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C.G. Gross

– Renaissance ‘psychosurgery’

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IERONYMUSBOSCH(c. 1450–1515) is one of themost enigmatic painters of all time. Art historianshave variously characterized this Flemish artist as afanatic orthodox Christian, a satirical heretic, a pornog-rapher and a member of a secret black-magic sect (the‘Adamites’) worshipping the divinity of the sex act.His rich and flamboyant symbolism has been decoded(supposedly) in terms of such things as alchemy, folk-lore and magic, various secret Christian sects, Freud and Jung, the Hebrew Cabala, and the use of hallucinogenicdrugs

1–8

.Two things are clear about Bosch. One is that theplethora of conflicting interpretations reflects the imagi-nation of art historians more than any solid evidence.The second is that Bosch had a 20th-century mentality.His fantastic images have been viewed as anticipatingSalvador Dali and the Surrealist painters. NormanO. Brown said Bosch foreshadowed modern ideas of ‘therapeutic sexuality’. Henry Miller claimed him aninspiration to his own creativity. New interpretationsof Bosch still pour out, and his images are found on thecovers of rock-music albums (for example,

One NationUnderground

, Pearls Before Swine, 1967) and books onthe holocaust (for example, see Ref. 9)

1–8

.Perhaps the Bosch painting of most interest to neuro-scientists is

The Cure for Madness (or Folly)

, also knownas

The Stone Operation

(Fig. 1). This painting shows some-one making a surgical incision in the scalp. The inscrip-tion has been translated

as ‘Master, dig out the stonesof folly, my name is “castrated dachshund”’. This isusually interpreted as reflecting a contemporary belief that folly, stupidity and madness were due to stones inthe head. ‘Castrated dachshund’ was an epithet for asimpleton

2,3,5,8,10

.The art-historical literature is replete with a largenumber of conflicting interpretations of the details of this painting, such as the role of the two onlookers, thefunnel on the surgeon’s head, the book on the woman’shead, the fact that a water tulip, not a stone, is beingextracted from the head, the gibbet in the backgroundand other puzzling aspects. (The significance of the watertulip is obscure and controversial, although it has beensuggested that, in 16th-century Holland, it carried theconnotation of stupidity

. A more-recent interpretationproposes that the ‘tulip’ is in fact a lotus, an ancientsymbol of spiritual awareness

.) In spite of the disagree-ment on the meaning of the various apparent symbolsin the painting, virtually all interpretations of the paint-ings fall into one of two classes. The first class views thepainting as representing (and ridiculing) an actual prac-ticewhereby itinerant medical charlatans deceived peo-ple into believing that they could cure mental and‘psychosomatic’ symptoms by removing stones fromthe head

7,11–14

: supposedly, the ‘quack’ would make ascalp incision and then pretend to remove stones from

Charles G. Grossis at the Dept of Psychology, PrincetonUniversity,NJ 08540, USA.

‘Psychosurgery’ in Renaissance art

Charles G. Gross

Hieronymus Bosch and other early Renaissance artists depicted ‘stone operations’ in which stones were supposedly surgically removed from the head as a treatment for mental illness.These works have usually been interpreted either as portraying a contemporary practice of medicalcharlatans or as an allegory of human folly,rather than a real event.As trepanation for headinjury and mental disease was actually carried out in Europe at this time,another interpretationof these works is that they are derived from a common medical practice of the day.

Trends Neurosci

. (1999) 22, 429–431

Fig. 1.

H. Bosch ‘The Cure of Folly or The Stone Operation’ (16th century).

The inscriptionis translated in the text.

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the head. The second class of interpretation claims thatthere is no evidence at all for any such contemporarypseudo-medical practice

3,8,10

; rather, the painting isviewed as an allegory of the extreme stupidity andgullibility of humans, a recurrent theme in Bosch’swork.After Bosch, there were a number of works, again usu-ally Flemish, depicting the removal of stones from thehead as a cure for madness and folly by Peter Bruegel, Jan Steen, Pieter Huys, Nicolaes Weydmans and others(Figs 2 and 3). Following the two overall interpretationsof the Bosch mentioned above, these later works havebeen interpreted either as depicting an actual commonpractice of medical ‘quackery’

12–14

or simply as imitatingBosch’s allegory of human stupidity (as each of theseartists was clearly influenced by Bosch). In both theseart-historical interpretations of the depictions of ‘stoneoperations’, the possibility that legitimate surgical op-erations on the head were actually performed to relievesymptoms, was apparently, quite inconceivable

3,14

Trephining

The oldest known surgical procedure is trephiningor trepanning, the removal of a piece of bone from theskull. It began in the late Paleolithic period and hasbeen carried out in virtually every part of the world. Itis still used in the modern neurosurgical suite, in tra-ditional Kenyan medicine and as an ‘alternative medi-cine’ method of enhancing consciousness. Trephininghas a strong and continuing tradition in Westernmedicine. It is described in detail in the Hippocraticwork

On Wounds in the Head

where it is indicated forvarious types of head injury. From the Renaissanceuntil the beginning of the 19th century, trephiningwas widely advocated for the treatment of headwounds, particularly for depressed fractures and pen-etrating head wounds. It was also used, at least into the18th century, for the treatment of epilepsy and mentaldisease

15–18

.Roger of Parma (c. 1170) wrote in his

Practica Chirugiae

(

The Practice of Surgery

For mania or melancholy a cruciate incision is made in thetop of the head and the cranium is penetrated, to permit thenoxious material to exhale to the outside. The patient is heldin chains and the wound is treated, as [described] above

Robert Burton, in his still-in-print classic

Anatomy of Melancholy

(1652), similarly prescribed boring a holein the head for melancholy:

Tis not amiss to bore the skull with an instrument, to letout the fuliginous vapors... Guinerius cured a nobleman inSavoy by boring alone, leaving the hole open a month togetherby means of which, after two year’s melancholy and madnesshe was delivered

Thomas Willis, Professor of Natural Philosophy atOxford, one of the founders of the Royal Society andauthor of

Cerebri Anatomie

(1664), the first comprehen-sive monograph on the brain (dealing with anatomy,physiology and clinical neurology) noted that:

Threatening, bonds or strokes were ‘Curatory’ for madmen[but] Specifick Remedies such as St. John-wort as well asChirurgial Remedies such as Trephining or opening the skull[were also indicated]

It is interesting to note the reference to the use of St John’s Wort to treat ‘madmen’ in the 17th century.The mechanism of action of this herb is still unknownover 400 years later, although it is used by many totreat depression and anxiety.Figure 4 is a 1573 woodcut showing a trephinationin progress in a home operation

. When the operationwas moved into hospital settings in the beginning of the 19th century, the mortality rate was so high fromthe rampant infections characteristic of contemporaryhospitals that trephination, for any reason, declinedmarkedly until the introduction of modern antisepsisat the end of the century

C.G. Gross

– Renaissance ‘psychosurgery’

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Fig. 2.

Painting by P. Huys (16th century).

Courtesy of the Wellcome Institute Library, London

Fig. 3.

Engraving by N. Weydmans‘Operation for Stones in the Head’ (16th century).

The legend reads ‘Come, run, be filled with joy; Here we are cutting the woman of her stone’