Daniel OMaley Health and Human Disease in Ancient Populations Kristina Killgrove Wiki Entry Definition Trepanation (sometimes

spelled Trephination) refers to the removal of portions of the skull, which results in the exposure of the membranes (dura) covering the brain. The term is derived from the Greek word trypanon, which means borer or drill, and refers to one of the techniques that trepanation is performed. Trepanation is a practice that has been documented in a number of regions worldwide, and is believed to have first been practiced at least as far back as the Neolithic Period. Scholars have suggested that it may have been performed either for therapeutic reasons or for magicoritualistic purposes related to freeing individuals from harmful spirits. In spite of the dangers associated with operation so close to the brain, a surprising number of individuals survived (up to 90% in some situations according to Nystrom 2007) as indicated by bone remodeling around the site of incision. Likewise, many individuals received multiple trepanations over a series of years. This indicates that practitioners were often well skilled and that the procedure was apparently producing the desired effects. While trepanation is often considered an ancient medical/ritual procedure, it is still being practiced today for a variety of reasons. Cranial trepanation has been practiced since at least the Neolithic Period (often considered to have begun in 9500BC), and some conjecture that it was even practiced earlier in the late Paleolithic period although there is little evidence to substantiate this claim (Roberts and Manchester 2005:125; Fabbri et al. 2010). However, it was in 1867 when Paul Broca correctly identified an incision in a pre-Columbian Peruvian skull that trepanation truly caught the attention of archaeologists (Fernando and Finger 2002:3). Broca had been sent a skull by the diplomat Ephraim George Spier who requested Broca confirm his belief that the incision showed signs of at least two weeks of healing and thus was performed with the individual was alive. At the time Broca was a well-established scientist and when he presented his report to the New York Academy of Medicine archaeologists took notice. While some have labeled this the discovery of trepanation, a more apt term would be rediscovery. Indeed, the procedure was performed even during the Middle Ages in Europe. Brocas pronouncement, however, would bring the practice under the scientific microscope as never before. Evidence in the Archaeological and Historical Records Scholars have long sought to determine the origins of trepanation. Given the apparent consistency of methods worldwide some contend that it was developed in one or two sites and then was diffused globally (Brothwell 1994). More recent research has argued the opposite that it was a procedure developed in many different places independently (Littleton and Frifelt 2006; Sankhyan and Weber 2001). Diffusion still took place, but not on a global scale. The fact that the first signs of trepanation appeared in the Neolithic period make it very hard to determine.

Skeletal Evidence A variety of trepanation methods have been documented in the archaeological record. The four primary techniques are scraping, drilling, circular grooving, and linear cutting. All of these methods have been found throughout the world, and there is no geographical correlation to their use. Distinguishing which method was used on a skull is often difficult, and is particularly so when there has been a significant amount of bone healing. In these cases the new bone growth can often obscure how the trepanation was performed. Likewise, with the exception of drilling implements, the stone and metal objects used to perform these operations are often not recovered. That may be to the fact that the cutting implements are not specific to this particular task, but are used for a variety of cutting activities. Scraping Scraping is the most commonly found technique in the historical record used to perform trepanation. It is found in all regions where trepanation was practiced. A sharp implement often metal or stone is used to slowly scrape away the bone of the skull. Typically a flap of skin on the head is cut and then peeled back in order to allow direct access to bone. This also appears to reduce the amount of bleeding. This method results in a circular hole in the skull with a beveled inner edge (Ortner 2003:172). The advantage to this technique is that it allows for a slow, careful removal of bone that lessens the chances of harm to the brain. Drilling The drilling method entails drilling either one large hole in the skull or a cluster of small holes that are then connected to create a larger opening by dislodging the remaining bone in between then and removing it from the site. This is the method practiced by the Greeks and thus the word trepanation is derived from the Greek trypanon, meaning borer or drill. The Greeks used two types of drills: the trypanon and the prion. The trypanon was a standard drill bit, while the prion was hollow. Because both these tools leave a similar hole in the skull, our knowledge about them comes from the work of Hippocrates. These same tools were used in the Mediterranean area, which evidence also found in Anatolia and Italy. Likewise, the writings of Celsus indicate that these same tools were also used during the Roman period (Fabbri et al. 2010). Circular Grooving Circular grooving involves the removal of a round plug of bone through circular incisions. This method can be difficult to differentiate from scraping because of the external beveling at the incision site that both techniques produce. Bone healing can even further complicate determining the distinction (Valerie A. Andrushko and John W. Verano 2008:6). Linear Cutting Cutting is the least common method to perform trepanations, and apparently the most likely to cause fatality (Nystrom 2007:49). Sharp implements both metal and stone

are used to cut into cranial bone. The bone located within the lines of the incision is removed from the skull. This technique resulted in openings that were rectangular or polygonal. Historical Evidence The Greek medical writer Hippocrates is the first person known to have written about the procedure in the fifth century BC. He recommended trepanation for cases of wounds to the head and hematomas (Roberts and Manchester 2005:127). In the second century AD, the Roman physician Galen, who had read Hippocrates work, also advocated for the use of trepanation to relieve cranial pressure produced by trauma. By this time surgical implements had been standardized to perform this procedure and Galen even conducted experiments on animals using these implements (Rocca 2005:254). Evidence of trepanation has also been found in art. Perhaps the most notable example is the medieval painting The Stone Cutting or The Cure of Folly by the Dutch artist Hieronymus Bosch indicates European knowledge about trepanation. The name suggests it was being used as a cure for mental illness. The presence of a priest in the painting also indicates the seemingly religious component of the procedure. Explanations Over the years archaeologists have long intended to discern the reasons people in the past performed trepanations. Since its discovery in the 1860s anthropologists have generally fallen into two camps those who believe it was performed for magicoritualistc purposes and those who contend it was a primitive form of surgery. Current literature on trepanation generally still mirrors this divide or at least acknowledges these two interpretations. Likewise, subsequent findings revealed that cranial surgery was being performed in the past to harvest skull bone, which was understood to have powerful symbolic meanings. This section will examine the reasons that have been posited for trepanations and cranial skull removal in the past. Superstition In the wake of Brocas discovery in 1867 prominent scientists had already broken into two general camps. Broca was convinced that these primitive surgeries were being performed in order to free evil spirits that ancient people thought were stuck in peoples head. As early as 1867 Broca stated, I think for my part they were inspired not by observation, but by superstition (Broca cited in Finger and Clower 2002:28). This is an overtly ethnocentric perspective. Likewise, it indicates that knowledge about trepanation, which had been practiced by the Greeks and Romans who anthropologists looked up to in the period, appears to have been largely forgotten. A belief that this was practiced by savages further discounted the notion that there could have been any actual medical value to the procedure. To this day authors still often mention that there may have been a magicoritualistic aspect even though getting at those rituals and their meanings is often

difficult to get at, especially with little historical context. While this aspect should not be discounted, its prevalence in the literature is an indication of the staying power of these ideas first espoused by Broca more than a century ago. Ritual There is one form of cranial skull removal that does appear to be largely ritualistic, and not therapeutic in nature. This involves the removal of small roundels of skull bone that have most commonly been found in burials with other individuals. This indicates that the possession of the cranial skull of other individuals had a great deal of symbolic value (Fabbri et al. 2010). Finding these small roundels of bone in the archaeological record is difficult and thus the actual extent of this practice is often very hard to determine. While conducting his explorations in Africa, Albert Schweitzer noted this practice in some African communities lending ethnographic evidence to this assertion (Ortner 2003:171). Another corollary to this practice is scalping. However, in contrast to scalping, which is performed typically on group outsiders, this practice involved removing bits of the skull, often of already dead individuals, to keep as reminders of them or possibly as a way to capture their essence for posterity. Therapy/Medical There has been a long debate about whether or not people in the past were sophisticated enough to have developed this procedure in order to provide therapy. In the 1880s the British physician Victor Horsely, one of the pioneers of modern brain surgery, contended that trepanation was performed on the living for therapeutic reasons - notably seizure disorders. This grew out of his analysis on the location of trepanations on the skull compared to his knowledge of the location of the motor cortex of primates, which were his primary area of research. This correlation led him to believe that epilepsy may have been a condition individuals who had trepanations might have suffered. However, prominent anthropologists of the time such as Francis Galton, rejected this idea because they felt ancient savages would have been incapable of such logical deductions (Finger and Clower 2002:34). Yet, research on trepanation has overwhelmingly supported the idea that it served medical purposes. The fact that trepanation is often found at the site of trauma indicates that people were being treated for injuries. Likewise, the current use of trepanation-like techniques in Western medicine is further evidence that even individuals in the past understood the basics of both brain mechanics and the function of the brain. More recent work has tried to bridge the divide between ritual and therapy. Researchers have pointed out ritual and medical purposes in the past may not be so easily distinguishable as some scientists argue that they are presently. Understanding this could help develop better hypotheses about these practices by getting past the superficial and misguided dichotomy between medicine and ritual (Sankhyan and Weber 2001). Without a doubt, more recent work in Medical Anthropology and Science and Technology Studies (STS) shows how culturally embedded even Western science is and the way that it is influenced by cultural biases. Thus, distinguishing between magicoritualistc and medical behavior is much harder than was previously assumed, arguably even in the present.

Complications and Healing While the fact in some cases up to 91% of people survived trepanation (Nystrom 2007) is surprising in a period of time when there was no knowledge of germ theory, this does not mean that it was without significant risks even for those who did survive. Individuals who survived the initial bone removal procedure still faced significant threats and many individuals only survived a short period of time afterward. Ortner (2003) has developed three categories of possible complications: 1) Direct injury, 2) Bleeding into the Brain Tissues. After the removal of the skull bone the exposed membrane is incredibly delicate and any trauma in this region could be extremely dangerous. This is why some people wore protective gear (metal or bone) to protect the region. Excessive bleeding would be due to an incision that goes to deep. An infection could be due to a host of issues relating either to the cleanliness of the implement used or the treatment and healing after the procedure. Other infections that are not initially associated with the resulting would could also eventually work their way to the area. This has been seen with mastoiditis, an infection of the inner ear, which has been noted as a possible common complicating factor with trepanation (Andrushko and Verano 2008:9). Indeed, other infections in the cranial region (e.g., an acute tooth infection) could pose a threat to a skull with exposed brain membrane. The varying rates of survival have also led scholars to wonder about what might increase survival chances. Most important, researchers have noted that scraping is most effective because it appears to give the practitioner the most control, while linear cutting is the most dangerous. The location of the hole has also thought to be a factor, with trepanations on the parietal bone being the most successful. Additionally, in their work in Peru, Andrushko and Verano (2008) have also shown that survival rates are higher when trepanations are performed in areas with lower levels of cranial musculature. Performed in areas with more muscle tissues the chances of death are higher. Since trepanations were often performed at sites of trauma, it is likely that individuals did not choose these locations and may have realized the dangers they posed, but decided to proceed anyway.

Case Studies While trepanation has been practiced in a wide variety of regions since the Neolithic period, its actual practice has varied greatly. A brief overview of cases from different regions during a number of time periods will reveal particularities about the practice of trepanation. The research employed in this section often deal with the reasons people used trepanation, the evolution of how the procedure was practiced, and how knowledge about the method may have been diffused from region to region. There is a large body of research on the topic, and this is just a mere sampling of some of the most recent work on the topic. Oman

Evidence of trepanation in Oman dates back to the early 3rd millennium BC, and thus predates evidence in many surrounding regions. Yet trepanation was not commonly used, which may explain why long-term survival rates were lower in this region overall. Excavations at Jebel Hafit in present-day United Arab Emirates revealed two fragmentary skulls with numerous cranial lesions indicative of trepanation (Littleton and Frifelt 2006). The authors suggest that a sharp metal implement was used to perform a scraping trepanation, which involved peeling back the flesh on the head before rasping away bone. The first skull examined had nine lesions indicating trepanation, while the other had four. All of the incisions were not performed at the same time, but it did appear that it was common to perform more than one at the same time. In each of the cases the individuals showed only some signs of healing, and one incomplete and unhealed hole indicates on of the individuals might have died during the procedure. What is most notable about this research is how the techniques at the site are similar to ones discovered in South Asia site of the Harrapan Civilization. Multiple trepanations performed at the same time, the lack of signs of trauma, the locations on the skull, and the scraping method have all been find by others (Sankhyan and Weber 2001) in South Asia. This suggests transmission of the knowledge from Oman to South Asia. This is supported by evidence that these two regions were in close contact with each other due to trade. Research in Oman thus supports a multi-focal diffusion hypothesis of the spread of trepanation. Pakistan The reasons why trepanation is performed are not always obvious from the skeletal record, and such is the case for cases of trepanation discovered from the Harappan civilization located in the Indus river valley in present-day Pakistan. Trepanation in the region is argued to have been imported from the Middle East. This is due to the way that the technique was performed and the close contact between these two regions at the time (Littleton and Frifelt 2006). Data to support this theory comes largely from the site of Burzahom, where a young female was shown to have a series of 11 trepanations performed on her skill. Researchers have been particularly interested in why these procedures were performed on her. When she was first examined by B. Alichin and R. Alichin (1968) it was determined that the procedure was medical in nature. However, subsequent analysis by Roy Chowdhury (1973) and Basu and Pal (Basu and Pal 1980) suggested that it was ritualistic in nature, particularly because there were no visible signs of trauma. However, a more recent analysis by Sankhyan and Weber (2001) argues that it was indeed medical in nature. They contend that there is no contextual evidence (i.e., treatment of the body with ritualistic paints or grave goods) to argue that it was performed for a ritual. The removal of cranial roundels would have presented itself differently on the skull and would not likely have resulted in partial trepanations. In their opinion the procedure was done to releive some type of mental disorder, perhaps epilepsy, that would not show itself on the bone. The repeated trepanation attempts are argued to have been a sign of the degree to which those around her tried to save her.

This case, and the multiple ways that trepanations can be interpreted demonstrate the difficulties anthropologists encounter in making inferences about the past. It also shows how theories about the reasons for trepanation continue to circulate and be discussed in the scientific literature. Unfortunately at Burzahom, a site of only ten individuals, there is only on individual with trepanations. A larger, population study might be better able to answer this debate. Turkey An important aspect of understanding trepanation is documenting the way that it changed over time. Indeed, there is no one-way evolution of the technique, but rather different groups merely changed their approaches for a variety of reasons which researchers have been interested in understanding. Work in Anatolia, present-day Turkey, has shown this process. The first evidence of trepanation in the region comes from over 10,000 years ago from the Aceramic Neolithic era (9th millennium BC), and it was employed up until the late to the Late Ottoman period (early 20th century AD). Erdal and Erdal (2011) examined forty individuals from 23 communities in order to get a broad overview of the practice in the region. The earliest cases of trepanation indicate that the drilling method was used. Evidence of scraping emerged in the Early Bronze age (3300 BC 2000 BC), and the in the Iron age (1300BC 600BC) cutting then again emerged as the primary technique. The technique was generally used in cases of trauma, indicating it was medical rather than ritualistic in nature. Considering cutting is considered the most risky form of trepanation, this example shows that the technology did not necessarily progress toward being safer and more reliable. This case also shows how methods of trepanation can shed light on cultural contact as well as the origins of the practice. For example, Erdal and Erdal concluded that the methods practice in Anatolia were similar to those in surrounding regions in the Mediterranean, and were markedly different from those practiced in Europe in the corresponding periods. This would indicate that there was relatively little transfer of knowledge, and hence cultural contact, between these areas. Yet, they did notice that trepanation practices in Anatolia were more similar to those practiced in Peru in South America. This suggests that there was not a global diffusion of trepanation, but that it was developed independently in different groups around the world. Peru Cuzco (Central Andes) Understanding trepanation in the past is also sheds light on the structures of societies that were employing this practice. In looking at trepanation in the Central Andes, present-day Peru, during the Inca Empire (1100 AD to 1500 AD), Andrushko and Verano (2008) have shown that state formation and consolidation are linked to the spread of technology and improvements in health outcomes for individuals who have been trepanated. They examined 109 trepanation in 11 burial sites near Cuzco, the capital of the Inca Empire. They found that while linear cutting was found in the oldest of individuals at the site, later evidence of trepanation relied mainly on circular grooving and scraping. Survival rates in this area (roughly 78%) were markedly higher than regions in the south (between

43% and 36%). There appears to have been a certain amount of standardization, which is probably due to the spread of knowledge through the centralized state which facilitated contact among groups on its periphery. This case in the Andes also points to the way that use of trepanation in the past was, in many cases, largely for medical purposes. Trepanation was often performed at the site of cranial trauma. Trepanations might also have covered up trauma that otherwise would have been visible if there had been no intervention. Antiseptic balms identified on some skulls were probably not ritualistic, but rather therapeutic in nature in that they would have decreased the chance of infection. In the Andes there is also a heated debate about whether or not cranioplasty was practiced. Cranioplasty involves covering the opening produced by a trepanation after the surgery in order to protect the brain. This is done with either the bone that was removed or another strong material strong enough to protect the brain. In the past many researchers claimed that there was evidence of this procedure in the Central Andes pre-contact. Andrushko and Verano (2008) found that there was actually very little to sustain this argument. However, one individual unearthed at the site of Kanamarca was found with a piece of bone that had originally been removed from the skull. Lack of healing on the site indicates that it may have been placed with the body at time of death and was not actually cranioplasty. Nonetheless the debate is ongoing. Ultimately it demonstrates that in the Andes most of the attention is focused on trepanation as being understood as a medical practice rather than a ritualistic behavior. Peru Chachapoyas Not all current research points in the direction of trepanation being clearly for medical purposes. Nystroms research in the Chachapoyas region in the northern section of present-day Peru sees little link between cranial trauma and trepanation. Of the four burial sites examined, only at one, Kulep, was there any evidence of trepanation (8% of the population). In this sample only one individual showed signs of trauma and trepanation, which the author considered strange since the Inca considered the people in the region violent. However, 91% of trepanations indicated signs of healing, which indicated they were successful when they employed the method. (Nystrom 2007:48). Scraping and circular grooving were the most successful methods, and cutting was also found. Drawing on ethnohistorical data about witch-doctors and ancestor veneration, Nystrom suggests that perhaps in this region ritual factors were most important in the practice of trepanation. This result differs sharply from Andrushko and Verano work further south in the Andes, and is surprising given that the groups in these areas were in close contact.

Contemporary Practice When Broca first brought attention to trepanation in 1867 it was no longer being practiced in Europe. Indeed, much of the knowledge about trepanation had been forgotten, which is one of the reasons why it piqued the interest of European scientists.

However, its use never died out completely on a global scale and it continued to be used by sporadically, largely in relatively isolated communities. Indeed, there is evidence that pre-modern forms of trepanation similar to the kind evidenced in the archaeological record are still being performed in Africa and Polynesia (Ortner 2003:172; Campillo 1984; Meschig, Schadewaldt, and Kiwit 1982). While pre-modern trepanation has been largely discouraged by Western medicine, more recently doctors have noted the positive effects of this kind of cranial surgery. Currently the removal of sections of the skull is used to relieve pressure on the brain caused by violent trauma. After the initial trauma, it is the swelling of the brain within the cranial vault that poses life-threatening risks. Such was the case with Representative Gabrielle Giffords who was shot at point-blank range through the left side of her brain. Neurosurgeons removed a large section of her left skull in order to accommodate the swelling brain. Only months later, in a procedure called a cranioplasty, was a plastic mold of the removed bone placed over the exposed dura in order to protect the brain on a more permanent basis. Thus, knowledge that individuals in the Neolithic period used to treat head trauma is still being employed by medical doctors, albeit in a much more precise fashion. Inspired by accounts of trepanations in the archaeological record, a small number of individuals have begun practicing trepanation because they believe it has beneficial outcomes that ancient populations discovered, but where then forgotten. The belief is that removing skull bone will facilitate more oxygen reaching the brain. This, in turn, will lead to higher states of awareness. This trend emerged in the 1960s in England when a non-practicing doctor, Dr. Bart Huges toyed with the idea after having experimented and grown disillusioned with the power of drugs such as LSD and marijuana, The fringe movement has grown slowly, and now organizations like the International Trepanation Advocacy Group are pushing for more research on how blood flow through the brain improves brain functioning. Nonetheless, few individuals are electing to have trepanation performed and since it is not sanctioned by western medicine, individuals often perform the procedure in makeshift operating rooms. Conclusion Trepanation has caught the imagination of archaeologists and enthusiasts alike because it is extremely impressive that individuals in the past were so successful at performing what is an incredibly risky procedure. While there is a significant amount of debate about why people performed trepanation, there is overwhelming evidence that it was most often performed as a type of therapy either for traumatic injuries or mental problems such as epilepsy. Indeed, the use of largely similar techniques used across such a varied swath of societies over centuries is indication that it was most likely not a magicortirualistic practice, although there were certainly religious and spiritual components just as our own Western medicine is infused with cultural influences. What can be said is that trepanation, and its relatively high survival rates, indicate that ethnocentric opinions of the supreme superiority of Western societys medical practices are clearly misguided.

This perspective obfuscates the knowledge and skill of people who surely only risked this procedure when they felt it was necessary for whatever reason that may have been.

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Nystrom, K. C. 2007. Trepanation in the Chachapoya region of northern Per. International Journal of Osteoarchaeology 17(1):39-51. Ortner, Donald. 2003. Identification of Pathological Conditions in Human Skeletal Remains. 2nd ed. San Diego: Academic Press. Roberts, Charlotte, and Keith Manchester. 2005. The Archaeology of Disease. 3rd ed. Ithaca: Cornell University Press. Rocca, Julius. 2005. Galen and the Uses of Trepanation. Pp. 253-272 in The Archaeology of Disease, edited by Charlotte Roberts and Keith Manchester. Ithaca: Cornell University Press. Sankhyan, Anek R, and George H. J Weber. 2001. Evidence of surgery in Ancient India: trepanation at Burzahom (Kashmir) over 4000 years ago. International Journal of Osteoarchaeology 11(5):375-380. Verano, J. W., and V. A. Andrushko. 2008. Cranioplasty in Ancient Peru: A Critical Review of the Evidence, and a Unique Case from the Cuzco Area. International Journal of Osteoarchaeology n/a-n/a.