack to a chronic illness that could last for several days.

Losing legitimacy

These historical descriptions of migraine reveal that we have lost something. In all of the sources from the medieval and early modern period that I have come across during the five years I have spent tracing the history of migraine, one thing is clear: these people took migraine seriously.

This is important. Migraine is now accepted as a “real” disorder which affects around one in seven people, two-thirds of whom are women, and is recognised by the WHO as the sixth highest cause worldwide of years lost due to disability (YLD). But despite this, it (along with other headache disorders) is nevertheless chronically under-funded, its sufferers often ignored, dismissed or blamed, and their ailments under-diagnosed and under-treated. In her recent book Not Tonight, the sociologist Joanna Kempner has described this situation as migraine’s “legitimacy deficit”.

So what has happened? Historical sources suggest that the question we need to ask is not how we can begin to give migraine the legitimacy it needs, but when and why we stopped taking it seriously in the first place.

‘La migraine’, 1823.

Over the course of the 18th century, something changed, as migraine became the stuff of ridicule. In May 1782, for instance, a flamboyant character graced the King’s Theatre Masquerade in London, and introduced himself to the gathering as “Le Sieur Francois de Migraine, Docteur en Medicine”. And in the summer heat of August 1787, the General Evening Post described how “half Paris had the migraine, and no lady of fashion could be prevailed upon to quit her boudoir”. Migraine was becoming something to joke about, a complaint that affected a particular kind of person, usually female.

By the 19th century, physicians routinely talked
of young female “martyrs”, and of sick headache and megrim as a disorder of “mothers in the lower classes of life” whose minds and bodies had been weakened by daily toil, disturbed sleep, insufficient nourishment and constant lactation.

Ring any bells?
Migraine Action

During the 1980s, many migraine sufferers took the opportunity to share their experiences of migraine by entering four international art competitions. The resulting collection, which includes over 500 pieces, reveals the powerful effect migraine has on people’s lives. Perhaps most striking is the frequency with which motifs such as arrows, hammering, pounding, light, glare and disorientation appear in this art – seemingly as familiar to sufferers today as they were to the medieval poets and physicians who discussed this disorder nearly 1,000 years ago.

For the first time, this collection is the subject of a dedicated website, which has now been launched by the charity Migraine Action as part of Migraine Awareness Week.

These paintings, backing up a thousand years of historical sources, make it clear that migraine is more than just a headache. It needs to be taken as seriously now as it was by Galen.

The Conversation

Katherine Foxhall, Lecturer in History, University of Leicester

This article was originally published on The Conversation. Read the original article.

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Finding the Patients in the Notes.

It seems a long time since my summer immersed in the strange world of Anglo-Saxon and medieval medicine, and maintaining momentum on my research project is proving tricky halfway through a full semester of teaching mainly colonial history. Nevertheless, I’ve been spending a few days in the lovely Queen Square Library, home to UCL’s Institute of Neurology Library and the archival collections for the National Hospital for Neurology and Neurosurgery, originally the National Hospital for Paralysed and Epileptic when it first opened in 1860.

National Hospitals for the Paralysed and Epilectic.

The National Hospital for the Paralysed and Epilectic (from Building News, 1884) Courtesy of Wellcome Library, London.

The archives are home to the case notes of the physicians who worked at the National Hospital, a collection of approximately 1500 bound volumes dating from 1863-1946.

Although John Hughlings Jackson, William Gowers and their colleagues at the London Hospital must have often encountered patients with migraines, particularly when illness affected a patient’s ability to work, case notes specifically diagnosing migraine are relatively few among the volumes that discuss inpatient cases. It is clear, however, that patients who presented with migraine – particularly those who experienced distortions of vision – were of particular interest to Hughlings Jackson because their experiences offered insight into the relationship between the two sides of the brain. Migraine was one variation of a whole series of disorders that he believed could be caused by lesions in different parts of the brain. In his lectures and writings, Hughlings Jackson often used migraine as a footnote to illustrate a complex argument he was making with regard to epilepsy.

But medical casenotes are about more than the history of biomedicine. At particular moments of strain, they transcribe and immortalise ordinary people’s accounts, and their efforts to deal with, and understand the reasons for their illness. These are accounts of the everyday world which are usually left unrecorded.

A sixteen year old girl recounted her childhood; although she was always well-fed and clothed, her family had lived in a ‘very unhealthy’ house, draughty and damp, where the drains emptied straight into a stream. The girl said that she had sickness and pains in the head ever since she could remember. These had worsened when she started school, and increased again since she learnt to read.

One female patient explained that her pain was worse on the right side than the left. It often commenced with a flushing of her face and head, and she experienced noises in her head and ears that she described “like an engine letting off steam”.

Pulvermacher galvanic belts.

Pulvermacher galvanic belts. Credit: Wellcome Library, London.

Another woman described her attempts at self-treatment: “Has tried all kinds of diets, starving herself & lived once on toast & water for a month, but no good; taken patent medicines and tried Pulvermacher’s [galvanic belt] and other appliances but no good. Taken chlorodyne.”

Dr Gowers’ notes record the case of a 54 year-old deaf cab driver. After experiencing headaches, vomiting and dimness of sight for twenty years, the attacks had got suddenly worse in 1887, forcing him to give up work. He had been treated by Dr Beevor at Queen’s Square for six months, and his health had improved, but in early 1897 “he again commenced to have daily attacks & he has been laid up ever since”.

These cases are fascinating because they give such personal accounts of the experience of migraine and similar disorders in the nineteenth century. But they are also important because they represent rare institutional records of migraine treatment. These are real cases being treated by the men who were at the forefront of neurological knowledge in the nineteenth century. We know a great deal about these physicians, but very little about the medical practice, and the ordinary people that shaped their ideas.

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Diagnosing Hildegard of Bingen

‘The Heavenly City’, miniature from Scivias (c.1165), reproduced in Charles Singer (ed.) Studies in the History and Method of Science (Oxford, 1917).

In 1913, more than eight centuries after she died, Hildegard of Bingen got a migraine. During her life she had admitted to long periods of illness, but this was something quite new. Continue reading

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Oliver Cromwell’s Migraine

https://upload.wikimedia.org/wikipedia/commons/2/24/Oliver_Cromwell_by_Samuel_Cooper.jpg

Oliver Cromwell (1599–1658) by unknown artist. Reproduced courtesy of BBC Your Paintings. http://www.bbc.co.uk/arts/yourpaintings/paintings/oliver-cromwell-15991658-62668

On 23 March 1657, representatives of Oliver Cromwell and Cardinal Mazarin of France signed the Treaty of Paris, a surprising and uneasy alliance that would unite the two countries against Spain. In the weeks before the agreement, however, Cromwell had not been well: ‘Cromwell has a vertigo or migraine in his head, and fell twice on Sunday week’, correspondence from France revealed. Continue reading

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Passing on the Bauble.

Or, what do a piece of migraine artwork, the first test-tube baby, E.T. and the Sistine Chapel all have in common?

When I get the chance, I have recently been spending some time in the offices of Migraine Action, a wonderful UK advice and support charity for people affected by migraine (you can listen and donate to their recent BBC Radio 4 Appeal here).

The reason for my visits is that the charity also has a collection of art, submitted to four competitions held between 1981 and 1987. The competitions invited migraine sufferers to draw either their impressions of visual disturbance or to illustrate the effect migraine had on their lives. The resulting archive consists of over 500 pieces. These range from children’s sketches on notepaper to detailed and intricate works in oil, collage and airbrush. As a collection, the archive is a powerful and at times deeply uncomfortable witness to the intense pain and disruption that people with migraine experience. Some of the most beautiful pictures depict migraine aura, and the collection has provided clinical researchers with important evidence about this otherwise entirely subjective neurological phenomenon. A selection of the artworks can be viewed online here, and the collection as a whole is discussed in this book by Klaus Podoll and Derek Robinson.

Migraine

‘Migraine’. Reproduced with kind permission of Migraine Action. Image Ref: 313.

I will post more about my own research on these images over the coming months, but to begin with I want to share one image that grabs my attention every time. Continue reading

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