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September 17, 2000 - National Geographic
Ancient humans recognized that sometimes a hole in the head was exactly what was needed.
Skulls with holes bored in them have been found by archaeologists in virtually every region of the world, and scientists have debated for more than a century about the motivation for the holes. Are they evidence of an emerging medical technology or an artifact of practices involving magic, ritual, warfare, or religion?
"Good evidence exists to show that trepanation was performed as a treatment for skull fractures," says John Verano, a physical and forensic anthropologist at Tulane University in New Orleans, in the September 16 issue of the journal New Scientist.
Verano, who specializes in the prehistoric cultures of the Andes, has compiled a data base documenting the physical characteristics of nearly 700 trepanated skulls from Peru and Bolivia.
Evidence of trepanation - deliberately cutting or drilling a hole in the skull - dates back to 3000 BC, and possibly as far back as 10,000 years ago. Trepanation is discussed in medical texts of ancient Greece; Hippocrates (c. 460 to 355 BC) wrote extensively about when, why and how to perform trepanations.
Until the mid-1800s, though, the received wisdom among archaeologists and anthropologists held that prehistoric trepanations were performed only after death. Scientists attributed the holes to burial rituals or war practices, parading the head of an enemy on a stick or hanging it by a string. Among some early cultures, pieces of bone were carved from the skulls of the fallen mighty and worn as amulets.
In the 1860s, anthropologist Paul Broca recognized signs of healed bone surrounding a hole in a prehistoric skull. This convinced him that surgery had been performed on the living. As old evidence was reviewed and new evidence found, the idea that prehistoric humans practiced trepanation became widely accepted.
The argument as to motivation, however, remained.
Evidence of the Andes
While evidence of trepanning has been found around the world, the most skulls - about 1,000 - have turned up in South America.
Verano's data base includes skulls from Peru and Bolivia spanning nearly 2,000 years, from 400 BC to 1500 AD. These were violent times for the peoples of the Andes. The weapons of choice were slingshots and clubs, and skull fractures were a fact of life. Among skulls found in the central highlands region of the Andes dating from 900 to 1500 AD, more than half the men had at least one skull fracture, as did 32 percent of the women and 27 percent of the children, according to the New Scientist report.
"There was probably a lot of village warfare in which everyone got involved," says Verano.
Verano's data shows not only that trepanned skulls were highly associated with skull fractures but also that surgical techniques improved over time. "The holes got smaller over time," he says. "The earliest were quite large; 4 inches by 4 inches, (10 centimeters by 10 centimeters) or even larger, while some of the later ones are no larger than a single drill hole. It looks like they figured out that they didn't have to take quite so much bone. "
With improved techniques, survival rates also improved.
Surgeons on the southern coast of Peru around 400 BC scraped away the bone around a head wound with stone tools, and had a survival rate of about 40 percent. By 1350 AD, Inca surgeons in the central Andes had developed a range of techniques for performing the surgery - and appear to have had a survival rate of more than 80 percent. Anthropologists can tell whether a patient survived the surgery because, given time, the rim around the hole becomes smooth.
The improved success rate, the development of several techniques for performing the surgery, and evidence that surgeons made choices about which technique to use, combine to show that the surgery was part of an emerging medical repertoire, says Verano.
The peasant's skull had been operated on
A skull belonging to a 40-year-old peasant man, who lived between 960 and 1100AD, is the firmest evidence yet of cranial surgery, say its discoverers.
The remains, found in Yorkshire, show the man survived an otherwise fatal blow to the head thanks to surgery.
Nearly 700 skeletons were unearthed by English Heritage at a site near Malton.
Scientists have been examining the remains from the now deserted village of Wharram Percy.
Once a thriving community built on sheep farming, it fell into steep decline after the Black Death and was eventually completely abandoned.
The village of Wharram Percy
The skull in question, dating back to the 11th century, had been struck a near-fatal blow by a blunt weapon, causing a severe depressed fracture on the left hand side.
Closer examination revealed the victim had been given life-saving surgery called trepanning.
A rectangular area of the scalp, measuring 9cm by 10cm, would have been lifted to allow the depressed bone segments to be carefully removed.
This would have relieved the pressure on the brain.
Roman and Greek writings document the technique of trepanning for treating skull fractures, but there is no mention of it in Anglo-Saxon literature.
Some historians have theorised that western Europe was deprived of such surgical knowledge for centuries after the fall of Alexandria in the 7th century.
Dr Simon Mays, skeletal biologist at English Heritage's Centre for Archaeology, said: "This skull is the best evidence we have that such surgery to treat skull fractures was being performed in England at the time.
How the village would have looked at the time
"It predates medieval written accounts of the procedure by at least 100 years and is a world away from the notions that Anglo-Saxon healers were all about spells and potions."
Skulls dating back to Neolithic times show trepanning was performed on individuals with no head wounds.
Historians believe this was presumably to treat other ailments, possibly including mental illness.
The skull of the 40-year-old Yorkshire peasant shows the fracture healed well.
Scientists believe the hole that remained would have eventually closed over with hard scar tissue.
The peasant was probably involved in the medieval equivalent of a pub fight.
Dr Simon Mays, skeletal biologist at English Heritage's Centre for Archaeology
But they have questioned how a peasant would have been able to afford this complicated medical treatment.
Examination of the other skeletons at the site revealed high levels of malnutrition, disease and stunted growth.
Dr Mays said: "Medical skills were largely reserved for the elite.
"So the treatment handed out to Wharram's peasant doesn't square at all with our knowledge of the period.
"It seems most probable that the operation was performed by an itinerant healer of unusual skill, whose medical acumen was handed down through oral tradition."
Ten of the other skeletons, including a child, also showed signs of head injury caused by blunt objects.
Dr Mays said: "Violence at Wharram seemed to involve objects that were near at hand, like farming tools.
"The peasant was probably involved in the medieval equivalent of a pub fight, or could have been the victim of a robbery or a family feud."
13.3 TREPHINATION, AN ANCIENT SURGERY
I. TREPHINATION IN HISTORY
Primitive cranial trephining, the surgical opening of the skull performed with primitive tools and techniques, is one of the most fascinating surgical practices in human history. It probably started in the Neolithic at least 7000 years ago.
Remarkably, it is performed yet today in parts of Africa, South America, and Melanesia.
The word trepanation is derived from the Greek. It means auger or borer. The word trephination more specifically means an opening made by a circular saw of any type. In this article we will use the terms interchangeably.
Skull trepanation in early times was independently practiced in many areas of the world, with the highest concentration of activity in Peru and Bolivia. Evidence for it also is found in Europe, Asia, New Zealand, some Pacific Islands, and North America. The evidence of the practice nearest to Chicago is on the Rock River at Sterling, Illinois.
The operation consisted of removing a piece of the skull (frontal, parietal, or occipital bones) from a living patient to expose the dura mater. The dura mater is the tough fibrous membrane forming the outer envelope of the brain. If it is not breached, a patient in the pre-anaesthesia, pre-antisepsis era had a fair to good chance of surviving without brain infection.
Although the operation was performed on men, women, and children, it was most often performed on adult males. Overall, patients that underwent the operation had an impressive recovery rate. As many as two thirds of the skulls examined reveal various degrees of healing--which is the evidence for survival. Considering the danger of severe bleeding, shock, brain edema, and infection, the achievements of such postoperative results suggest considerable skill and experience.
II. WHY WAS IT DONE?
The motives for Neolithic trephining have been the subject of speculation since the first specimens were discovered in the nineteenth century. Generally, it is surmised that, on the living, it was performed for the escape or entrance of spirits. This, of course, is conjectural. It may have been done for therapeutic reasons, such as for headaches, fractures, infections, insanity, or for convulsions. It might have been done for religious reasons. It has been suggested that the motive was to acquire rondelles (the disks of bone obtained from the cutting of circular holes in the skulls). In this event, they would have been used for charms, amulets, or talismans.
Frequently, there is evidence of skull fracture, suggesting that the procedure was done to relieve intra cranial pressure.
The following essential aspects of trephining must be accounted for in any explanation of the practice:
a. The practice was astonishingly widespread.
b. It was practiced in the presence, and absence of head trauma.
c. Only a small percentage of discovered skulls are trephined.
d. The practice was performed on the living and on the dead.
e. Men, women, and children were operated upon.
f. Some skulls show multiple operations.
g. In some skulls, the trephining was incomplete, as if the procedure was abandoned mid-operation.
From a modern perspective, the performance of such surgery is intrepid and audacious. It is all the more remarkable, since the 'surgeons' had little or no knowledge of anatomy or physiology and only rudimentary knowledge or instrumentation at their disposal. There were probably three general techniques: scraping, drilling, and cutting.
Trepanning drills have smooth wooden shafts and tips of very hard material, to cut into the bone as neatly as possible. The earliest trepanned skulls are from the Neolithic Stone Age long before the introduction of metallurgy. Their holes were cut not by a drill, but with a sharp-edged flint scraper or knife. A circular or rectangular groove was made. The practitioner would cut deeper and deeper until penetration to the dura mater was accomplished. In ancient Peru, people used knives of bronze or obsidian. They would cover the wound with a shell, a gourd, or even a piece of gold or silver.
The most common of the techniques was the bow drill. The bow was made of springy wood and had a leather thong wound around the drill several times. To perform the procedure, the operator positioned the drill tip on the head and thereby made the bore through the bone.
Drilled holes were usually roughly circular. Knife cut ones were usually more square. A few skulls have up to five holes, the longest of which measures two inches across.
It is interesting that in modern times, neurological surgery is one of the more recently developed specialties. Yet, it has this remarkable antecedent in Neolithic times. It is very unlikely, however, that Neolithic surgeons entered the brain itself. We can only conjecture as to why they did it.
A Trephined Skull
IV. SYMBOLIC TREPHINATION
The most remarkable trephination in our time is the spectacular case of a modern African who had endured a large number of these operations. He could only recall the range between five and 30 trephinations. Afterward a very large portion of his skullcap was entirely missing. Examples like these tend to overshadow another extreme--very small trephinations. These are called "symbolic trephinations" in recent literature.
Cases from Hungary, Russia, and Bulgaria are well documented. The bore holes were on the order of 2 mm in diameter. In the Bulgaria site, close to one-third of the skulls recovered had been trephined in this manner. Of the 85 skulls, healing suggests that all the persons survived the procedure. The investigators suspect that the trephining was a mass administration of the procedure for therapeutic purposes.
V. REVIVAL OF TREPHINING?
A good sense of humor is suggested as you read this section.
Sometime in the early '70s (he doesn't remember exactly when), a jeweler from Pennsylvania by the name of Peter Halvorson made a T-shaped incision in his scalp, secured a power drill to his bathroom ceiling and proceeded to perforate his skull. He reported that it took several drill bits. They kept getting clogged with blood and bone. Halvorson stopped when he felt the drill give way and penetrate into the cranial cavity.
His interest isn't an isolated affair. Eli Kabillio, an award-winning independent filmmaker has produced a documentary entitled "A Hole in the Head." He was reportedly making attempts to have PBS or HBO broadcast it. Orthodox medical doctors are not enthusiastic about this sort of thing. They are astonished that anyone would do trephining. The 'revival' of trephining has been dismissed as the ultimate in body piercing. Are you interested?
The International Trepanation Advocacy Group web page is www.trepan.com
It had 35,000 hits in 1998.
..... CJ '99
Sources and further reading
Alt, K. et al "Evidence for Stone Age Cranial Surgery " Nature 387: p 364 (22 May 1997).
Parker, S. Collins Eyewitness Science: Medicine. Sydney: HarperCollins Publishers, 1995.
Price, W. Nutrition and Physical Degeneration. New Canaan: Keats Publishing, Inc., 1989.
Prioreschi, P. "Trephining" Perspect Biol Med Winter, 34: 296-303, 1991.
Stone, J. and Miles, M. "Skull Trepanation Among the Early Indians of Canada and the United States" Neurosurgery 26: 1015-1020, 1990.
Valasco-Suarez, M., et al "Archaeological Origins of Cranial Surgery: Trephination in Mexico" Neurosurgery 31: 313- 319, 1992.
Vogt, A. "Hole-istic medicine: Try getting your HMO to cover this procedure. Chicago Tribune. June 11, 1998.
Yordanov, A. and Dimitrova, A. "Symbolic Trephinations in Medieval Bulgaria" Homo Vol. 41/3, pp 266-273 Gustave Fischer Verlag, Stuttgart.