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tissue of his brain.
    He describes this process in an excerpt from his postoperative report:
    The dura was incised in the temporal region with #15 blade and immediately liquid hematoma came out under high pressure. Further bone was removed to carry out a temporal decompression. The dura was then further opened in a large curvilinear flap and the hematoma was removed fairly easily using suction and irrigation. The underlying brain appeared to be in good condition. However, there was active arterial bleeding arising from the temporal lobe inferiorly. There was an evident temporal contusion, which was removed using suction and irrigation. The source of the bleeding was controlled using bipolar cautery and ultimately this gave good hemostasis [the process by which bleeding is stopped, which is the first stage in the healing of a wound]. The patient received frozen plasma. The brain was now gently swelling out through the dural opening. The dura was expanded and the bone flap was left out and sent to the bone bank for storage. The soft tissues were closed in multiple layers using staples for the skin.
    A craniectomy differs from a craniotomy in that the bone that is removed to perform the surgical procedure is not replaced after the procedure is complete, as it is after a craniotomy. The skull bone is stored either in a deep freeze or, in an attempt to minimize the risk of infection, in a patient’s abdomen or thigh, to be replaced, hopefully, at a later time. Both procedures have their historical roots in trepanation, the ancient surgical practice of drilling holes in the skull. Prehistoric skulls with holes that vary in size from a few centimeters to half the skull have been found in several countries across Europe. Trepanation was also common in Peru, where more than ten thousand trepanned skulls have been found, some dating back to the first millennium before Christ. Although surgical tools used to perform these surgeries were rudimentary—say, a piece of sharp obsidian, bronze, or copper attached to a carved wooden handle—there is evidence that many individuals survived the procedure and even lived for several years after.
    That trepanation was performed, and often, indicates that early humans had some notion of the brain’s central role in the body’s functioning. Before Aristotle argued that the heart, not the brain, was the primary organ of rational thought; before Galen, surgeon to Ancient Roman gladiators, dissected the nervous system of oxen and coined the word
autopsy
; before René Descartes stated “I think, therefore I am” and attempted to separate the machine of a material body from his immaterial and immortal soul—before all this, ancient man was opening the skull for an array of medical, spiritual, and mythical reasons. Evidence suggests that trepanation was performed in an attempt to treat a range of conditions: depressed skull fractures, headaches, convulsions, and possession by evil spirits. Trepanation may also have played, for some cultures, a fundamental role in important rituals, informing both superstition and belief. Those strong enough, or lucky enough, to survive the dangerous procedure may have been honored as being blessed with special power.
    Emil Kocher, in 1901, and Harvey Cushing, in 1903, became the first medical men in modern times to describe the use of a craniectomy to relieve the buildup of pressure in the brain. Despite long historical roots, craniectomies remain controversial. Termed a “salvage procedure,” it is not subject to specific guidelines or protocols that state exactly when or in what circumstances the procedure is appropriate, and most research does not support its routine use in adults. The clinical difficulty is in knowing who is and who is not a good candidate for a particular intervention; the ethical difficulty is in employing an intervention that might convert certain death into a lifetime of profound disability. The decision to perform a craniectomy remains