Editing Trepanning (section)

== History ==
[[File:Trepanated skull of a woman-P4140363-black.jpg|thumb|The perimeter of the hole in this trepanated [[Neolithic]] skull is rounded off by ingrowth of new bony tissue, indicating that the patient survived the operation.|218x218px]]
[[File:Crânes trépanation âge du bronze.jpg|thumb|Skulls from the [[Bronze Age]] exhibited at the Musée archéologique de Saint-Raphaël (Archeological Museum of [[Saint-Raphaël, Var|Saint-Raphaël]]), found in [[Comps-sur-Artuby]] (France). The subjects survived operations.]]
[[File:Dr John Clarke trepanning a skull operation.jpg|thumb|right|[[Dr. John Clarke]] trepanning a skull, {{circa|1664}}, in one of the earliest American portraits. Clarke is alleged to have been the first physician to have performed the operation in the [[New England Colonies]].]]
[[File:1750 Trepanationsbesteck anagoria.JPG|thumb|Trepanation instruments, 18th century; Germanic National Museum in Nuremberg]]

=== Prehistoric evidence ===
Trepanation dates back to 7,000–10,000 years ago,<ref name=":4" /> is perhaps the oldest surgical procedure for which there is [[archaeological]] evidence,<ref>{{Cite book |author=Capasso, Luigi |year=2002 |title=Principi di storia della patologia umana: corso di storia della medicina per gli studenti della Facoltà di medicina e chirurgia e della Facoltà di scienze infermieristiche |location=Rome |publisher=SEU |isbn=978-88-87753-65-3 |oclc=50485765 |language=it}}</ref> and in some areas may have been quite widespread. The main pieces of archaeological evidence are in the forms of human remains. At one burial site in [[France]] dated to 6500&nbsp;BCE, 40 out of 120 [[prehistoric France|prehistoric]] skulls found had trepanation holes.<ref name="restak2000">{{cite book |author=Restak, Richard|chapter=Fixing the Brain |title=Mysteries of the Mind |publisher=National Geographic Society |location=Washington, D.C. |year=2000 |isbn=978-0-7922-7941-9 |oclc=43662032}}</ref> At the time only around 40% of people survived the procedure.<ref name=":4" />

More than 1,500 trephined skulls from the Neolithic period (representing 5–10% of all cranial remains from that era) have been uncovered throughout the world{{spnd}}from Europe, [[Siberia]], China and [[the Americas]].<ref>{{Cite journal|last=Faria|first=Miguel A.|date=2015-05-07|title=Neolithic trepanation decoded – A unifying hypothesis: Has the mystery as to why primitive surgeons performed cranial surgery been solved? |journal=Surgical Neurology International|volume=6|page=72|doi=10.4103/2152-7806.156634 |pmc=4427816|pmid=25984386 |doi-access=free }}</ref> Most of the trephined crania belong to adult males, but women and children are also represented.

There also exists evidence of trepanation being performed on a cow in France around 3400–3000&nbsp;BCE.<ref>{{Cite journal | doi=10.1038/s41598-018-23914-1| pmid=29674628| pmc=5908843| title=Earliest Animal Cranial Surgery: From Cow to Man in the Neolithic| journal=Scientific Reports| volume=8| issue=1| page=5536| year=2018| last1=Ramirez Rozzi| first1=Fernando| last2=Froment| first2=Alain| bibcode=2018NatSR...8.5536R}}</ref> If performed while alive, the cow did not survive the procedure. It is unclear if this was performed as a [[Veterinary surgery|veterinary procedure]], [[Animal testing|medical experimentation]] or for other unknown reasons. However, it could be the earliest archaeological example of veterinary surgery or animal medical experimentation.

=== Pre-Columbian Mesoamerica ===
{{main|Trepanation in Mesoamerica}}
In the more recent times of [[postclassical]] [[pre-Columbian]] [[Mesoamerica]], evidence for the practice of trepanation and an assortment of other [[Human cranium|cranial]] deformation techniques comes from a variety of sources, including physical cranial remains of burials, allusions in iconographic artworks and reports from the post-colonial period.

Among [[New World]] societies, trepanning is most commonly found in the [[Andes|Andean]] civilizations, such as pre-[[Incan Empire|Incan]] cultures. For example, the Paracas culture [[Paracas culture|Ica]], situated in what is now known as Ica, located south of Lima. Trepanation has also been found in the [[Muisca Confederation]]<ref>{{cite book|title=Sopó, historia, mitos y muiscas |last=Bohórquez |first=Ruth Marlene |lang=es}} Via {{Cite web |title=Cranioplasty in the Muisca Confederation |lang=es |url=http://conociendosopo.blogspot.com/2008/05/el-cacique-sop-se-detiene-en-el_04.html |website=Sopó contado y encantado |type=blog |access-date=2012-01-24}}</ref> (in modern-day Colombia) and the [[Inca|Inca Empire]]. In both, even [[cranioplasty]] existed.<ref>{{Cite web |title=Landmarks in the History of Traumatic Head Injury |pages=2–3 |author=Omar AL Awar |author2=Gytis Sustickas |url=https://www.researchgate.net/publication/314004316}}</ref> The prevalence of trepanation among Mesoamerican civilizations is much lower, at least judging from the comparatively few trepanned crania that have been uncovered.<ref name="tiesler2003a">{{Citation |author=Tiesler Blos, Vera|year=2003 |title=Cranial Surgery in Ancient Mesoamerica |publisher=Mesoweb |url=http://www.mesoweb.com/features/tiesler/Cranial.pdf |access-date=2006-05-23}}</ref>

The [[archaeological record]] in Mesoamerica is further complicated by the practice of skull mutilation and modification carried out ''after'' the death of the subject, to fashion "trophy skulls" and the like of captives and enemies. This was a widespread tradition, illustrated in pre-Columbian art that occasionally depicts rulers adorned with or carrying the modified skulls of their defeated enemies, or of the ritualistic display of [[human sacrifice|sacrificial]] victims. Several Mesoamerican cultures used a skull-rack (known by its [[Classical Nahuatl language|Nahuatl]] term, ''[[tzompantli]]''), on which skulls were impaled in rows or columns of wooden stakes. Even so, some evidence of genuine trepanation in Mesoamerica (i.e., where the subject was living) has survived.{{citation needed|date=March 2013}}

The earliest archaeological survey published of trepanned crania was a late 19th-century study of several specimens recovered from the [[Tarahumara]] mountains by the Norwegian [[ethnographer]] [[Carl Sofus Lumholtz|Carl Lumholtz]].<ref name="tiesler2003a" /><ref>{{cite journal |author=Lumholtz, Carl |author-link=Carl Sofus Lumholtz|title=Trephining in Mexico |journal=American Anthropologist |volume=10 |issue=12 |page=389 |year=1897 |doi=10.1525/aa.1897.10.12.02a00010|url=https://zenodo.org/record/1448966 |doi-access=free }}</ref> Later studies documented cases identified from a range of sites in [[Oaxaca]] and central [[Mexico]], such as [[Tilantongo]], Oaxaca and the major [[Zapotec civilization|Zapotec]] site of [[Monte Albán]]. Two specimens from the [[Tlatilco]] civilization's homelands (which flourished around 1400 BCE) indicate the practice has a lengthy tradition.<ref>{{Cite book |author=Romero Molina, Javier |chapter=Dental Mutilation, Trephination, and Cranial Deformation |title=Handbook of Middle American Indians, Vol. 9: Physical Anthropology |editor=T. Dale Stewart (volume ed.) |others=[[Robert Wauchope (archaeologist)|Robert Wauchope]] (series ed.) |publisher=[[University of Texas Press]] |location=Austin |year=1970 |edition=2nd. edition (revised) |isbn=0-292-70014-8 |oclc=277126 |chapter-url-access=registration |chapter-url=https://archive.org/details/handbookofmiddle00wauc |url-access=registration |url=https://archive.org/details/handbookofmiddle00wauc }}</ref>

Specimens identified from the [[Maya civilization]] region of southern Mexico, [[Guatemala]] and the [[Yucatán Peninsula]] show no evidence of the drilling or cutting techniques found in central and highland Mexico. Instead, the pre-Columbian Maya apparently used an abrasive technique that ground away at the back of the skull, thinning the bone and sometimes perforating it, similar to the examples from Cholula. Many skulls from the Maya region date from the Postclassic period ({{Circa|950–1400 CE}}), and include specimens found at [[Palenque]] in [[Chiapas]], and recovered from the [[Sacred Cenote]] at the prominent Postclassic site of [[Chichen Itza]] in northern Yucatán.<ref>{{cite thesis|author=Tiesler Blos, Vera|year=1999 |title=Rasgos Bioculturales Entre los Antiguos Mayas: Aspectos Culturales y Sociales |degree=Doctoral thesis in Anthropology |publisher=UNAM |language=es }}</ref>

=== Ancient China ===
Before 2007, archaeological evidence of trepanation in ancient China was nonexistent. Since Chinese culture mainly focuses only on [[traditional Chinese medicine]] that usually entails non-surgical treatments such as [[acupuncture]], balancing [[Qigong]], [[Cupping therapy|cupping]], [[Herbal medicine|herbal remedies]], etc. The resulting misconception was that trepanation was not practiced in ancient China. However, in 2007, Han and Chen from the Institute of Archeology, [[Chinese Academy of Social Sciences]] looked at six trepanned skulls spanning between the Neolithic period through the Bronze and Iron Ages ({{circa|5000–2000}} years ago) found in five different locations.<ref name=":0">{{Cite journal|last1=Hobert|first1=Leah|last2=Binello|first2=Emanuela|date=May 2017|title=Trepanation in Ancient China|journal=World Neurosurgery|volume=101|pages=451–56|doi=10.1016/j.wneu.2016.10.051|issn=1878-8769|pmid=27769950}}</ref> Along with the discovery of these trepanned skulls, another collection of 13 trepanned skulls was discovered and dated to 3,000 years ago.<ref name=":0" /> In 2015, an intact 3,600-year-old [[mummy]] with a trepanned skull was discovered. Meanwhile, the oldest trepanned skull (M382) analysed by Han and Chen was radiocarbon dated to around 5,000 years ago and discovered at the Fuija site in [[Guangrao]], [[Shandong]]. The skull, which belonged to an adult male, exhibited a right [[Parietal lobe|parietal]] [[Calvaria (skull)|calvarial]] defect (31 x 25&nbsp;mm) with evidence of scraping by a [[trephine]]-like tool.<ref name=":0" /> Additionally, bone regeneration and smooth edges suggest that the subject recovered from the surgery and lived a relatively long time afterward.

The 3,600-year-old perforated skull of a mummified female dating to 1615&nbsp;BCE was found in the [[Xiaohe Cemetery|Xiaohe tomb]] in China's [[Xinjiang Uygur Autonomous Region]].<ref name=":0" /> The only known female with a trepanned skull, it showed signs of bone spurs growth and retraction of the edges, suggesting that she also survived the surgery. Found in a massive burial site, this mummy was one of the hundreds found in the "Little River" Tomb complex.

The Bronze Age was found to be the period with the largest number of trepanned skulls in ancient China.<ref name=":0" />

=== Medieval East Africa ===
Trephining has a long history in [[East Africa]]{{Citation needed|reason=There is no evidence for this claim|date=March 2023}}. Bones of depressed fractures were elevated by surgeons of [[Bunyoro-Kitara]].<ref name="Davies 1959">{{cite journal | last=Davies | first=J. N. P. | title=The Development of ''Scientific'' Medicine in the African Kingdom of Bunyoro-Kitara | journal=Medical History | volume=3 | issue=1 | pages=47–57 | year=1959 | issn=0025-7273 | doi=10.1017/s0025727300024248 | pmid=13632207 | pmc=1034446 }}</ref> The hair may or may not have been shaved depending upon the site of the operation.

Trepanning at the [[Kisii people]] in Kenya was filmed in 1958.<ref>{{citation |first=Rolf |last=Meschig |title=Zur Geschichte der Trepanation unter besonderer Berücksichtigung der Schädeloperationen bei den Kisii im Hochland Westkenias |lang=de |location=Düsseldorf |year=1983 }}</ref>

=== Pre-modern Europe ===
Trepanation was known to prehistoric Europeans, with some populations having impressive success rates of 78% in the Iron Age. <ref>{{cite journal |last1=Moghaddam |first1=Negahnaz |title=Survival after trepanation—Early cranial surgery from Late Iron Age Switzerland |journal=International Journal of Paleopathology |date=5 November 2015 |volume=11 |pages=56–65 |doi=10.1016/j.ijpp.2015.08.002 |pmid=28802968 |url=https://www.sciencedirect.com/science/article/pii/S1879981715300085 |doi-access=free }}</ref>

Trepanation was also practised in the classical and [[Renaissance]]{{Citation needed|date=October 2016}} periods. [[Hippocrates]] gave specific directions on the procedure from its evolution through the Greek age, and [[Galen]] also elaborates on the procedure. During the [[Middle Ages]] and the [[Renaissance]], trepanation was practiced as a cure for various ailments, including seizures and skull fractures. Out of eight skulls with trepanations from the 6th to 8th centuries found in southwestern [[Germany]], seven skulls show clear evidence of healing and survival after trepanation, suggesting that the survival rate of the operations was high and the infection rate was low.<ref name="Weber">{{cite journal|author1=Weber, J. |author2=A. Czarnetzki |title=Trepanationen im frühen Mittelalter im Südwesten von Deutschland – Indikationen, Komplikationen und Outcome |journal=Zentralblatt für Neurochirurgie |volume=62 |issue=1|year=2001 |pages=10–14 |doi=10.1055/s-2001-16333 |pmid=11496341 |s2cid=71480502 |language=de}}</ref>

In the graveyards of pre-Christian ([[Pagan]]) [[Magyars]], archeologists found a surprisingly high frequency (12.5%) of skulls with trepanation, although more than 90% only partial (these served probably ritual purposes).<ref>{{cite web|url=http://sirasok.blog.hu/2008/09/10/agyafurt_magyarok_koponylekeles_a_honfoglalaskorban |title=Agyafúrt magyarok – Koponyalékelés a honfoglaláskorban – Sírásók naplója |lang=hu |publisher=Sirasok.blog.hu |access-date=2012-04-05}}</ref>{{sps|date=May 2022}} The trepanation was performed on adults only, with similar frequencies for males and females, but increasing frequency with age and wealth. This custom suddenly disappeared with the [[Magyars]]' conversion to Christianity.

A small area near (modern) [[Rostov-on-Don]], in southern Russia, may have been a centre for ritual trepanning, around 6000 years ago, according to archeologists who discovered remains of eight recipients of the practice, within a small area, all with the incision in the unusual [[obelion]] position, high on the back of the head.<ref>{{cite news |url=http://www.bbc.com/earth/story/20160826-why-our-ancestors-drilled-holes-in-each-others-skulls |title=Why our ancestors drilled holes in each other's skulls |work=BBC Earth |date=29 August 2016}}</ref>

During the 16th and 17th centuries, around 80% of people survived the procedure of trepanation.<ref name=":4" /><!-- there is much more info in this source! -->

=== Modern medical practices ===
The prefrontal leucotomy, a precursor to [[lobotomy]], was performed by cutting a [[trephine]] hole into the skull, inserting an instrument, and destroying parts of the brain.<ref name=Moniz1937>{{cite journal |last=Moniz |first=Egas |title=Prefrontal Leucotomy in the Treatment of Mental Disorders |date=1937 |journal=American Journal of Psychiatry |volume=93 |issue=6 |pages=1379–85 |issn=0002-953X |doi=10.1176/ajp.93.6.1379}}</ref> This was later made unnecessary by the development of the [[Lobotomy#Transorbital lobotomy|orbital transit lobotomy]] where a spike was inserted through the eye-sockets.

Trepanation is a treatment used for [[epidural hematoma|epidural]] and [[subdural hematoma]]s, and surgical access for certain other neurosurgical procedures, such as intracranial pressure monitoring. Modern surgeons generally use the term ''[[craniotomy]]'' for this procedure. Unlike in folk practices, a craniotomy must be performed only after diagnostic imaging (like [[CT scan|computed tomography]] and [[magnetic resonance imaging]]) has pinpointed the issue within the skull; preoperative imaging allows for accurate examination and evaluation. Unlike in trepanation, the removed piece of skull (called a bone flap) is typically replaced as soon as possible, where it can [[bone healing|heal]]. Trepanation instruments, nowadays being replaced with [[cranial drill]]s, are now available with diamond-coated rims, which are less traumatic than the classical trephines with sharp teeth. They are smooth to soft tissues and cut only bone.<ref name="TrepanationJournal">{{cite journal |last1=Mondorf |first1=Y. |last2=Abu-Owaimer |first2=M.|last3=Gaab |first3=M.R. |last4=Oertel |first4=J.M. | date=December 2009 |title=Chronic subdural hematoma – craniotomy versus burr hole trepanation.|journal= [[British Journal of Neurosurgery]]|volume=23 |issue=6 |pages= 612–16|doi=10.3109/02688690903370297|pmid=19922275 |s2cid=41293769 }}</ref> Additionally, the specially designed drills come with a safety feature that prevents the drill from penetrating into the brain tissue (through the dura mater). Along with antisepsis and prophylaxis of infection, modern neurosurgery is a common procedure for many reasons other than head trauma.

In documented cases of trepanning done in Africa and Oceania during the 20th century, patient survival rate was seen to be approximately 90%.<ref name=":4" />

=== Myth of trepanation as a treatment for headaches ===
After the retrieval of some skulls from the [[Neolithic]] era that showed signs of trepanation, in the nineteenth century, the false belief that these holes were drilled for the treatment of headaches or other neurological disorders started spreading. During the 1870s, the French anthropologist and physician [[Paul Broca]] found several European and South American children's skulls dating to the Neolithic age that were perforated surgically. Since no signs of fractures that could justify this complex procedure to relieve trauma were found, a debate emerged around why these children were subjected to trepanation while they were still alive. Broca theorized that this operation had a ritual or religious purpose, probably to remove "confined demons" inside the head of the patient, or to create healing or fortune talismans with the removed skull fragments. However, he also suggested that the operation may have been performed to treat some infantile conditions such as febrile seizures to explain why it was performed only on children.

Broca never mentioned headaches, though, and the association was established only several decades later by the world-famous Canadian physician [[William Osler]] in 1913. Osler misinterpreted Broca's words, and added other conditions such as "infantile convulsions, headache and various cerebral diseases believed to be caused by confined demons." Osler's theory was seen as particularly palatable by other [[Armchair theorizing|armchair anthropologists]], who were fascinated by the idea that folk traditions and/or myths could be linked with the treatment for common conditions such as migraine. Eventually, Broca's speculation came to be accepted as fact, and the myth was perpetuated by other historians and physicians. To this day, there's no credible evidence supporting this theory, especially since children are much less frequently affected by migraine and headache disorders than adults. Nevertheless, the myth persists.<ref name=":5" />

=== Cultural perspectives on trepanation ===
The motivations behind trepanation varied significantly across cultures, often tied to beliefs about health, spirituality, and the treatment of ailments. Early instances of the practice may have been influenced by a combination of supernatural beliefs and early understandings of physical ailments, leading to its acceptance in various medical traditions. In many cultures, it was believed that drilling a hole in the skull will let out the evil spirits that caused pain and illness. It can be explained as most head injuries and diseases, such as migraine, felt like pounding, so cutting a hole in head may help to relieve the pain and pressure. In Africa and Europe, not only this procedure was performed for spiritual reasons, but also the discs made of cranial bones were commonly used as shield from demons and evils.<ref>{{Cite journal |last1=Apuzzo |first1=Michael L.J. |last2=Liu |first2=Charles Y. |last3=Sullivan |first3=Daniel |last4=Faccio |first4=Rodrick A. |date=July 2007 |title=Surgery of the Human Cerebrum — A Collective Modernity |url=https://journals.lww.com/00006123-200707001-00002 |journal=Neurosurgery |language=en |volume=61 |issue=1 |pages=31 |doi=10.1227/01.NEU.0000255493.34063.7B |issn=0148-396X|url-access=subscription }}</ref> In China, twelve shaman corpses in a tomb were found with trephined bodies because they also had duties of doctors.<ref name=":0" /> This tells about connection of cranial surgery to religion; there was conception that open hole in head contributes to communication with god and souls of dead people. Trepanation was also associated in Chinese medicine with the balance of vital energy, or qi.<ref>{{Cite journal |last=Bates |first=Ann |date=2024-06-04 |title=Beneath the surface: A historical exploration of trepanation practices across cultures and eras |url=https://journals.sagepub.com/doi/10.1177/17504589241253486 |journal=Journal of Perioperative Practice |language=en |doi=10.1177/17504589241253486 |issn=1750-4589|url-access=subscription }}</ref> They understand trepanation as a way to balance the body and energy, spiritual and physical health. On the other hand, it was thought that cerebral disorder arise from the loss of spiritual image in ancient Peru, illness developed after being separated from body.<ref name=":6">{{Cite journal |last=Rifkinson-Mann |first=Stephanie |date=October 1988 |title=Cranial Surgery in Ancient Peru |url=http://journals.lww.com/00006123-198810000-00001 |journal=Neurosurgery |language=en |volume=23 |issue=4 |pages=411–416 |doi=10.1227/00006123-198810000-00001 |issn=0148-396X|url-access=subscription }}</ref> Trepanation would have been done in order to allow the spirit to reenter the body. In these cases, the patient may have suffered from paralysis, cerebral palsy, severe depression, or mental retardation.<ref name=":6" />