While searching for answers to what it means to be Jewish — and at the same time completing a neuroscience course requirement — a doctoral student at Washington University in St. Louis came across what may be one of the earliest documented cases of brain surgery. And he found it in, of all places, the ancient texts of the Talmud.
(The Talmud was written at approximately the beginning of the Common Era as a means of documenting orally taught Jewish law and philosophy.)
“Although this account raises several questions about the ailment itself, it provides us with a rare look at invasive cranial surgery dating nearly 2,000 years,” writes Adam Weinberg, a doctoral student in psychology in Arts & Sciences and author of an article on the surgery in the current issue of the Journal of the History of the Neurosciences (Volume 15, No. 2/June 2006).
Weinberg, who earned both a bachelor’s and a master’s degree in psychology from the university, first spotted the cranial surgery reference in his sophomore year when he began meeting with a rabbi “to figure out exactly what it meant to be Jewish.” The surgery, done to preserve a marriage and to cure a painful skin ailment called ra’atan, intrigued him, not only for its implications to modern neuroscience, but also for its relevance to Jewish law and practice.
In his journal article, “A Case of Cranial Surgery in the Talmud,” Weinberg points out that many pages of the Talmud deal with remedies for a large number of injuries and illnesses, but only a handful of these remedies involve surgery. The Talmud describes preparation for the surgery, the application of a potential anesthetic, the surgical environment and the removal of some sort of growth from the brain.
The surgery described in the Talmud is by no means the earliest known instance of people opening a skull for medical or ritual reasons, says Weinberg’s research adviser Stanley Finger, Ph.D., a noted historian of medical science and professor of psychology at Washington University. And while the Talmud surgery does not approach the level of complexity found in modern brain surgery, it does represent a step in that direction, says Finger.
“Neolithic people going back over 4,000 years ago were making holes (trepanning) in skulls in Europe, with some survival,” says Finger, “but brain surgery itself — if defined as removing tumors or draining abscesses successfully — seems to be a much later and more dangerous development than what was described in the Talmud.
“The Talmud case falls between cranial surgery and true brain surgery,” Finger continues. “Yes, the skull was opened, so it is cranial surgery. But the operator was also scraping the meninges (the system of membranes that envelope the central nervous system) to get rid of something there, so we are not simply witnessing a skull opening to allow a harmful spirit to escape, nor directives to remove broken bone from a wound that might be pressing on the brain.”
A drastic measure
“Until the time of the Modern Era, when they cracked open peoples’ heads, they would die — most likely due to crude surgical environments and preparation, which we can assume led to infection,” says Weinberg.
“The Talmud offers a case where these things were taken into account in hopes of patient survival. This was occurring when brain surgery was not an elevated medical practice. Physicians were elevated and surgeons were considered laborers.”
Motivation for this surgery resides in Jewish law, according to Weinberg, who writes it was performed as a last resort to prevent dissolution of the “marriage contract.” The ra’atan was so painful, according to the Talmud, it made the “husband’s duty of sexually satisfying his wife nearly impossible,” and thus unable to “fulfill a biblical commandment.”
“In the case of a man in whom certain defects arose after he was married, and whose wife wanted a divorce, we do not compel him to divorce,” describes the Talmud. “Rabban Shimmon ben Gamliel said: In what cases were these things said? In the case of minor defects, which his wife is expected to tolerate? But with major defects, we do indeed compel him to divorce.”
“It was clearly done from the standpoint of Jewish law,” says Weinberg. “The Talmud doesn’t pretend to be a medical book. It seems that this was a drastic measure taken because divorce was viewed as a last-case scenario.”
The Talmud carefully describes the symptoms to diagnose and procedures to treat ra’atan — a type of growth or organism that can affect the meninges.
“What are its symptoms? His eyes tear, his nostrils run, he brings spittle from his mouth, and flies swarm around him,” describes the Talmud.
Cure for ra’atan, according to the Talmud, involves operating on the patient in a “house of marble” — with no draft — after pouring 300 cups of a boiled herbal potion over the skull to soften it. The skull would then be torn open to expose the organism on the membrane, which then must be removed in its entirety to avoid its return.
“This case shows that people did care about anesthesia and were investigating its use for a long time,” according to Weinberg, who says that anesthetics, such as ether, were not popularized until the 1800s. Yet this case shows an interest in anesthesia 1,500 years earlier.
“It’s also one of the earliest examples that this type of surgery needed to be done for survival,” adds Weinberg. “The surgery was of the utmost importance. It stressed that the whole organism must be removed for the patient’s recovery.
“When skulls had been cracked open earlier, people may have hemorrhaged,” says Weinberg. “One understanding is that these procedures may have been performed to let out ‘demons trapped in the skull.’ The cranial surgery described in the Talmud is clearly for a different purpose.”
‘Important steps’
“Adam’s paper came as a most pleasant surprise to me, since it drew needed attention to a chapter in the history of the brain sciences that seems to have been completely missed by medical historians,” says Finger. “Moreover, the case contains many surgical details, which is unusual for documents from antiquity.
“Yet just what sort of ‘skin disorder’ was being treated by carefully scraping something off the meninges of the brain was not clear to us or the physicians we consulted,” Finger says.
The exact nature of ra’atan may never be known. Weinberg reasons, however, that it is probably not leprosy or meningitis.
Weinberg applauds the efforts of these ancient rabbis in “making important steps in dealing with the brain,” including their use of an attempted anesthesia and a clean, dust-free operating environment.
This case of cranial surgery in the Talmud, Weinberg writes, “expresses knowledge of the brain’s delicacy, the importance in prescribing a means for removing the growth, and the foresight to say, ‘Remove it entirely … for if not it returns to the victim.'”
And if all went well, it preserved a marriage!