Editing Trepanning

{{Short description|Surgically drilling a hole in the skull}}
{{Redirect|Trepanation}}
{{Distinguish|Trepanging}}
[[File:Hieronymus Bosch 053 detail.jpg|thumb|325px|Detail from ''[[The Extraction of the Stone of Madness (The Cure of Folly)|The Extraction of the Stone of Madness]]'', a painting by [[Hieronymus Bosch]] depicting trepanation ({{circa|1488–1516}})]]

'''Trepanning''', also known as '''trepanation''', '''trephination''', '''trephining''' or making a '''burr hole''' (the verb ''trepan'' derives from [[Old French]] from [[Medieval Latin]] {{lang|la|trepanum}} from [[Ancient Greek|Greek]] {{lang|grc-Latn|trúpanon}}, literally "borer, auger"),<ref>{{OEtymD|trepan}}</ref><ref>{{LSJ|tru/panon|τρύπανον|ref}}. [[Henry Liddell|Liddell, Henry George]]; [[Robert Scott (philologist)|Scott, Robert]]; ''[[A Greek–English Lexicon]]'' at the [[Perseus Project]].</ref> is a surgical intervention in which a hole is [[drill]]ed or scraped into the [[human skull]]. The intentional perforation of the cranium exposes the ''[[dura mater]]'' to treat health problems related to intracranial diseases or release pressured blood buildup from an injury. It may also refer to any "[[Burr (cutter)|burr]]" hole created through other body surfaces, including nail beds. A [[trephine]] is an instrument used for cutting out a round piece of skull bone to relieve pressure beneath a surface.<ref>{{Cite web |last=Backhouse |first=Sarah |date=2013-10-25 |title=A hole in the head {{!}} RCP Museum |url=https://history.rcp.ac.uk/blog/hole-head |access-date=November 24, 2024 |website=Royal College of Physicians}}</ref>

Trepanning was sometimes performed on people who were behaving in a manner that was considered abnormal. In some ancient societies it was believed this released the evil spirits that were to blame.<ref>{{cite book |last=Nolen-Hoeksema |title=Abnormal Psychology |edition=6th |publisher=McGraw-Hill Education |year=2014 }}</ref> Evidence of trepanation has been found in prehistoric human remains from [[Neolithic]] times onward. The bone that was trepanned was kept by the prehistoric people and may have been worn as a charm to keep evil spirits away. Evidence also suggests that trepanation was primitive emergency surgery after head wounds<ref name="Weber" /> to remove shattered bits of bone from a fractured skull and clean out the blood that often pools under the skull after a blow to the head. Hunting accidents, falls, wild animals, and weapons such as clubs or spears could have caused such injuries. Trepanations appear to have been most common in areas where weapons that could produce skull fractures were used.<ref name="Rogers">{{cite book |last1=Rogers |first1=Spencer |title=Primitive Surgery: Skills Before Science |date=1985 |publisher=Charles C. Thomas |location=Springfield, IL |isbn=0-398-05123-2 |pages=[https://archive.org/details/primitivesurgery00roge/page/17 17-18] |url=https://archive.org/details/primitivesurgery00roge }}</ref> The primary theories for the practice of trepanation in ancient times include spiritual purposes and treatment for epilepsy, head wound, mental disorders, and headache, although the latter may be just an unfounded myth.<ref name=":2"/><ref name=":5">{{Cite book |last=Butticè |first=Claudio |title=What you need to know about headaches |date=April 2022 |publisher=[[Greenwood Publishing Group]] |isbn=978-1-4408-7531-1 |location=Santa Barbara, California |pages=29–30 |oclc=1259297708}}</ref>

In modern eye surgery, a trephine instrument is used in [[Cornea transplant|corneal transplant surgery]]. The procedure of drilling a hole through a fingernail or toenail is also known as trephination. It is performed by a physician or surgeon to relieve the pain associated with a [[subungual hematoma]] (blood under the nail); a small amount of blood is expressed through the hole and the pain associated with the pressure is partially alleviated. Similarly, in abdominal surgery, a trephine incision is when a small disc of abdominal skin is excised to accommodate a [[Stoma (medicine)|stoma]]. Although the abdominal wall does not contain bone, the use of the word ''trephine'' in this context may relate to the round excised area of skin being similar in shape to a burr hole.

== 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" />

== Tools and methods ==
In ancient times, trepanation instruments were less complex, and were commonly made out of flint, obsidian, or harder material such as stone knives, and later with metal such as bronze and copper.<ref name=":1">{{Cite journal|last=Verano|first=John W.|date=2017-12-01|title=Reprint of-Differential diagnosis: Trepanation|journal=International Journal of Paleopathology|language=en|volume=19|pages=111–118|doi=10.1016/j.ijpp.2017.03.004|pmid=29198392|issn=1879-9817|doi-access=free}}</ref> Additionally, the procedure was done by practitioners utilizing ''[[tumi]]'' (ceremonial knife in early Peru), sharpened seashells (South Pacific), a trephine drill, bronze knife, etc.<ref name=":1" /> The Greeks and [[Surgery in Ancient Rome|Romans]] were the first to design medical instruments to penetrate the skull.<ref name=":2">{{Cite journal|last=Faria|first=Miguel A.|date=2013-04-05|title=Violence, mental illness, and the brain – A brief history of psychosurgery: Part 1 – From trephination to lobotomy|journal=Surgical Neurology International|volume=4|page=49|doi=10.4103/2152-7806.110146|issn=2229-5097|pmc=3640229|pmid=23646259 |doi-access=free }}</ref> Such instruments includes the ''terebra serrata'', made to perforate the cranium by positioning the instrument's pointed end against the cranium and manually rolling the instrument's shaft back and forth between the surgeon's two hands.<ref name=":2" /> By the Renaissance period, when trepanation was routinely performed, a range of instruments were developed to accommodate the demand.

As many as five main methods were found for trephination: 
# Rectangular intersecting cuts
# Scraping utilizing an abrasive instrument such as flint
# Circular grooving
# Boring and cutting by a circular trephine or crown saw
# Burr hole done by drilling several circle holes closely to create a space and then cut/chisel the bone between the hole.<ref>{{Cite web|url=https://thereader.mitpress.mit.edu/hole-in-the-head-trepanation/|title=A Hole in the Head: A Complete History of Trepanation|date=2019-08-29|website=The MIT Press Reader|language=en|access-date=2020-04-28}}</ref><!-- this citation applies to all 5 items -->
The scraping method was found to be the most common in prehistoric times.<ref name=":1" /> The differences in method vary in the amount and depth of bone being removed. The trepanation surgical procedure includes exposure of the dura mater without damaging the underlying blood vessels, [[meninges]], and brain. Over time, the skin will reform over the puncture site, but the hole in the skull will remain.

The location of the trepanation on the skull varies by geographical region and period, common locations are the [[Frontal bone|frontal]] and the [[Occipital bone|occipital]] bones.<ref name=":3">{{Cite journal|last1=Kushner|first1=David S.|last2=Verano|first2=John W.|last3=Titelbaum|first3=Anne R.|date=June 2018|title=Trepanation Procedures/Outcomes: Comparison of Prehistoric Peru with Other Ancient, Medieval, and American Civil War Cranial Surgery|journal=World Neurosurgery|volume=114|pages=245–51|doi=10.1016/j.wneu.2018.03.143|issn=1878-8769|pmid=29604358|hdl=10150/628576|s2cid=4484348|hdl-access=free}}</ref> In most cases, trepanation was a one-off operation, with only a small percentage of the trepanned skulls having undergone more than one surgery. In those with multiple openings, the extent of bone remodelling helps identify whether the opening was done at around the same time or at different times during the individual's life.<ref name=":3" />

== Risks ==
A [[Neurosurgery|neurosurgeon]] can perform the procedure safely, although it comes with severe repercussions such as direct or indirect perioperative complications, which include increased damage to the brain, infection, blood loss, hemorrhage, and potentially death due to the trauma as the skull's protective covering is compromised.<ref>{{Citation|last=Nikita|first=Efthymia|title=Chapter 8 – Pathological Conditions|date=2017-01-01|url=http://www.sciencedirect.com/science/article/pii/B9780128040218000085|work=Osteoarchaeology|pages=301–54|editor-last=Nikita|editor-first=Efthymia|publisher=Academic Press|doi=10.1016/B978-0-12-804021-8.00008-5|language=en|isbn=978-0-12-804021-8|access-date=2020-05-05|url-access=subscription}}</ref> The operation leaves very minimal space for error and a high incidence of mortality if the dura mater is penetrated. Additionally, there is a high risk of infection if the operation is conducted with contaminated tools or improper sanitary wound care.<ref>{{Cite journal |date=2000-03-04 |title=Doctors warn of the dangers of trepanning |journal=British Medical Journal |volume=320 |issue=7235 |page=602 |issn=0959-8138 |pmc=1173790}}</ref> If the infection is not caught and treated immediately, it can be fatal or lead to significant and permanent brain damage. After surgery, neither the surrounding bone nor the trepanned bone piece ever show any osseous healing like other bones. Osteoclastic and osteoblastic activity occurs after the first week; [[Hyperaemia|hyperemia]] and [[osteoclast]]ic activity are seen on the necrotic bone surrounding the trepanation site, due to loss of blood supply.<ref>{{Cite journal |last1=Rungta |first1=Ravi L. |last2=Chaigneau |first2=Emmanuelle |last3=Osmanski |first3=Bruno-Félix |last4=Charpak |first4=Serge |date=2018-07-25 |title=Vascular Compartmentalization of Functional Hyperemia from the Synapse to the Pia |journal=Neuron |volume=99 |issue=2 |pages=362–375.e4 |doi=10.1016/j.neuron.2018.06.012 |issn=0896-6273 |pmc=6069674 |pmid=29937277}}</ref><ref>{{Cite journal |last=Knüsel |first=Christopher |date=March 2004 |title=Trepanation: History, Discovery, Theory. R. Arnott, S. Finger & C.U.M. Smith (eds). Swets & Zeitlinger Publishers, Lisse, The Netherlands 2003. 408 + XIIpp. ISBN 90 265 1923 0. £67/$99 |url=https://onlinelibrary.wiley.com/doi/10.1002/oa.703 |journal=International Journal of Osteoarchaeology |language=en |volume=14 |issue=2 |pages=151–153 |doi=10.1002/oa.703 |issn=1047-482X|url-access=subscription }}</ref>

== Voluntary trepanation ==
Since the early 1960s, voluntary trepanation has been performed by people interested in "enhancing mental power and well-being".<ref name=":4">{{Cite journal |last=André |first=Charles |date=2017 |title=Evolving story: trepanation and self-trepanation to enhance brain function |journal=Arquivos de Neuro-Psiquiatria |language=en |volume=75 |issue=5 |pages=307–313 |doi=10.1590/0004-282X20170040 |pmid=28591391 |issn=0004-282X|doi-access=free }}</ref> The practice of trepanning also continues today due to belief in various [[Pseudoscience|pseudoscientific]] medical benefits.<ref>{{cite web|url=https://www.vice.com/en/article/drilling-a-hole-in-your-head-for-a-higher-state-of-consciousness/ |title=An Interview with the Woman Who Drilled a Hole in Her Head to Open Up Her Mind |author=Joseph Cox |date=August 14, 2013 |access-date=2013-08-15 |url-status=live |archive-url=https://web.archive.org/web/20160917195052/http://www.vice.com/en_au/read/drilling-a-hole-in-your-head-for-a-higher-state-of-consciousness |archive-date=2016-09-17 }}</ref> For example, some have tried trepanation as a means of emulating the "[[third eye]]", in order to achieve [[clairvoyance]] or as a means of maintaining a "permanent state of [[euphoria]]".<ref>{{Cite book |last=Wilcock |first=John |url=https://books.google.com/books?id=OqFsAAAAMAAJ&q=trepanation+occult |title=An Occult Guide to South America |date=1976 |publisher=Book Division of Laurel Tape & Film; Briarcliff Manor, N.Y.: this ed. distributed by Stein & Day |page=65 |isbn=978-0-8128-2107-9 |language=en}}</ref><ref>{{Cite book |last=DeMello |first=Margo |url=https://books.google.com/books?id=s0122BsqrZwC&pg=PA286 |title=Encyclopedia of Body Adornment |date=2007 |publisher=ABC-CLIO |isbn=978-0-313-33695-9 |page=286 |language=en}}</ref> Other proponents claim that trepanning results in increased blood flow.<ref>Frood, Arran. [https://www.newscientist.com/article/mg20227121.400-like-a-hole-in-the-head-the-return-of-trepanation.html?full=true "Like a hole in the head: The return of trepanation "] {{webarchive|url=https://web.archive.org/web/20140202154057/http://www.newscientist.com/article/mg20227121.400-like-a-hole-in-the-head-the-return-of-trepanation.html?full=true|date=February 2, 2014}} February 2, 2014, at the [[Wayback Machine]]. ''[[New Scientist]]'' (17 June 2009)</ref> Individuals have practiced non-emergency trepanning for psychological purposes. A prominent proponent of the modern view is Peter Halvorson, who drilled a hole in the front of his own skull to increase "brain blood volume".<ref name="restak2000" />

One of the most prominent advocates of trepanning was [[Netherlands|Dutch]] librarian [[Bart Huges]]. In 1965, Huges drilled a hole in his own head with a dentist drill as a publicity stunt. Huges claimed that trepanning increases "brain blood volume" and thereby enhances cerebral metabolism in a manner similar to cerebral [[vasodilators]] such as [[ginkgo biloba]]. These claims are unsubstantiated by research. Huges and his girlfriend also made several comic books in the 1970s, which promoted trepanation.<ref>{{Cite web | url=https://www.lambiek.net/artists/d/dijk_eveline-van.htm | title=Eveline van Dijk}}</ref>

In a chapter of his book ''Eccentric Lives & Peculiar Notions'', esotericist [[John Michell (writer)|John Michell]] cites Huges as pioneering the idea of trepanning in his 1962 monograph, ''Homo Sapiens Correctus'', which is often cited by advocates of self-trepanation. Among other arguments, Huges contends that children have a higher state of consciousness and since children's skulls are not fully closed, one can return to an earlier, childlike state of consciousness by self-trepanation. Further, by allowing the brain to freely pulsate Huges argues that a number of benefits will accrue.

Michell quotes [[Joey Mellen|Joey Mellen's]] book, ''Bore Hole''.  At the time the passage below was written, Joey and his partner, [[Amanda Feilding]], had made two previous attempts at trepanning Mellen.  The second attempt ended up placing Mellen in the hospital, where he was reprimanded severely and sent for psychiatric evaluation.  After he returned home, Mellen decided to try again.  He describes his third attempt at self-trepanation:

<blockquote>After some time there was an ominous sounding schlurp and the sound of bubbling. I drew the trepan out and the gurgling continued. It sounded like air bubbles running under the skull as they were pressed out. I looked at the trepan and there was a bit of bone in it. At last!</blockquote>

Feilding also performed a self-trepanation with a drill, while Mellen shot the operation for the short film ''[[Heartbeat in the Brain]]'', which was long thought to have been lost. Portions of the film can be seen in the documentary ''[[A Hole in the Head (1998 film)|A Hole in the Head]]''.<ref>{{cite web|url=https://www.vice.com/en/article/meet-the-man-who-drilled-a-hole-in-his-own-skull-to-stay-high-forever/ |title=I Drilled a Hole in My Own Skull to Stay High Forever |access-date=2016-02-13 |url-status=live |archive-url=https://web.archive.org/web/20160826054415/http://www.vice.com/read/meet-the-man-who-drilled-a-hole-in-his-own-skull-to-stay-high-forever |archive-date=2016-08-26 |author=John Doran |date=February 12, 2016}}</ref>

Michell also describes a British group that advocates self-trepanation to allow the brain access to more space and oxygen. Other modern practitioners of trepanation claim that it holds other medical benefits, such as relief from depression and from other psychological ailments. In 2000, two men from [[Cedar City, Utah]], were prosecuted for practicing medicine without a license after they performed a trepanation on an English woman to treat her [[Myalgic encephalomyelitis/chronic fatigue syndrome|chronic fatigue syndrome]] and [[Clinical depression|depression]].<ref>[http://www.rcfp.org/browse-media-law-resources/news/abc-ordered-hand-over-unedited-head-drilling-tapes Reporters Committee for Freedom of the Press (2000) ''ABC ordered to hand over unedited head-drilling tapes''] {{webarchive |url=https://web.archive.org/web/20160823161314/http://www.rcfp.org/browse-media-law-resources/news/abc-ordered-hand-over-unedited-head-drilling-tapes |date=August 23, 2016 }} August 23, 2016, at the [[Wayback Machine]].</ref>

In 2023, Michael Raduga, a Russian lucid dreaming researcher, performed self-neurosurgery that included trepanation, electrode implantation, and electrical stimulation of the motor cortex. The goal was to stimulate the brain during REM sleep, sleep paralysis, and lucid dreams.<ref>{{cite news |url=https://www.newsweek.com/russian-implants-chip-brain-control-dreams-hospital-1814256 |work=Newsweek |date=July 20, 2023|title=Man Implants Chip in His Brain to Help 'Control' His Dreams}}</ref><ref>{{cite news |url=https://www.elpais.com.co/mundo/aterrador-para-controlar-sus-suenos-hombre-se-perfora-su-propio-craneo-2044.html |work=El Pais |date=July 23, 2023|title=Aterrador: para "controlar sus sueños" hombre se perfora su propio cráneo}}</ref><ref>{{cite news |url=https://heraldodemexico.com.mx/tendencias/2023/7/19/insolito-se-realizo-una-cirugia-cerebral-si-mismo-para-controlar-los-suenos-523440.html |work=El Heraldo |date=July 19, 2023|title=Insólito: se realizó una cirugía cerebral a sí mismo "para controlar los sueños"}}</ref><ref>{{cite news |url=https://www.mk.ru/social/2023/07/20/issledovatel-raduga-rasskazal-kak-prosverlil-sebe-cherep-dlya-upravleniya-snami-priblizil-budushhee.html |work=Московский Комсомолец |date=July 20, 2023|title=Исследователь Радуга рассказал, как просверлил себе череп для управления снами: "Приблизил будущее"}}</ref>

== Modern interpretation and research ==
Modern forensic and medical research on trepanned skulls demonstrates advanced surgical skills in prehistoric societies and highlights how trepanation influenced later developments in neurosurgery and the history of medicine. With the advancement of technology, it became possible to examine and interpret the trepanned skull with CT scans and new techniques of bioarchaeology. A recent study provided new perspective of the healing process of skull after cranial trepanation: even though there are many examples of prehistoric cranial lesions that have been classified as "healed trepanations", the research shows that definition of “healing” is not consistent. One of the reasons of distinction in variations of healing process is difference of surgical methods such as “scraping” or “grooving” that might alter the angle of the edge. The first smoothening of bone begins in 5 months, but total healing or closure never happens.<ref>{{Cite journal |last1=Partiot |first1=Caroline |last2=Lepetit |first2=Aliénor |last3=Dodré |first3=Emilie |last4=Jenger |first4=Camille |last5=Maureille |first5=Bruno |last6=Liguoro |first6=Dominique |last7=Thomas |first7=Aline |date=December 2020 |title=Cranial trepanation and healing process in modern patients—Bioarchaeological and anthropological implications |journal=Journal of Anatomy |language=en |volume=237 |issue=6 |pages=1049–1061 |doi=10.1111/joa.13266 |issn=0021-8782 |pmc=7704229 |pmid=32584468}}</ref>

By the 20th century, the ancient practice of trepanning evolved into procedure of bone marrow biopsy, which became vital for identifying illnesses including anemia, leukomia, lymphoma, and tuberculosis.<ref name=":7">{{Cite journal |last=Parapia |first=Liakat A. |date=October 2007 |title=Trepanning or trephines: a history of bone marrow biopsy |url=https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2141.2007.06749.x |journal=British Journal of Haematology |language=en |volume=139 |issue=1 |pages=14–19 |doi=10.1111/j.1365-2141.2007.06749.x |issn=0007-1048|url-access=subscription }}</ref> This change happened as doctors realized the need of accessing the inside of bones for diagnostic purposes, especially in the treatment of blood-related ailments. The initial tools of trepanation as crown trephine transitioned into the biopsy needles in modern medicine such as Vim-Silverman needle and Jamshidi needle.<ref name=":7" /> The instrument created a small hole in the skull, reducing the possibility of significant injury. These instruments’ adaptation in performing multiple medical functions, ranging from diagnosing blood and relieving cranial pressure, shows how tools adapt to advancements in medicine.

== See also ==
* [[Craniotomy]]
* [[Mütter Museum]]
* [[Shrunken head]]

== References ==

{{Reflist|30em}}

== External links ==
{{Commons category|Trepanation}}
* [https://web.archive.org/web/20060427150903/http://www.steinergraphics.com/surgical/006_17.6.html WHO surgical instructions on burr holes]
* [http://skepdic.com/trepanation.html Skeptic's Dictionary entry about Trepanation]
* [https://web.archive.org/web/20080917004902/http://scienceblogs.com/neurophilosophy/2008/01/an_illustrated_history_of_trep.php An illustrated history of trepanation]
* [https://web.archive.org/web/20080807235902/http://scienceblogs.com/neurophilosophy/2008/08/lunch_with_heather_perry.php Interview with self-trepanner Heather Perry]
* {{usurped|1=[https://web.archive.org/web/20210224101451/https://phisick.com/article/an-abc-of-craniotomy/ ABC: A History of Craniotomy]}} phisick.com 14 Nov 2011

{{Prehistoric technology|state=collapsed}}
{{Pseudoscience}}
{{Authority control}}

[[Category:Body modification]]
[[Category:History of neuroscience]]
[[Category:Neurosurgical procedures]]