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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 different parts of the world. We report a case of self-trephination of the skull by a patient using an electrical power drill subsequently requiring neurosurgical intervention. Key words: Self-in¯ icted, superior sagittal 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-ful® 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 the drill hole (arrow) anterior to the coronal suture and the frontal 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 Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/31/14 For personal use only.

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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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