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British Journal of Neurosurgery (1997);11(2):156± 158
SHORT REPORT
Self-trephination of the skull with an electric power drill
J. P. WADLEY, G. T. SMITH & C. SHIEFF
Department of Neurosurgery, The Royal Free Hospital, London , UK
Abstract
There is extensive archaeological evidence of the practice of trephination of the skull in many ancient cultures in differentparts of the world. We report a case of self-trephination of the skull by a patient using an electrical power drill subsequentlyrequiring neurosurgical intervention.
Key words: Self-in¯ icted, superior sagitta l sinus, trephination
Case report
A 65-year-old unemployed man presented to his
local casualty department with a small circular
wound of the scalp just behind the hairline in the
left frontal region. His chief complaint was of leak-
age of clear ¯ uid from the wound and upon ques-
tioning the patient admitted to drilling a hole
through both the scalp and skull using a power drill.
The patient claimed that this was in response to a
television programme that he had recently watched
which, somewhat lightheartedly, had featured two
individuals who had advocated such acts as a means
of self-fu l® lment. Subsequently, he had purchased
an electric power drill, shaved a 4 3 4-cm area of
scalp, applied topical local anaesthetic cream, and
proceeded to press forth the drill in front of a
mirror, taking 30 min to penetrate the inner table of
the skull. This was heralded by profuse haemor-
rhage, at which point the patient thought it prudent
to stop. After several hours the haemorrhage had
ceased, aided by digital plugging of the hole; the
patient was unaware of any sensations of enhanced
well-being. Indeed, he began to feel dizzy and
noticed a discharge of clear colourless ¯ uid from the
wound. He then decided to attend the accident and
emergency department of his local hospital. After
initial inspection and plain radiographs which
demonstrated the track of the drill bit with complete
penetration of the skull (Fig. 1), the patient was
transferred to our neurosurgical unit for further
management. Upon arrival, examination revealed a
1-cm diameter ragged laceration of the scalp with a
surrounding area of shaved hair lying approximately
3 cm anterior to the coronal suture just to the left of
the midline. Cerebrospinal ¯ uid was issuing from
the wound and air bubbles were visible upon cough-
ing. Apart from exhibiting somewhat strange behav-
iour characterized by agitation and a curious
ambivalence to the unusual nature of his actions, the
FIG. 1. Lateral plain X-ray of the skull demonstrating thedrill hole (arrow) anterior to the coronal suture and thefrontal lobe clearly outlined by subfrontal air.
Correspondence: Mr J. P. Wadley, Department of Neurosurgery, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK. Tel:0181 846 1234. Fax: 0181 846 7487.
Received for publication 20th January 1996. Accepted 2nd March 1996.
0268-869 7/97/020156± 03 $9.50 Ó The Neurosurgical Foundation
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Self-trephination 157
FIG. 2. CT scan of the head through the skull vault with thecylindrical defect clearly visible.
FIG. 3. CT scan of the head showing air lying over bothfrontal lobes.
an attempt at self-harm. Psychiatric review did not
demonstrate any psychotic or suicidal ideation, but
a documented history of psychiatric interviews over
a period of 20 years was discovered, with a record of
antisocial and violent behaviour, and previous con-
victions for theft and assault. The current diagnosis
was of `dissocial personality disorder’ . CT of the
head clearly illustrated the cylindrical defect in the
skull (Fig. 2) and the presence of subdural air over
both frontal lobes con® rmed a dural laceration
(Fig. 3).
Initially, the patient refused consent to operation,
but he was made aware of the consequences of
intracranial sepsis and surgery was duly performed
the next day under general anaesthetic. A bicoronal
scalp ¯ ap was re¯ ected revealing a neat 0.8-cm hole
in the skull. Utilizing the original hole and a new
burr hole, a small local free bone ¯ ap was raised.
The wound was carefully irrigated with saline, re-
moving fragments of lacerated scalp, pericranium
and bone dust. The large portion of the dural lacer-
ation overlay the superior sagittal sinus, and sub-
sequent profuse haemorrhage resulting from
removal of the contaminated blood clot was arrested
with muscle graft and tamponade. The operative
® eld was irrigated free of debris, the external surface
and galeal margins of the laceration were excised
and sutured, and the scalp incision closed in the
usual fashion. The small bone ¯ ap was left out
because of the risk of subsequent infection.
Postoperatively, the patient completed a course of
broad spectrum intravenous antibiotics, the wounds
healed without problem and there were no signs of
infection. When seen in the outpatient clinic 2
months later there were no untoward features and
he was receiving outpatient psychiatric attention.
Discussion
There are two descriptive terms that are commonly
used to de® ne the deliberate act of creating an
aperture in the bone of the skull and their distinc-
tion from one another often gives rise to confusion.
The term `trepanation’ derives from the ancient
Greek `trypanon’ meaning an auger or borer,
whereas the term `trephination’ more speci® cally
indicates an opening in the skull made by a circular
saw, trephine or more modern instrument, and
derives from the modern French.1 Archaeological
specimens ® rst brought this ancient practice to the
attention of anthropologists in the last century, the
® rst examples being described by E. G. Squires in
18632 and Prunieres in 1868.3 The earliest
trephined skulls from Peru and Bolivia date back to
3000 BC3 and the practice of trephination is known
to have been practised by pre-Hispanic Aztec and
Incan civilizations in Central and South America,4
Indians in prehistoric Canada and The United
States,5 the Arabs of Algeria and Morocco,3 as well
as ancient groups in Africa and Europe.1 There is
patient was found to be apyrexial, alert and orien-
tated, and with no demonstrable neurological
de ® cit. The story of self-trephination was
con® rmed, the patient being absolutely adamant
that the purpose was for therapeutic bene® t and not
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158 J. P. Wadley et al.
also evidence of its contemporary practice in North
Africa.3
Techniques of fashioning an aperture employed
twist drills, serrated saws, circular trephines, and
simple metal implements or sharpened stones used
for scraping.3,4,6 The placement of the hole seems
largely to have been random, but some groups were
familiar with anatomical hazards, North African
Arabs avoiding the midline and suture lines, which
were referred to as the `® ngerprints of Allah’ .3 Evi-
dence of osteomyelitis and thus probable fatal infec-
tion can be seen in some skulls, and likely survival
deduced from rounded, healed bone edges, a con-
cept ® rst proposed by Broca when he examined
Prunieres’ specimen.1,6 The reasons for trephination
of the skull remain speculative, but the vast majority
were probably for therapeutic reasons such as for
trauma, headaches, epilepsy, insanity or paralysis.1 ± 5
It is most unlikely that self-trephination was per-
formed in the ancient world.
Our patient performed the act of self-trephination
of the skull with the therapeutic aim of enhancing
his sense of well-being. The cases of a married
couple who had performed a similar act upon each
other without coming to harm or to surgery had
been highlighted in a recent television series,7 and it
was these persons’ exhortations of the bene® ts of
such a seemingly dangerous procedure that had
persuaded our patient to emulate their example. It
was claimed that drilling a hole in the skull would
release the pressure imposed upon the brain by the
rigid con® nes of the skull and lead to a bene® cial
increase in its blood supply, allowing it to `pulsate
normally’ . Their case was featured in some detail
even if from a somewhat lighthearted viewpoint.
The midline of the skull was apparently the best site
to drill a hole since this was the area of richest blood
supply, a dangerous anatomical truth that could
have had fatal consequences in our patient. We
know of no other cases of contemporary trephina-
tion for therapeutic purposes in modern Western
countries that have required neurosurgical interven-
tion, even less so self-trephination using such a
hazardous tool. Clearly, television producers should
be aware of the gullability of some individuals when
presenting such material even though it may seem
lighthearted in nature to most members of the view-
ing public.
References
1 Gross RA. A brief history of epilepsy and its therapy inthe Western Hemisphere. Epilepsy Res 1992;12(2) ; 65±74.
2 Froeschner EH. Two examples of ancient skull surgery.J Neurosurg 1992;76 ; 550± 2.
3 Rawlings CE, Rossitch E, Jr. The history of trephina-tion in Africa with a discussion of its status and con-tinuing practice. Surg Neurol 1994;41:507± 13.
4 Velasco- Suarez M, Bautista Martinez J, Garcia Oliv-eros R, Weinstein PR. Archaeological origins of cranialsurgery: trephination in Mexico. Neurosurgery
1992;31 ; 313± 18.5 Stone JL, Miles ML. Skull trepanation among the early
Indians of Canada and the United States. Neurosurgery
1992;26 ; 1015± 19.6 Ballance C. A glimpse into the history of the surgery of
the brain. Lancet 1922;i ; 111± 16.7 In Search of Happiness. Talkback Productions for BBC
Television, 1994.
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