What is Trephination: History, Techniques and Risks

In today’s world, medicine and treatments are constantly growing, trying to find the most effective methods to help patients. Naturally, that also means that surgery has developed a lot over time, looking for safer procedures with higher success rates. But have you found yourself wondering how old some of the procedures performed today might be? Surgery, itself, sounds to be complicated and needs to be backed up by research. It’s not a matter to be taken lightly, since surgery involves physically reaching into a person’s body. Many devices and tools have been developed to assist in safe surgeries now. But what were surgical procedures like in the olden days, where the doctors had to depend on nothing but their skills? This article gives you a glimpse of the early surgical world, as it explores one of the oldest procedures known to humans, ‘Trephination’.

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What is Trephination?

Trephination, also known as trepanation or burr holing, is a very old surgical procedure developed centuries ago. In this procedure, a hole is drilled into the bone, and excised or scraped. This procedure is usually done on a human skull, though it isn’t limited to it, and can be performed on fingernails or toenails as well. Burr holing can be done on patients, as well as individuals postmortem.

Trepanation can be used to treat head injuries or fractures. It worked on the principle of releasing intracranial pressure. It was also aimed at healing symptoms of epilepsy in earlier days. It was used as a method of treatment for mental illnesses to let out evil spirits in people. This surgical process was also used to increase blood flow, reducing the occurrence rate of degenerative diseases such as Alzheimer’s. Burr holing was not only seen to be used for medical reasons, it was also meant to satisfy ritual and spiritual beliefs. While the survival rates varied around the world, they still seemed to be decent. In Kushner’s 2018 study, 800 trepanned crania were analysed to find and compare the degree of healing. The result found that the average rates of survival during the Inca period were 75-83%. However, complications may arise during the procedure. Since it is abrasive, the risk of infection increases. It might also cause brain damage or haemorrhage.

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In earlier days, research has shown that trephination was the primary form of emergency surgery in case there was damage to the skull. In these cases, trepanation was aimed at removing pieces of bone or clearing a formed blood pool. This method of surgery had diverse roots and saw its prevalence all around the world. This fact was further supported by the discovery of trephined skulls in many locations throughout the world.

History of Trephination:

Trephination has been long present as a part of history. It is said to be dated back to about 7000 to 10000 years ago. Trephined skulls from the Mesolithic period, which is the transitional period in the Stone Age, have been found. Out of these skulls, many showed signs of healing, confirming that trephination has also seen success during this period. The practice has likely emerged from North Africa, Ukraine and Portugal. Later, in the Neolithic period, trepanation was located in some areas of South America, France and the Czech Republic. Evidence of its existence in the Stone Age was not limited to human remains but was also seen in the form of cave paintings. The end of the Stone Age did not take down the practice of burr holing with it.

As supported by evidence, trephination was seen to be practiced in the 5th century BC by both the ancient Romans, as well as the ancient Greeks. During this time, the practice caught the attention of Hippocrates, who is regarded as the Father of Modern Medicine, and the Greek Physician Galen. The technique prospered in both the continents of America, and also in Europe. Physicians who followed Hippocrates’ techniques used trephination for blood to flow out. This was because Hippocrates believed that blood was like stagnant water, and was at risk of turning into pus. However, this practice soon ceased to be used for this purpose since recorded cases of infection were high, and survival rates were low. It was not until the 19th century that trephination regained its former glory. This is because, with research, physicians better understand that trephination can be useful in the treatment of traumatic head wounds, skull fractures, brain tumours, etc.

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Trephination has emerged repeatedly throughout history as a solution for mental, spiritual, as well as medical reasons, all varying based on time and location. In the history of China, Han and Chen hypothesized that this method was used on people, alive or dead, to procure brain disks, intending to gain protection from demons. The Hungarians got into the practice of ritual trepanation following a person’s demise. Over time, trepanation ceased to be practised as therapy or for ritualistic reasons. However, it continued to be used for medical purposes.

Today, with developments in research, trepanation has been replaced by the safer modern procedure of craniotomy. This practice is different from the centuries-old trephination as it is done only after analyzing brain image scans such as MRIs. This procedure also replaces the removed pieces of the skull as soon as the unwanted object (tumour, fragments, etc.) is removed.

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Tools and Techniques:

Trephination, in many cases, was done to cure, and not to kill. It was adapted as a medical treatment over time. This could be performed by four techniques. Let’s look at what they are.

• Scraping: In this method, a blade or flint knife is used in a circular slicing motion to create a hole. Many skulls found in the Altai region of Siberia demonstrated signs of scraping.
• Circular Grooving: This method involves cutting a circular groove to lift the bone disc. This method was common until recently in areas like Kenya.
• Drilling Several Connected Holes: This method started by drilling several small holes close to each other to form a circle. This circle was then taken out by hammering or scraping the small spaces between each drilled circle. This was suggested by Greek Philosopher, Celsus. Reported usage was from locations such as Peru or North America.
• Rectangular Intersecting Cuts: Common in Mesoamerica, this method sliced the skull into a cross-hatch pattern to make a rectangular hole.
• Boring and Cutting using a Crown Saw: A crown saw or a circular trephine is used to bore and further remove the part of the skull to create a hole.

Use of Trephination in Mental Health Treatments

Trephination has seen multiple uses over the years. One of them was its use as a method to get rid of mental illnesses. Not all of them had medical basis to back up the procedure. Let’s look at some reasons why trephination was chosen as means to treat these illnesses.

• Trial and Error: In the olden days, lack of knowledge about the causes of mental illnesses also meant that people didn’t know the solution to it. Thus, different methods were used with the hopes of finding a solution.
• Releasing Spirits: Many people believed that spirits possessed the root cause of mental illnesses. Trephination was done to give way for evil spirits to leave the body. This method was often fatal since most people performing trephination for this purpose weren’t skilled.
• Balancing Humor: Hippocrates proposed the theory of humor, in which he said that the body consists of four humors, which are the black bile, yellow bile, blood and phlegm. He also suggested that the cause of mental illnesses was the imbalance of these humors. Trephination was used to retain balance by letting out the excess fluids.
• Symbolic Rituals: Some cultures used trephination as a symbol of healing. There was no medical evidence to support their action. This method was meant to initiate rituals that were believed to heal a person.
• Treating Head Injuries: Many believed that head injuries were the cause of mental illnesses. Thus, trephination was used to relieve pressure on the brain, letting it heal and cure mental illness.
• Cleansing: Trephination was used as a way to purify all the impurities in a person. Cleansing was also seen as a way to eliminate negative forces that might be within an individual.

Trephination in India

Trephination was used world-wide, and India was not left behind. Evidence found has shown that trephination dates back to the Bronze Age (4300BC) among the people of the Indus Valley Civilization. Among these evidences were the skull of a 9-10 year old child with a square hole at Lothal, a site at Harappa. (Sarkar, 1972).

Ayurveda, which is an ancient medical system, says that trephination is a method that can relieve pressure built within the skull. It says that this procedure can be used in those treatments which are related to the brain. Further, trephination also reflected as a part of religious and spiritual practices in ancient India. One belief that was held in these Indian communities was that a hole in the skull can help in building a connection between one’s physical and spiritual self.

India is a diverse country with multiple communities. Thus, beliefs regarding trephination varied in all. Although it was earlier seen in Harappa, evidence has shown that this procedure took place all over the Indian sub-continent. A skull with evidence of trephination was retrieved from Kashmir, which was traced back to the Neolithic Age. Another one with two holes on either side of a suture was found in the Maski region of Karnataka, dated back to the Iron Age. Trephination was widely used in India. However, this process declined over time with medical advancements and new research.

Risks Involved in Trephination:

The surgical procedure of trephination, if not done skillfully, could involve several risk factors. This abrasive process was very likely to cause brain damage in the patient. Further, it carries risks of blood loss, haemorrhage, infection or problems such as epilepsy. It also carried the potential risk of being fatal. Although it was used as a method to treat the very same problems, trephination carried the risk of causing them as well. Thus, trepanation needed to be performed with skill. This operation method leaves minimal room for error, making it unsuitable for therapeutic purposes.

In earlier days, these risk factors were often increased due to the use of contaminated instruments. Many times, any error in surgery went unnoticed. This led to an increase in permanent brain damage. The procedure also increased the risk of stroke in patients. However, Laurence Watkins, a consultant neurosurgeon at the Institute of Neurology, London, says that in the hands of a skilled neurosurgeon, this is not a risky procedure.

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Variations in Practice

The earliest trephination procedures likely happened spontaneously, such as at the site of a skull fracture. Later techniques became more systematic and ritualistic but with regional differences in traditional methods and tool types. Peruvian cultures used sharpened flint or bronze knives for scraping repetitive cuts or drilling holes into the head. Some speculation suggests this release of blood may have held religious significance for Incan healers. In other South American societies like the Aztecs or Mayans, priests conducted ceremonial trephination, aiming to treat certain conditions by opening a hole for evil spirits to exit.

Meanwhile, in ancient China, crude stone burrs with serrated edges were turned manually against the soft skull tissue, showing less uniformity but perhaps greater speed than ceremonial techniques. Neolithic Africans used crude scrapers of sharpened stone or bone to aggressively cut or scrape openings in the cranium. But more delicate, advanced techniques also emerged quite early on. Fine obsidian blades helped create clean incisions and uniform flap removal among some Native American tribes. And surprisingly steady hand motions produced smooth, round holes in European skulls dating back 7,000+ years using flint points or narrow blades.

While specifics shifted across regions, trephination remained a widespread therapeutic, even spiritual practice long before the modern rise of sterile hospitals and electric drills. Early surgeons around the globe intuitively pursued the development of holes in the head to address medical conditions, cultural rituals, head trauma and more.

Cultural and Anthropological Perspectives  

As an early form of surgery embedded deeply in various cultures worldwide, trephination reveals unique insights from an anthropological lens. The risks involved make it clear this was no casual activity but rather an important ritual that spoke to belief systems of health, mysticism and the workings of the body.

Speculation persists of a cult revolving around trephination, particularly in ancient parts of France and Germany. Archaeological evidence shows certain members of a community – either healers, high-status individuals or those afflicted by illness and seizures – repeatedly underwent trephination procedures. The purpose may have ranged from attempting medical cures to symbolic demonstrations of endurance and faith. Some evidence even suggests people had multiple holes reopened over time as part of a recurring ceremonial process.  

Additionally, skull openings were sometimes marked with etchings or coloured inlay flakes, as if to commemorate this permanent body alteration. Subjects lucky enough to survive may have been viewed as blessed or privileged. So the decorated skulls suggest a celebration of coming through this intensive rite of invasion and healing. These mysterious holes represent far more than early surgery alone. The evidence indicates deep mystical views on health and spirituality behind the global practice of boring holes into the cranium across ancient cultures.

Modern Perspectives

Today the long history of trephination has given way to advanced neuro and cranial surgery practices. With antiseptic standards, anaesthesia, medical imaging and electric surgical tools, the risks and uncertainties of trephination have appropriately been replaced in modern medicine. Surgeons can now precisely target affected areas of the brain or skull while minimizing side effects and infection.

However, the term trephination is still sometimes used for procedures that remove a circular piece of skull. This can be done to mitigate swelling in the brain after a traumatic head injury. Or may proceed with another neurosurgery to access the brain tissue below if needed for tumour removal, aneurysm clipping or seizure treatment. 

The surgeon will use imaging data to precisely mark and remove a skull “window” with a special trephine tool. Then a custom-made implant is set to replace the bone after completing the interior surgery. So similar to its ancestral namesake, this form of modern trephination creates a hole for medical reasons. But it does so via advanced imaging, safe surgical controls and the benefit of research on anatomy and neurology – assurances absent in ancient times!

Ultimately the shift away from ancient trephination practices signifies the progress of medical science through evidence, ethics and technology. While still occasionally useful in specific applications, blind drilling into skulls based on spiritual customs or arbitrary medical theories is no longer applicable or advisable.

Ethical Considerations

Evaluating any ancient medical practice from a modern perspective inevitably raises some ethical questions – particularly for one as potentially gruesome but mysteriously commonplace as trephination. While beliefs, hygiene, anaesthesia and surgical capabilities have evolved drastically, the ethics are not as clear cut. On one hand, trephination was certainly gruesome by modern standards and carried major risks like infection, uncontrolled bleeding and damage to brain tissue. Unlike animal sacrifices or similar rituals, the traumatic nature targeted to the living individual makes evaluating ethical intentions difficult. Did subjects always consent? Were desperate patients and families given false hope? We will likely never have enough context to assess how willing and informed participants were regarding these intimidating procedures.  

However, judging ancestors who intuitively pursued medical solutions without modern knowledge introduces some ethical dilemmas itself. Cultures around the world independently trialled trephination to treat very real problems for millennia. Calling this inherently wrong from the comfort of modern hospitals seems somewhat ungrateful and shortsighted. Additionally, various societies incorporated trephination into complex belief systems and the scientific knowledge available at the time, similar to approaches like bloodletting or herbalism. So while side effects could be severe, the intent centred on spiritually curing afflictions and illnesses.

Summing Up

Trepanation is one of the oldest known surgical procedures. It has its roots in the Stone Age as well. It was also widely used, with evidence confirming its practice in various locations around the world. The procedure had no single reason to be used. Rather, its usage over time has been seen to address mental, spiritual and medical problems. The practice, although risky, had been successfully carried out in many patients while they were alive.

The evidence of healed skulls has proven that trepanation was conducted on people while they were alive. Further, evidence also shows that many individuals survived multiple trephinations. The success rate is hard to believe, considering that anaesthetic medicine was not prevalent in the olden ages. The procedure of trephination was seen to develop in different parts of the world independently.

Thus, different methods were used to carry it out. Today, trephination has ceased to exist. However, it has given way to research that has contributed to the development of modern surgical procedures such as craniotomy, which is much safer than burr holing. Trephination is one such procedure that has brought to attention that surgery is a century-old concept that has been growing with time, adapting to new and improved findings.

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