Wednesday, April 15, 2009

Trepanation AKA Burr Hole



Trepanation (also known as trepanning, trephination, trephining or making a burr hole) is an antiquated medical intervention in which a hole is drilled or scraped into the human skull, thus exposing the dura mater in order to treat health problems related to intracranial diseases. A trephine is an instrument used for cutting out a round piece of skull bone. The modern procedure is known as craniotomy.

Evidence of trepanation has been found in prehistoric human remains from Neolithic times onwards. Cave paintings indicate that people believed the practice would cure epileptic seizures, migraines, and mental disorders[1]. The bone that was trepanned was kept by the prehistoric people and probably worn as charms to keep evil spirits away. Evidence also suggests that trepanation was primitive emergency surgery after head wounds[2] 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. Such injuries were typical for primitive weaponry such as sling shots and war clubs. [3]

There is some contemporary use of the term. In modern eye surgery a trephine instrument is used in 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 sub-ungual hematoma (blood under the nail); a small amount of blood is expressed through the hole and the pain associated with the pressure is partly alleviated.


Old World

Trepanation is perhaps the oldest surgical procedure for which there is evidence,[4] and in some areas may have been quite widespread. Out of 120 prehistoric skulls found at one burial site in France dated to 6500 BC, 40 had trepanation holes.[5] Many prehistoric and premodern patients had signs of their skull structure healing; suggesting that many of those that proceeded with the surgery survived their operation.

Trepanation was also practiced in the classical and Renaissance periods. Hippocrates gave specific directions on the procedure from its evolution through the Greek age, and Galen elaborates on the procedure, too.

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-8th centuries 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.[2]

Pre-Columbian Mesoamerica

In pre-Columbian Mesoamerica, evidence for the practice of trepanation and an assortment of other cranial deformation techniques comes from a variety of sources, including physical cranial remains of pre-Columbian burials, allusions in iconographic artworks and reports from the post-colonial period.

Among New World societies, trephinning is most commonly found in the Andean civilizations such as the pre-Incan culture such as the Paracas Ica situated in what now is Ica located South of Lima. Its prevalence among Mesoamerican civilizations is much lower, at least judging from the comparatively few trepanated crania which have been uncovered.[6]

The archaeological record in Mesoamerica is further complicated by the practice of skull mutilation and modification which was carried out after the death of the subject, in order to fashion "trophy skulls" and the like of captives and enemies. This was a reasonably widespread tradition, illustrated in pre-Columbian art which on occasion depicts rulers adorned with or carrying the modified skulls of their defeated enemies, or of the ritualistic display of sacrificial victims. Several Mesoamerican cultures used a skull-rack (known by its 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 been recovered.

The earliest archaeological survey published of trepanated crania was a late 19th-century study of several specimens recovered from the Tarahumara mountains by the Norwegian ethnographer Carl Lumholtz.[6][7] Later studies documented cases identified from a range of sites in Oaxaca and central Mexico, such as Tilantongo, Oaxaca and the major Zapotec site of Monte Albán. Two specimens from the Tlatilco civilization's homelands (which flourished around 1400 BC) indicate the practice has a lengthy tradition.[8]

A study of ten low-status burials from the Late Classic period at Monte Albán concluded that the trepanation had been applied non-therapeutically, and, since multiple techniques had been used and since some people had received more than one trepanation, concluded it had been done experimentally. Inferring the events to represent experiments on people until they died, the study interpreted that use of trepanation as an indicator of the stressful sociopolitical climate that not long thereafter resulted in the abandonment of Monte Alban as the primary regional administrative center in the Oaxacan highlands.[citation needed]

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 seemed to have utilised an abrasive technique which ground away at the back of the skull, thinning the bone and sometimes perforating it, similar to the examples from Cholula. Many of the skulls from the Maya region date from the Postclassic period (ca. 950–1400), 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.[9]

Modern medicine

Trepanation is a treatment used for epidural and subdural hematomas, and for surgical access for certain other neurosurgical procedures, such as intracranial pressure monitoring. Modern surgeons generally use the term craniotomy for this procedure. The removed piece of skull is typically replaced as soon as possible. If the bone is not replaced, then the procedure is considered a craniectomy. Trepanation instruments are now available with diamond coated rims (Diamond Bone Cutting System), which are less traumatic than the classical trephines with sharp teeth. They are smooth to soft tissues and cut only bone.

Voluntary trepanation

Although considered today to be pseudoscience, the practice of trepanation for other purported medical benefits continues. The most prominent explanation for these benefits is offered by Dutchman Bart Huges (alternatively spelled Bart Hughes). He is sometimes called Dr. Bart Hughes although he did not complete his medical degree. Hughes claims that trepanation increases "brain blood volume" and thereby enhances cerebral metabolism in a manner similar to cerebral vasodilators such as ginkgo biloba. No published results have supported these claims.

Other modern practitioners of trepanation claim that it holds other medical benefits, such as a treatment for depression or 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 chronic fatigue syndrome and depression.[10]

However, individuals may practice non-emergency trepanation for psychic 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".[5]
Trepanated skull, Iron age. The perimeter of the hole in the skull is rounded off by ingrowth of new bony tissue, indicating that the patient survived the operation.

In a chapter of his book, Eccentric Lives & Peculiar Notions, John Michell describes a British group that advocates self-trepanation to allow the brain access to more space and oxygen. The chapter is called "The People With Holes in their Heads". Michell cites Bart Huges as pioneered the idea of trepanation specifically his 1962 monograph, Homo Sapiens Correctus, as most cited by advocates of self-trepanation. Among other arguments, he 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 a book called Bore Hole written by Joey Mellen. 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:

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!

Amanda Feilding also performed a self-trepanation with a drill, while her partner Joey Mellen filmed the operation, in the film titled Heartbeat in the Brain. The film has since been lost. Portions of the film can be seen, however, in the documentary A Hole in the Head.

In popular culture

* Trepanation is a significant plot point in two sections of the His Dark Materials series by Phillip Pullman, in which it allows a greater quantity of Dust to fall on the recipients.
* Fictional mathematician Max Cohen in the movie Pi performs a trepanation on himself using a drill.
* The Army of the Third Eye in the role playing game Delta Green use Trepanation to expose and destroy the alien Insects from Shaggai.
* Darryl Revok, the fictional antagonist in the movie Scanners, is shown being interviewed after he performs self-trepanation. A circular scar on his forehead can be seen throughout the movie.
* The character of Mason from the television series Dead Like Me is shown to have died from a botched self-trepanation.
* The manga Homunculus by Hideo Yamamoto revolves around an experiment of trepanation on a homeless man.
* In the Law & Order: Criminal Intent episode "Want" (based on the Jeffrey Dahmer case) John Tagman performs trepanation on his victims. One young woman is found alive, but her doctor informs Detectives Goren and Eames that he found scalding on the victim's brain and that her spinal fluid was hypertonic, having been diluted with hot water. Det. Goren determines that Tagman intended to give the woman a "homemade lobotomy" to prevent her from leaving.
* In the Rome (TV series) episode "How Titus Pullo Brought Down the Republic," the character Titus Pullo receives a trepanation after being involved in a bar fight with cheating gambling opponents.
* Rock band Cave In has a song titled Trepanning from their Perfect Pitch Black album.
* Heavy Metal band Machine Head has a song titled "Trephination" on their album Supercharger.
* On Grey's Anatomy, Izzie Stevens drilled burr holes into a man's skull, with the help of McSteamy and The Chief.
* In Star Trek IV, Chekov is being taken into surgery to have a craniotomy performed to relieve pressure from a Subdural Hematoma caused by a traumatic fall, but is rescued by his crewmates before the procedure takes place.




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