Arab. arch. epig. 2006: 17: 139–151 (2006) Printed in Singapore.

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Trepanations from Oman: A case of diffusion?
Trepanations have been described from various locations around the world leading to a suggestion that this is a cultural practice that has widely diffused from one or two centres (1). In the UAE the earliest trepanations date to the Neolithic, significantly earlier than trepanations in surrounding areas. The discovery of at least two crania in Oman, dating apparently to the early third millennium and resembling in technique and placement trepanations from north India may be evidence of the diffusion of a therapeutic practice from the Gulf to the subcontinent. However, the lack of any trepanation among the numerous contemporary skeletons from Bahrain suggests that any diffusion has distinct limits and that, as anthropological work from the South Pacific (2) indicates, practices like trepanation are often heavily embedded in broader, culturally located explanatory models. Keywords: trepanation, ancient surgery, Bronze Age Oman

Judith Littleton1 and Karen Frifelt2 1 University of Auckland, New Zealand 2 ˚ rd Museum, Moesga DK–8270 Højbjerg, Denmark

J. Littleton Dept of Anthropology, University of Auckland, Private Mail Bag 92019, Auckland, New Zealand. e-mail:

Introduction In 1971 during the Danish excavation of two stone cairns at Jebel Hafit, two fragmentary skulls marked with numerous cranial lesions indicative of trepanation were recovered. Trepanations have been found in the UAE dating to the Neolithic period (3). The two Bronze Age skulls described here add to this growing corpus of trepanations from the southern Gulf. However, we argue that the Jebel Hafit crania vary in significant ways from the Neolithic trepanations and bear a striking similarity to later trepanations from north India, suggesting that the linkages between the southern Gulf and north India were not just of trade goods but also of ideas. The finds also imply a striking discontinuity in that transfer to the Dilmun region of the Gulf, although it is of course always dangerous to argue from the point of negative evidence. This paper, therefore, is an analysis of the two crania and a comparison with other trepanned crania from the Middle East and north India addressing the issues of the cause of trepanation and its role as a cultural attribute.

Background and date of the material The two stone cairns, OA 1309 and 1315, were situated on mountain ridges between Al Ain and Jebel Hafit in the Buraimi oasis in Abu Dhabi and were excavated together with a number of other cairns in 1971 during an archaeological campaign ˚ rd Museum. The led by K. Frifelt of the Moesga graves are of Hafit style: a rounded stone mound with the gap between inner and outer walls filled with stone. The centre of the mound consists of a small chamber and entrance way. They resemble similar cairns, nos 1–25, excavated in the previous 1961–62 and 1962–63 campaigns in the same area (4). The most complete skull (1309.1) comes from cairn no. 9, which was excavated by Niels Axel Boas, Steen Andersen, Michael Beck, Bo Madsen and Karen Frifelt. Within the grave were the fragmentary remains of five individuals along with some beads and two Jemdt Nasr pots. In the excavation diary it was noted that some of the cranial fragments have heavy lesions. The second skull (1315-C) comes from cairn no. 15, which was excavated by Bo Madsen and Karen


The similarity of the trepanations (discussed below) as well as their proximity indicates the probable contemporaneity of the skeletons.1 Cranium 1 is the reconstructed calotte still in two pieces (Fig. The partial preservation of the skull means that the sole indicator of age is cranial suture closure. The cranium was reconstructed at the Smithsonian Institution out of fragments 2–5 cm in size. LITTLETON AND K. This skull is particularly thin and has a weathered surface. sagittal and lamb- Fig. While highly variable. sharp orbital border and a small nucchal torus. indicative of a possible male. The calotte itself is near complete. especially on its left side. In addition. The right temporal is also partly preserved. The initial dating of these tombs was to the Jemdt Nasr period on account of the pottery finds. Although the scanner’s 1 mm resolution was not good enough to observe detailed anatomical features. Cranium 1 — 1309. The use of a micro-CT scanner and SEM was discussed. The basicranium is missing along with most of the face although there is an associated right superior orbit. the second cranium (1315-C) was examined by CT scanning. However. the lack of any closure of the external cranial sutures (coronal. 140 . doidal) and minimal closure of the endocranial coronal suture only is more consistent with an age attribution of a possible young adult (7). They are contemporary with many of the Hafit graves and are now more commonly referred to as belonging to the Hafit period 3200–2600/2500 BC (5). This extremely thin skull is markedly gracile with a small supraorbital torus. on balance. Earlier Neolithic and later Umm an-Nar remains from the Emirates are robust (8) and suggest that. While it is most likely that they do date to the Hafit period. some of the Hafit graves have been used for secondary burials in the later third and mid-second millennium BC and a Hafit period date is therefore tentative (6). this skull should be identified as a possible female. 1). Along the lambdoid suture there is a large irregular inca bone as well as some probable wormian bones (now missing). However. accurate cross-sections of areas of interest were produced. FRIFELT Frifelt. Again the tomb contained the remains of multiple individuals (an estimated three) alongside some beads. Methods The lesions were examined macroscopically and microscopically in order to confirm the extent of mechanical marks and the presence or absence of any signs of associated infection or healing. the zygomatic root extends onto the mastoid that is moderate in size. this was not completed. A Siemens Somatom CT scanner was used to explore internal and external surfaces and densities in a non-destructive and noninvasive manner. Given its incompleteness.J. because this would have included destructive procedures. it was not possible to take any measurements of the skull. 1. There is no clear sign of pathology although the occipital on the endocranial surface is markedly asymmetrical. Calotte of Cranium 1309. indicating a female.

particularly visible on the anterior border. where not broken. The lack of any external bone surface makes it difficult to determine whether the lesion shows signs of remodelling. The perforation edges. The lesion is oval shaped with straight sides. Longitudinal striations are visible on the surface of the lesion and extend up onto the bone surface.8 (30.0 9.0 15.4 31. exposing the diploic bone. Under a microscope it is clear that the surface of the groove is planed and therefore represents deliberate and not accidental damage to the skull.0) M-L 12. Unlike lesions 1 and 2. Table 1. The left side of the perforation is missing post-mortem. The groove is very shallow but appears to have perforated the inner table.0) (<13. There is an oval-shaped depression with a straight lateral edge extending beyond the rounded anterior border.3) (8. lesion 3 is a rectangular lesion located on the mid-left parietal. this is all indicative of a lack of healing. The current perforation is larger due to postmortem breakage.9 26. The anterior and posterior ends slope gently but the lateral side Fig.4) (<8. 2).0–14. leaving a small irregular hole. Numbers in parentheses are estimates of original dimensions. The edges curve inwards with a gradual slope antero-posterior but with much steeper medial and lateral sides. On the endocranial surface the perforation impinges on a third-order anterior branch of the middle meningeal artery. Lesion dimensions in mm on Cranium 1309. The lesion is roughly oval shaped on the antero-medial to posterior-lateral axis and is bevelled externally.0 15. Under a microscope there is no visible sign of remodelling.9) 5. The lesion is aligned anteromedial to postero-lateral.2 (14. 2. Lesion 2 is located on the anterior left midparietal. There are no clear scratch marks and the irregularity of the hole plus the lack of the sharp edges suggests possible remodelling (confirmed by microscopy) and slight infilling of diploe on the lateral side. No signs of healing are visible.5) (<21. The anterior border is straight sided and angled slightly towards the medial edge.0 23.5) 10.9 (3.TREPANATIONS FROM OMAN The cranium has a series of nine erosions which all penetrate the inner table (Fig. The medial side of the lesion is missing. are slightly rounded but with no thickening and there is a sharp medial border.7 12. Its distal end crosses the coronal suture but the suture is only superficially affected. On the anterior part of the lesion the sides are sharp while the slope on the posterior half is much gentler. The posterior border is rounded and blurred in outline. The inner table is only perforated towards the anterior end.1 (<8.8) – – – M-L 7.1 (16.0) – – – 141 .1 27. There are external scratch marks parallel to the long axis of the lesion.0) (3.6) 5.1.4 (5. The medial and lateral sides are fairly straight and approximately parallel. Lesion 4 is located on the left parietal adjacent to the posterior third of the sagittal suture.6 23. Internally the lesion crosses a third-order branch of the anterior branch of the middle meningeal artery. Diagram of locations of trepanation lesions on Cranium 1309. while a post-mortem fracture runs through the hole.8) (<9.4 (<5. Lesion 1 is located on the left frontal adjacent to the coronal suture. It is probable that the inner table was perforated but this is now broken post-mortem. Each lesion has been numbered and the following paragraphs describe each one in turn while the dimensions are presented in Table 1.0 15. the scratch marks are clear and unremodelled. The long axis of the lesion is parallel to the sagittal plane.3 32.0) Internal A-P 7. The bone surrounding the lesion is weathered and the surface eroded. External Lesion 1 2 3 4 5 6 7 8 9 A-P 26.3 5.

The anterior and medial half of the lesion is missing. The long axis is oriented antero-posterior. This is an oval-shaped depression oriented in an antero-lateral to postero-medial direction. The diploe shows no indication of infilling although the margins are slightly rounded. The diploe is still clearly visible. broken postmortem. None of the trepanations is associated with signs of bone inflammation and for the most part there is 142 . Lesion 7 is an oval lesion located in the superior section of the right mid-parietal.J. and the lower border of the internal perforation also appears rounded. Deeper grooving is visible at the slight medial-anterior angle to the medial border. Scratches are visible on the external surface medial to the lesion and extend 18. lesion 9 is only preserved in its posterior section. The lateral margin still appears very sharp. The lesion did not affect the sagittal suture and was apparently very shallow. These are also visible at the posterior border. There is no indication of remodelling under the microscope. There are differences in the shape and depth of the trepanations: one (possibly two) is quadrilateral in shape while the remainder are shallow oval grooves (Figs 4–5). The lesion is oval. Internally the lesion probably impinged on a third-order branch of the anterior middle meningeal artery. FRIFELT has a much steeper bevel. Lesion 8 is a poorly preserved oval depression located on the posterior half of the inferior left parietal. There is no other macroscopic or microscopic evidence of remodelling. It was possibly not finished since the maximum possible complete dimensions are less than 21 mm long and less than 13 mm wide. The centre of the lesion and the lateral border are missing and broken. There is an apparent small perforation of the inner table but the bone edges of the perforation have fractured so that exact dimensions are difficult to determine. There are no visible striations on the outer table. The edges of the lesion are very blurred but the shallow groove has a planed surface.5 mm beyond the subsequent depression. Each perforation is an angled groove between 21–32 mm long and 12–15 mm wide.or endocranial indication of bone reaction. There are no signs of either ectocranial or endocranial bone reaction. The oval depression is aligned in an antero-lateral to postero-medial direction. There is a series of small parallel striations visible on the outer table adjacent to the anterior end. The diploe is exposed. Lastly. The lesion is a shallow regular groove and there is no real indication that the inner table was actually perforated. There is no ecto.or fourth-order branch of the anterior middle meningeal artery. To the naked eye there are no clear scratch marks on the external surface but some are visible under the microscope. The posterior border of the internal perforation has a slightly rounded edge. LITTLETON AND K. The lesion is very close to the sagittal sinus but perforation of the inner table was unlikely to impinge on it. The surface is weathered and broken and the lateral and anterior edges are partly missing. Parallel linear scratches are visible across the surface of the lesion aligned to the long axis. which is indicative of deliberate trepanation (Fig. It is located on the anterior left parietal adjacent to the sagittal suture. while the medial border is near vertical with only a slight curvature towards the base of the perforation. although the bone at the base of the lesion is very thin (<1 mm). The anterior and posterior borders have a shallow angle. The diploe is slightly exposed. The edges are smooth and the borders are still sharp. with no clear infilling except possibly at the posterior border (not confirmed by microscopy). 3). Lesion 6 is located on the inferior half of the midparietal. Lesion 5 is an oval-shaped lesion located on the right anterior mid-parietal adjacent to the coronal suture. All edges of the lesion are blunt and slightly rounded. There is no apparent impinging on the fifth-order branch of the middle meningeal artery. It appears that a small part of the posterior margin of the internal perforation is still present. The lesion internally impinged on a third. There is possible infilling of diploe at the posterior end. Summary Each perforation is marked by linear striations parallel to the long axis of the perforation. Microscopically the bone is too eroded to determine if any signs of remodelling were present or not. Internally it appears that the surgery did not cause any damage although it may have crossed a fourth. At the base of each groove a small segment of the inner table has been removed with only 5–9 mm by 3–7 mm of the soft tissue exposed.

143 . It should be noted that these signs of possible healing are very slight and difficult to evaluate. CT reconstruction of Cranium 1315 with the lesion numbers marked. given the fragmentary nature of the skull. Fig. 4. 6.TREPANATIONS FROM OMAN no evidence of healing. Lesion showing the linear striations produced by scraping with a stone implement. presumably either because the operation was aborted (given its proximity to the sagittal and coronal sutures it may have been thought too risky) or because the patient died during the process. It may be that this variation is more a response to the relative thickness of the skull. Fig. 5. 3. 2. with the thinner parts of the skull (closer to the temporal suture) being accommodated by delimiting the lesion first with a blade or chisel. reconstructed skull (Fig. this does not correspond to the pattern of possible remodelling. however. lesions 5 and 8 being in the oval style and lesion 2 in the square form. however. Quadrangular lesion on Cranium 1309. Lesions 5. The variation in the nature of the lesions suggests at least two episodes of surgery. Cranium 2 — 1315-C This is a fragmentary. Oval grooved lesion from Cranium 1309. and possibly 8. 6). The outer table of the bone is chipped at the anterior frontal and weathered on the left-hand side and around the basicranium. The skull is fragmentary but the average fragment size is 8–10 cm in diam- Fig. On the other hand lesion 9 appears to be unfinished. Fig. do appear to have started to heal.

7 Internal A-P (7. There is possible infilling of the diploe on the medial-posterior end.J. The anterior border has had a vertical angular chip removed. The left temporal is also missing. The long axis runs parallel to the suture. and the coronal suture is partly fused as is the squamous suture. While the depression crosses the coronal suture. along with a third of the frontal. Lesion 2 is an oval lesion with straight sides situated on the anterior half of the right mid-parietal. There is a probable wormian bone (now missing) in the right lambdoidal suture.1 34. Ectocranially the sagittal suture is still open as is the lambdoidal suture. Under the microscope the borders have sharp edges and again there are small fragments of bone caught in the diploic spaces near the base of the groove. FRIFELT eter. On the lateral side of the lesion the depression is slightly convex. Lesion 3 is an oval lesion on the mid-parietal alongside the sagittal suture.0) – 4. The long sides of the lesion are sharp with little evidence of rounding. Horizontal striations are visible at the base running along the long axis. No facial bones remain and a large proportion of the right side of the skull is missing. The lesion is aligned in a medial-lateral direction. and a near-vertical but slightly chipped lateral border. This is a shallow groove with an irregular central perforation. There is no post-mortem breakage except for some erosion of the external surface. Lesion 4 is a deep oval lesion on the posterior left parietal. The lesion is deeply grooved with near-vertical lateral and medial margins. The skull has a moderate to large mastoid. At the base of the lesion is a small circular hole penetrating the inner table. The long axis of the lesion is antero-posterior.4 – 6. near-vertical medial border. There are no indications of pathology other than the four depressions on the skull. The lesion has a sharp. there is some loss of diploic spaces and no visible scratching.8) (9. all of which are suggestive of a limited degree of remodelling prior to death. and there are no endo. There is no clear evidence of infilling and the horizontal striations remain clearly visible at the base of the hole. External Lesion 1 2 3 4 A-P 33.1 16. Lesion 1 is an oval perforation of the skull on the right frontal. Lesion dimensions in mm on Cranium 1315-C. These indicate a possible male but this attribution is tentative given the incompleteness of the skull. the perforation itself probably did not affect the suture line. All of the visible sutures are beginning to fuse on the endocranial surface.0 Summary The grooves are slightly longer and wider on average than on Cranium 1 although the grooving stopped at the same point of perforation so that only 144 . This is possibly debris from the scraping process. there are still broken pieces of bone visible under the microscope within the diploe. Again the only indicator of age is the degree of cranial suture closure.1 3. The groove has steep sides exposing the diploe. There is no evidence of reactive bone on either the endo. thirdor fourth-order branch. There are some horizontal striations along the surface of the groove. and there is a visible nucchal torus. There is post-mortem damage to the hole’s margins. rounded and shallowly curved anterior and posterior borders.or ectocranial indications of bone reaction. Table 2. The diploe is visible in most of the lesion but the inner table is perforated in the centre of the depression. Longitudinal striations are visible to the naked eye along the lengths of the perforation. the zygomatic root continues onto the mastoid process. This suggests a young to middle-aged adult.2 – 14. The anterior and posterior edges are shallower and with rounded rather than sharp margins. These are numbered as indicated on Figure 6 and dimensions are given in Table 2. Under microscopy fine parallel scratches are visible on the posterior edge of the groove. The internal perforation impinges on the anterior middle meningeal artery. leaving an irregularly shaped hole.1(23) M-L 16. just crossing the coronal suture. There is an irregular perforation through the inner table at the base of the lesion with the diploe exposed. LITTLETON AND K. which runs in an antero-posterior direction.5 M-L 5. Under the microscope there are clear scratch marks on the medial side of the groove that still has relatively sharp edges.4 – 31.or ectocranial surfaces. Despite being cleaned after excavation.

a stone implement may have been used. It may be that this is an accommodation to the thin cranial bones of this individual. as evidenced by the parallel grooves along the base of the lesion.TREPANATIONS FROM OMAN a very small area of the soft tissue was exposed (Fig. 8). Fig. 7. The lesion itself was subsequently completed in the normal fashion by scraping down. particularly of the inner perforations. thus limiting the extent of the lesion. which would have required moving the head and reorienting. In lesion 4 on the lateral edge the bone is rounded and the diploe infilled. which allowed for the initial cuts to be made. it seems likely that lesions 1 and 4 were in any case not done at the same time. 7). Grooved lesion from Cranium 1315. The trepanations compared In both crania the basic method of trepanation was similar. This is a relatively common technique across the world and has the advantage of slow and careful removal (9). however. 9). Fig. The difference in length is potentially due to a difference in the thickness of the skull. 4). with loss of diploic spaces and no visible scratches. Lesions 1 and 4 are deeper and both appear to have minor signs of healing (Fig. particularly in the case of the second cranium. This suggests a minimum of two episodes of surgery and given the different orientation of the lesions and their placement. Cross section of lesion 1 with indications of rounding of internal margins plus thickening of lesion border. Lesion with possible signs of healing including infilling of diploe. 8. There is very little variation in the size of the lesions. 9. is very controlled and relatively small. A CT section of this lesion indicates a rounded margin. Fig. The scalp was cut back exposing the skull and a groove was produced by repeated scraping. Cranium 2 was much thicker and in order to remove 145 . as well as evidence of particles of bone caught in the diploe across the lesions. In lesion 1 the diploe appears to be infilled on the medial posterior end. The size of the lesions. There is evidence of this in the form of small chips lost from the linear edges (see Fig. the lesion was started with the use of a (presumably) metal chisel or blade. In the case of the squarer trepanations on Cranium 1. but even in the first cranium the width of the lesions varies little. An indication of the size of original exposure is given by the extent of scratching around lesion 9 on Cranium 1. Judging by the parallel grooving. an area of denser bone on one side of the lesion and increased density near the inner table on the opposing side (Fig.

and Burzahom. particularly in the case of the left parietal. in that the position of lesions 5 and 8 on Cranium 1 are mirrored in Cranium 2. lesions 1 and 4 in the second individual. were the first trepanations to be conducted on the first individual. but they appear to be post-mortem and are probably the result of the trepanations weakening the skull rather than being pre-mortem fractures prompting the surgery. meningitis. scalp wounds. Unfortunately the incomplete and fragmentary nature of the crania makes it difficult to be absolutely certain that there is no pre-existing pathology that provided the rationale for these operations. in the case of feuds. LITTLETON AND K. All of these classifications blur into each other since other medical systems incorporate therapy in ritual systems. sinusitis etc. perforating a thick adult cranium could take as long as 40–50 minutes before the dura mater was exposed (10). epilepsy. There is a curious coincidence. judging by the signs of healing. Comparison of lesion position between Crania 1309. probably three separate head positions. This difference in the thickness of the skull and the amount of work required to remove the bone was noted by Broca. However. the scraping would necessarily have continued for longer and across a wider plane of the skull. 10). Ruffer (13) points out that even up to the Middle Ages it was supposed that powdered cranial bones possessed curative powers. 146 . This is a common distribution across the world and reflects both ease of access in terms of treatment but also. for amulets). It does raise the possibility of there being a defined sequence of lesions since 5 and 8. however. Not all trepanations are related to physical trauma or physical signs. in the absence of a wider series. 10. and magico-ritual (e. who proved experimentally that while a thin child’s skull could be perforated in four minutes. that the operations on Cranium 1 probably involved five to six different head positions where the patient was angled in a different position in relation to the practitioner and on Cranium 2. in these cases the technique itself would have produced bone dust and debris that may itself have had a particular purpose. The fracture lines on Cranium 1 do cross the trepanations. and therefore these skulls are not unusual in that sense. this is simply speculation. 1315. concussion).J. neuralgia. however. the most frequent locations for trauma (11). although this is associated with post-mortem trepanations. In both instances the trepanations are restricted to the parietals with an exception in Cranium 2 where one is on the frontal. In a summary of potential causes Lisowski (12) summarises the motives for trepanation as: therapeutic (including fractures. The relationship of this to any precise neurological or behavioural abnormality is however impossible to hypothesise. At the very least it indicates that the heads of these two patients were held in a similar fashion to allow access to the crania (Fig.g. even down to the angle of lesion 8 (lesions 1 and 4). magico-therapeutic (including headaches. 1309 1315 Burzahom Fig. It is clear. FRIFELT sufficient bone to expose the dura mater. Furthermore. delirium. which may have been the result of asymmetrical premature closure of the left occipital suture. The only indication of anything unusual about either of these skulls is the asymmetry of the lambdoid of Cranium 1.

as argued by Maat. Healing of trepanation occurs with osteoclastic resorption. it was suggested that the trepanations were created using the same scraping technique. However. Given the sharpness of the hole and the lack of any signs of healing it seems very possible that this is a post-mortem operation. changes in what were considered precipitating causes and in the nature of the operation that makes multiple episodes likely. From the rest of the Gulf there is only one report where trepanation was suspected. an individual who survived a year had visible focal remodelling with smoothed defect margins. Overall trepanations in the Middle East and south Asia are not common. being a small circular hole produced by drilling. Lachish) (22) to small circular drilled holes (e. e. Similar lesions elsewhere have been interpreted as operations for retrieving roundels of bone or for hanging the skull (20). on the other hand.g. In these cases the signs of healing here are minor and are perhaps indicative of days and weeks rather than months between the first and last episodes (16). rather than the very regular and routinised lesions observed on the Hafit skulls. suggest that healing may commence relatively soon after the surgery. With the exception of South America. there was a series of operations undertaken with no apparent underlying physical cause. Jericho) (23). Two of the trepanations are clearly related to depressed fractures of the cranial vault. where each operation probably involved the production of more than one perforation and where Trepanations in south and west Asia As seen in Table 3 there is a relatively small number of trepanations from south and west Asia. However. the result of a fatal injury with a two-pronged tool. causing a loss of visible diploic structures so that ultimately the remodelled defect edges become just one compact bone layer (14). Apart from the other Emirati skulls. which smoothes the sharp edges of the defect. the size of the fracture. This is the Hellenistic burial from Failaka Island where the skull has two puncture wounds on the left parietal (21). although the time between the episodes is probably short. The comparison with Jebel Buhais tends to suggest the continuity of a therapeutic practice and also. Gradually the diploe is filled in. The care with which the scraping was done and the deliberately limited exposure of the dura mater also suggest pre-mortem trepanation. the discovery of trepanations is a rare occurrence as Table 3 indicates. potentially. Zias and Pomeranz (15). A recent study of survivors of trepanations by Nerlich et al. although at least in Iran this may reflect the rarity of skeletal remains. and there is also a notable lack of reported trepanations from modern Iraq and Iran. it differs markedly in form. Trepanations in the UAE Kiesewetter (18) has recorded three trepanations from Jebel Buhais dating to the Neolithic period. these are clearly peri-mortem rather than obviously pre-mortem lesions and are possibly. The removal of skull bone for amulets or to remove the brain after death frequently involves much more invasive operations and larger lesions than those observed here (17). This would seem to be a very different set of circumstances from those involving the two crania from Jebel Hafit. All were pre-mortem with evidence of healing. The one other recorded trepanation from the Gulf at Bawshar is either later or possibly even penecontemporary with these remains (19). By contrast. particularly when compared to the large number found in South America. suggests that there are no signs of healing among those who survived trepanning for a few hours to a few days. although these are significantly larger external and internal lesions and they do not have the evidence of any use of chisels as well as stone implements. although that is very hard to determine simply from photographs. while the third is possibly related to a cranial tumour. Accounts vary as to how long that healing takes.TREPANATIONS FROM OMAN In both individuals the slight signs of healing plus the difference in the style of trepanations on Cranium 1 suggest multiple episodes of trepanation.g. As with the Hafit remains. both the time frame and geographical relationship places 147 . The trepanations are variable in style and range from large square cuts (e. The size of these trepanations seems to be much more clearly related to the underlying cause.g. it seems highly likely that more will appear from the Emirates and that they are part of a long-standing tradition.

for multiple sitings for the trepanation. 10). the biological data (morphometric and dental) point to the closest affinities being with skeletons from cemetery R37 at Harappa (25). LITTLETON AND K. In both cases the size of the trepanations is small in comparison with the much larger lesions found in Iran and some of the Palestinian sites. The technique varies from the Oman instances since drilling was most likely used. however here. These are all with one exception on the left parietal. As Kennedy points out. this is not to imply that these two ancient populations were lineages of a single population but that populations throughout northern India ‘shared a higher frequency of genetic characters within this geographical sector of the subcontinent than they did with populations of peninsular India’ (26).2200 BC 2000 BC 83500–6000 BC Bronze Age Early Bronze Age 3500 BC Roman c. or even the earlier lesions from Jebel Buhais. Like the two Oman cases the Burzahom skull has multiple trepanations: six completed perforations and five shallow depressions. Trepanations identified in south and west Asia (35). has queried this interpretation.2300 BC Bronze Age Bronze Age c. The initial interpretation of the Burzahom skull was that the trepanations were post-mortem and conducted for ritual purposes such as retrieving roundels of cranial tissue possibly as amulets (27). drilled? (45) 1 adult — healed — produced by scraping (46) 1 adult male: fragment with 4 holes unhealed (47) 3 1 1 1 4 1 8 3 2 skulls — drilled? (48) child 8–9 yrs (49) adult with 4 trepanations — scraping and drilling (50) adult (51) skulls — ‘noughts and crosses’ (52) skull (53) individuals (54) adults with grooving and scraping technique (55) adults (56) the Jebel Hafit skulls closest to the examples found at Harappan sites (or sites associated with Harappa) in north India. The other similarities are the siting of the trepanations (Fig. In particular.2300–2000 BC c. The authors argue. as in Oman. Region/Site Arabian Gulf Jebel Buhais Bawshar (Oman) Bilad Al-Maiitin (Oman) South Asia Burzahom (Kashmir) Harappa Lothal Kalibangan (W India) Timargarha (Pakistan) Maski (S India) Iran Parchinah (Luristan) Dinkha Tepe Mesopotamia Isin (Isan Bahriyat) Levant Tell al Mazar Dimona (Palestine) Jericho Jericho (tell es-Sultan) Lachish Arad Wadi Makuqh Tell es-Sultan (Jericho) Tell Bi’a (Syria) Date 5100–4300 BC Iron Age Islamic? c. A more recent analysis.200 BC Iron Age c. on the basis of the size and shape of the depressions.J.1700 BC Comments 3 adults with trepanations (36) 1 fragment – drilled? (37) Crown trepan made of bronze (38) 1 adult — 11 attempts at trepanation. particularly given the discontinuous geographical distribution in the Middle East. FRIFELT Table 3. there seem to have been variations in technique. the pattern of multiple trepanations carried out at separate intervals and the type of trepanation is very similar to the Burzahom skull from north India (24). the lack of clear physical causation and the probability of not only multiple 148 .1500 BC Megalithic Iron Age Chalcolithic 1100–800 BC c. While Burzahom is a Neolithic site dating to the mid-second millennium BC with numerous cultural parallels to other cultures north of the Himalayas. partial healing? — produced by scraping (39) 2 adults (40) child 9–10 yrs — drilled (41) 1 adult — possible trepanation (42) 1 adult female (43) 1 adult — 2 circular trepanations (44) 3 trepaned skulls. however.

Adoption depends upon the assimilation not just of the practice but also of the associated justification and understanding of the world. given the earlier dates and long-term continuity in the Emirates. Bahrain has been interpreted by some as part of the same cultural zone as Harappa and the southern Gulf. also point to the subtlety of those linkages whereby practices unrelated to economic life and in fact very uncommon are either shared or diffused. The Pacific provides the clearest ethnographic parallel to this. It is striking that at the time of the Harappan skulls. is a rather different case. second. which involves not only cutting the scalp but also removing a part of the body (33). Medical practices are frequently situated within a set of precepts involving the role of ritual. As a basic interpretation the practice emphasises the wellknown cultural linkages and similarities between the two polities of Magan and Harappa and the distance between these and Dilmun. identification and treatment of illness or deviation from the norm (34). The remaining distinction is between diffusion and local invention. cannot be ruled out entirely. Trepanation is widely practised in some Pacific localities for varying reasons including treatment for head injuries and prophylaxis. The evidence from the Gulf and elsewhere. It is not that these need to be entirely congruent. despite even larger skeletal series from Egypt. most likely did involve the exchange of knowledge between individuals who physically met. 149 . that the skulls are much more closely contemporary and that they may represent actual foreign practices in one or other of the countries. notions of how the body works. no evidence of trepanation has been found (so far). Unlike pottery. Independent evolution. but if the new practice is to be taken up then it is more likely to be adopted if it does not do violence to preexisting rules and explanatory models. It does. however. again suggesting a lack of diffusion despite close cultural connections (30). Similarly.TREPANATIONS FROM OMAN operations but more than one lesion being created at one time. Trepanation. the wide dispersal in north India at the time (already indicative of diffusion). both Oman and north India are part of a wider zone of cultural and economic influence from Harappa. In a recent paper. the practice of trepanation that is found in Palestine is much rarer in Egypt. or that this is simply coincidence and we are looking at two independent inventions. some practices did not get imported or shared. and the nature of multiple pre-mortem trepanation. it is not immediately obvious where the site of the therapeutic action should be and secondly. and of the causation. Brothwell (29) argued for trepanation as a practice that originated in only one or two loci and then diffused across wide geographical areas. it is a highly developed technique with a high risk of death attached. Even where neighbouring groups share the practice the circumstances under which it is undertaken may vary greatly (32). despite large numbers of skulls from varying time periods on Bahrain. makes this rather questionable. particularly in the absence of clear open fractures. the burials at Hafit are consonant with other burials on the peninsula both in terms of style and grave goods (28). the stylistic similarity. these foci of trepanation are separated from each other by both thousands of miles and by other islands where the practice is simply not reported (31). suggesting that despite cultural similarities. however. There are three possibilities: that the idea and practice of trepanation is part of a shared cultural repertoire and has diffused from one place to the other (from the Oman peninsula to north India. However. While the evidence here is suggestive of a limited form of diffusion between two areas that we know were at least in contact for some periods. In the case of open-skull fractures with visible bone fragments (as at Jebel Buhais) one can easily understand how removing the fragments of bone from the field of injury may be an obvious response. if it occurred. yet. it seems most likely that the Hafit burials significantly predate the Harappan examples. however. given the dates). As such the adoption of a new medical or ritual practice (and often this is an arbitrary distinction) is not a straightforward process. The parsimonious explanation is diffusion. however. Part of the reason for discontinuities in its distribution is possibly to do with chance: the transport of uncommon practices relies upon the connection (in the absence of detailed written records) between two potential practitioners and presumably a suitable patient or victim. this is one of those instances where the initial diffusion. The second scenario is the most unlikely: first. Firstly.

Sankhyan A & Weber G. Frifelt K. eds. Murphy E. 24. Prehistoric and early historic trepanation: 659. University of Auckland. Zink A et al. Kuml 1970: 1971: 355–383. Die meschlichen Skelettreste aus den Gra ¨ bern von Umm an-Nar. Tu ¨ bingen: Unpublished PhD thesis submitted to Eberhard-Karls-Universita ¨ t. Martin G. Diseases in Antiquity. 27. Kiesewetter. Kuwait. Palaeodemography and Palaeopathology. Lonnee H & Noordhuizen H. Kunter V. In: Calvet Y & Gachet J. Standards for Data Collection from Human Skeletal Remains. Archaeology of the United Arab Emirates: Proceedings of the First International Conference on the Archaeology of the U. Ancient trephining: Multi-focal evolution or trans-world diffusion? Journal of Paleopathology 6: 1994: 129. Starkey J. However. eds. Evidence of surgery in Ancient India: Trepanation at Burzahom (Kashmir) over 4000 years ago. Trepanation: History. Berlin: Deutsches Archaologisches Institut Orient-Abteilung. Basu and Paul cited in Sankhyan & Weber. Discovery. Journal of Paleopathology 3: 1991: 137. 1967: 651–672. Washington DC: Smithsonian Institution. Desert Nomads in Prehistory. Analysis of human skeletons from the Hellenistic Period. for the original production of a poster on this research. (3. to Dr Frøhlich for undertaking the reconstruction. Prehistoric and early historic trepanation: 659. Discovery. Jt. 17. Fayetteville: Arkansas Archeological Survey Research Series. particularly in light of known cultural connections between this area and the Oman peninsula. Zias J & Pomeranz S. Chr. Lisowski. Brooke W. 2000: 281. God-apes and fossil men: 281. 18: 1990: 85. Oakley K. buried at a ruined Bronze Age building on Failaka. Potts DT. the similarity and temporal linkage do not clearly indicate whether this is a case of diffusion or of local inventions. The late prehistoric. 16.5 millennia ago. Trepanation in the South Pacific. God-apes and fossil men: Paleoanthropology of South Asia. 23. differential diagnosis. Lukacs and Smith who all assisted with information on other trepanations from the region. ed. eds.A. eds. Peschel O. The Neolithic population: 35.A. Theory: 209–222. Studies in the Archaeology of Oman. Kunter M. International Journal of Osteoarchaeology 11: 2001: 375–380. Lisowski F. 150 . 15. 20. 19. 12. 26/1: 1991: 163. Evidence of surgery: 375. On the birth of trepanation: The thoughts of Paul Broca and Victor Horsley. Acknowledgements Our thanks to Seline McNamee. Ann Arbor: University of Michigan Press. Finger & Smith. is extremely slight. 2.J. v. Lisowski. Nerlich A. Discovery. 1999: 78. Theory. 13. 14.E. Ortner D & Putschar W. Campillo A. Kennedy. Jamdat Nasr graves: 355. 44: 1994: 36. In: Arnott. 9. International Journal of Osteoarchaeology 2: 1992: 183. Journal of Clinical Neuroscience 2: 1995: 257. eds. In: Arnott. In: ducted and the frequency of the practice. Kiesewetter H. 3. Broca cited in Finger S & Clower W. Brothwell D. Prehistoric and early historic trepanation: 659. Abingdon: Swets & Zeitlinge. Al Naboodah H & Hellyer P. LITTLETON AND K. Finger S & Smith C. London: Trident. Kennedy K. Palestine. the similarity between the north India technique and execution (as seen at Burzahom) is striking. Personal communication. Cited in Lisowski. U. 2006. Finger & Smith. when it is hoped that it will be possible to see when. Trepanation: History. Buikstra J & Ubelaker D.). 8. Lisowski. 6. There are further questions still to be answered and which can really only be answered with further finds. 4. Individual skeletal diagnoses. Discovery of skulls with surgical holing at Tell Duweir. FRIFELT Conclusion In the current case. Trepanation: History. Prehistoric and early historic trepanation: 659. if it occurred at all. The Neolithic Population at Jebel Buhais 18: Remarks on Funerary Practices. healing and dry bone appearance in modern cases. 10. photography and CT scanning as well as commenting on the manuscript. 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