Controversy - the pros and cons

History of trepanation

Brain Pulsations

Effect of trepanation on brain pulsations

Mechanism and benficial effects of trepanation on cerebral circulation

Trepanation in ancient times

Trepanation across different cultural groups

References and citations

Advanced reading




Trepanation across cultures and civilizations

Trepanation has been documented in almost all the cultures and civilizations. It is also the oldest therapeutic procedure. The bibliography of trephining is vast, there are thousands of references, and much controversy as to motive and technique. The extensive literature deals mostly with "prehistoric" trepanation, particularly Neolithic European or pre-Columbian South American. But in actual fact, the operation has been practised almost everywhere in the world and at all periods, from the New Stone Age certainly and perhaps even from an earlier period in the evolution of man. The work "trepanation" is from the Greek trypanon, meaning "a borer," and dates from classical times. The more recent term "trephination" affords a variant, and is derived from the French. Essentially, both words mean the same, the making of a depression or perforation in the calvarium. Trepanation or trephination in the narrowest sense implies the boring of a hole through the intact skull of a living person. An extended meaning of this would include the making of a depression but not a hole in one or both tables of the cranium, or the removal of bone fragments already present from trauma or infection. The hole or depression is usually made by scraping (raclage, grattage), rasping, and cautery, but may also be accomplished by drilling, boring with a gimlet (vrillage) or knife-tip, cutting (burinage), and sawing (sciage). In the previous chapter, Dr. Peter Lisowski has considered ancient trepanation, and thus the aim of this present review is not archaeological or historical in nature, but rather to survey trephining in recent times by traditional medicine-men in primitive cultures, with particular reference to the Kisii of Kenya and the Tende south of them in Tanganyika.

There are a few out of the way places in the world where cranial trepanation is still carried out by native traditional medical practitioners. One of the areas where the operation has recently been known is in Polynesia and Melanesia. Trepanation has not apparently been reported in Micronesia, the northernmost Pacific islands. A number of reports have described the practice in Polynesia, the central south Pacific islands. As early as 1829, William Ellis, a missionary, reported "trepanation" in the Society Islands (Ellis, 1829). Actually this was removal of bone fragments after traumatic fracture, and not true trephining, the making of a depression or hole in the intact skull. He described how the natives repaired a bony deficiency in the skull by fitting in a piece of coconut shell. He also recounted the story that injured brain was removed and pig brain substituted---unsuccessfully, it is said, the person always becoming mad and dying! Coconut shell was undoubtedly chosen because of its hardness and its natural resemblance to the cranial vault---hard material indented with vein-like impressions, which infers a magical identification. Whether the shell was inserted in cranial deficits, or, as a dressing or protection placed over them, is not at all clear from the published reports (vide infra). Trepanation was reported by others in Polynesia, particularly in the Society islands, which include Tahiti (Ellis, 1829; Henry, 1928; Topinard, 1875; Wölfel, 1925). Stewart visited the Marquesas in 1830, and mentioned that trepanation with a shark s tooth was carried out by the tahunas (tauas) or priests (Stewart, 1831). Natives still remember the operation there (Handy, 1923; Heyerdahl, 1941-52). Holed skulls from the Marquesas are in the Musée National d Histoire Naturelle (Forgue, 1938) and the Musée de l Homme (Heyerdahl, 1952) in Paris. Trephining was customary also in the Tuamotu Archipelago, between the Marquesas and Society Islands (Emory, 1942; Heyerdahl, 1952). In Oceania, the practice of making holes in the cranium reached its height in Melanesia, the western islands south of the Equator (Heyerdahl, 1952; Parkinson, 1907-8; Wölfel, 1925. It has been reported from most of the larger islands, Fiji, Bismarck Archipelago, New Hebrides, New Caledonia and the Loyalty Islands. It is uncertain (Ford, 1937) whether the operation was indigenous to the Solomon Islands, though Wölfel (1925) claimed a skull from the island of Ysabel, and now in the Naturhistorisches Museum in Vienna, was trepanned. In the Bismarck Archipelago, cranial trephining was reported in New Britain, New Ireland, the Duke of York and also in some of the smaller islands. The instrument was an obsidian chip, a shell, or a shark s tooth. In New Britain (Neu Pommern) the operation was done only for fracture, usually from a sling-stone. The opening was scraped with a sharp stone, the fragments blown away, the scalp sutured, and elaborate dressings applied (Brodsky, 1936-8, Crump, 1901, Parkinson, 1907-8; Von Luschan, 1898). Descriptions of holed skulls, photographs of surviving trepanned natives, and of the operative process are on record. Trepan instruments from the Bismarck Islands may be seen at the Department of Surgery in the University of Sydney (Brodsky, 1938) and skulls at the Naturhistorisches Museum, Vienna (Wölfel, 1925-36), and the Wellcome Historical Medical Museum in London. A New Ireland skull now at the latter museum was holed in eight different places (Brown, 1910, Ford, 1937, Underwood, 1951). The native operator (tena-papait or tene a babait) who did this job was surpassed only by the "civilized" seventeenth century European surgeon Hendrik Chadbourn, who is said to have bored holes twenty-seven times in the head of Philip, the Count of Nassau (Ballance, 1922; Guthrie, 1842: Solingen, 1684)! The collection of Bismarck Island trepanned skulls once in the Royal College of Surgeons Museum in London (Keith, 1925; Rogers, 1930; Seligmann, 1906) was destroyed by German bombing of the city during World War II. In New Ireland (Neu Mecklenberg) the indications for trepanation were less specifically "surgical;" in addition to fracture it was recommended also for insanity considered to result from "pressure on the brain," and for a "a beating or plucking sensation" (Crump, 1901; Brown, 1910). It was also done for epilepsy and headache. Trepanning was known in the Duke of York Islands (Neu Lauenburg) between New Britain and New Ireland, and in the easterly outlying islands, Gerrit Denys (Lihar) and Caens (Tanga) (Ford, 1937). A type of operation in New Ireland was interesting, in essence being the cutting of two or three vertical channels down the forehead (Parkinson, 1907; Crump, with Horsley, 1901). The operation became fashionable there and was promoted as an amulet (i.e., a protection) and as an aid to longevity (Crump, 1901). Ford stated that trepanning the skull has disappeared from New Britain and New Ireland within the last thirty years, as a result of government prohibition of slingstone fights rather than suppression of native medical practice (personal communication, Aug. 1959). Trephining in the Loyalty Islands and New Caledonia (Nouvelle Calédonie) has been extensively reported. True trepanation was reported by Ella (1874) in Uvea for headache and vertigo resulting from a blow on the head. A hole was made in the skull by scraping with a piece of glass or a shark s tooth. The defect was filled (or covered?) with a coconut shell. He noted that about half of those who underwent the operation died from it, but later writers have questioned this high figure (Ford, 1937). The point should be made that Ella s percentage might have been correct at the time of his residence in the Islands. Perhaps the mortality became less over the next few decades, as sling-stone fights decreased and therefore brain trauma and infection less frequent. Trepanning the cranium alone, without damaging the brain, may have quite a low mortality, as in East Africa today (infra). The inclusion or addition of a foreign substance such as coconut shell would probably increase the incidence of infection and raise the mortality rate. Sarasin (1929), reporting on the Loyalty Islands, observed a coconut shell plate in situ and he heard of a man who is said to have had five such plates in different parts of his head. Bark, banana leaf, and sea shell were used also for plugging or dressing the trepan hole, in the Loyalty as in the Bismarck Islands. Eastern New Guinea and Papua would appear to be the westerly limit of the Pacific islands where trepanation has been practiced. In New Guinea, cuts were made in the forehead to treat headache (Ford, 1937; Hagen, 1899; Pöch, 1907) and true perforation of the cranium has been reported (Fritsch, 1907; Fritsch, Pales, cited in Guiard, 1930; Laloy, 1907). It is not known for certain if the practice was known in the Warrior Reefs in the Torres Strait between New Guinea and the mainland of Australia (Ford, 1937) and in Australia itself. Most authors have questioned whether trepanation was known in New Zealand, though Wölfel (1925-36) was satisfied that a New Zealand skull in the Naturhistorisches Museum in Vienna was trepanned for fracture. In a country the size of New Zealand and with such a written history, it seems strange that more New Zealand trepanned skulls have not come to notice.

While the trepanning operation might have reached Oceania from Peru (Heyerdahl, 1952) there are no adequate reports available that the custom prevailed in Peru during historical times, though current trepanning in Peru was mentioned in passing by Bandelier (1904), Freeman 1(1924), Hrdli_ka (1906) and Stewart (1950). Pre-Columbian trephination of the skull in Peru and elsewhere in South America is extensively documented. Cranial trepanation was practiced by the Aymara Indians of Bolivia at the turn of the century (Bandelier, 1904-10; Chervin, 1907-8) and actively suggested there as a cure for headache as recently as 1950 (Brooke in Oakley et al. 1959). Freeman (1924) noted that: "In the mountains of Peru, Chili (sic) and Bolivia, trephining for fractures is still practiced (sic) occasionally by native medicine-men." Field studies to determine whether trepanation is currently undertaken in Peru and neighbouring countries are very much needed.

The operation was known in aboriginal North America before the white man came, and has been recorded from Alaska, British Columbia, the United States and Mexico. There are no certain reports that it is still carried out by Indian tribes, but it is possible. Kidd (1946) notes the case of a British Columbian coastal Indian who came up to a missionary carrying a brace and bit, and begged him to bore a hole in his skull to let out the evil spirit causing his headaches! There are more than a dozen trepanned skulls from British Columbia sites, but they are archaeological and so fall outside the subject confines of this essay.

During the Middle Ages and right through to 1900, trepanation was an orthodox surgical procedure in Europe, particularly in fractures of the cranium, head injuries, and for various headaches, epilepsy, and mental trouble. With the spread of modern ideas about neurosurgery, the practice decreased in popularity before the turn of this century. The doctors of Cornwall until recently customarily trepanned miners who suffered head injuries, and perhaps not infrequently at the patient s own request for a "boring". With the growth of civilization and its technical improvements, trepanation declined in the heavily populated and advanced areas of the world. It did not always receded in the isolated backward locations where communication was limited; this was particularly true of mountainous places. Thus it was that this curious operation continued to be practised to the turn of this century (if not later) in the mounatins of Albania, and of Serbia and Montenegro.

The operations of cranial cautery and trepanation were widely practiced in the Caucasus Mountains of Daghestan, now in the U.S.S.R. It is not known if the custom is still extant there. Incomplete trepanning is currently practiced in Persia. The Bakhtiari of the Zagros mountains in western Iran operate on the skull after head injury. The operation consists essentially of removing bone fragments or of scraping the skull to remove discoloration or bleeding. The inner table is not scraped through, i.e., a hole is not made (Roney, 1954). Bailey (1961) related an anecdote about a friend who was visiting the grave of Sir Victor Horsley in Iraq. Two Arabs came by and in conversation they revealed that they belonged to an ancient family which had included trepanners for eight or nine centuries. Amongst the tribes inhabiting the mountain range of the Hindu Kush north of Kabul in north-east Afghanistan and in Dardistan, where India and modern Pakistan meet in the north, the practice of cranial cautery for disorders of the head was reported at the turn of the century (Zaborowski, 1897), and, as in Daghestan and elsewhere in primitive areas, particularly in Africa, this often is but little different in the operative intent as trepanning the outer table of the skull by cutting, scraping, boring and sawing.

Herodotus mentioned that the Libyans practised cauterization of the head on their children at the age of four years, "to prevent them from being plagued in their after lives by a flow of rheum from the head". If the operation threw the children into convulsions, they were sprinkled with goat s urine. This was the earliest historical reference to anything resembling trepanation in an African people. The Libyans of Herodotus probably were Tuareg Berber nomads, the autochthonous inhabitants of North Africa. Prehistoric trephined skulls, dating long before Herodotus, were found by General Faidherbe in dolmens at Roknia, north of Constantine in Algeria. These skulls were examined by Broca and are apparently in the Musée Broca in Paris. Considering the many thousands of skulls which have been excavated and examined, it is clearly significant that ancient trepanned skulls have not been found in abundance in Egypt; and it has not been reported that the true operation is practised there by traditional Arab or negro healers at the present time. The operation of trephining to remove bone fragments after head injury is extant in the north-west corner of Africa. Trepanation is currently well known to Arab surgeons from Arabia itself, and has been since the early days of medical history. It is customarily practised by the Chaouïa (Shawia) Arabized Berbers of the Sahara Atlas, particularly in the Aurès mountains north of Biskra in Constantine, Algeria, near Timgad or ancient Thamugadi. It is not unknown on the plains north and south of the Atlas. Hilton-Simpson (1913-22) has written an account of the practice in the Aurès. The scalp over the site is branded away to bare the bone and to check haemorrhage, then, to let out the pus or blood, a hole is made in the skull by spinning a drill between the palms of the hands. Care is taken to protect the brain and its membranes, and to avoid the cranial sutures, which are believed to be the patient s destiny written by the hand of Allah. Using saws and elevators, "bad bone" is removed day after day. Finally, the wound is dressed with honey, butter and herbs, and allowed to granulate in. The operation is also known among the Kabyle Berbers closer to the coast, and westward to Morocco. Bertherand, as early as 1855, indicated that he had heard of "médecins maures" who practised trepanation for cranial fractures but he was not able to confirm the practice. It remained for Martin (1867) and Paris (1868) to document trepanation by the Kabyles. There has since been an extensive additional French literature. The native trepanners in Algeria were said to have taught their skill in "schools" according to Malbot and Verneau (1897), Malbot (1898) and Védrènes (1885) but Hilton-Simpson was unable to find out about this. Busacchi (1935) reproduced a photograph by E. Chantre "Kayble trepané de Palestro" (Bertholon and Chantre, 1913). Bailey (1961) wrote that a skull found by a French surgeon in Morocco had been used to teach the trepanning procedure. A skull collected by Hilton-Simpson (1920) from El-Kantara in the Aurès may be examined in the Pitt-Rivers Museum at Oxford. It is probably trepanned but is "archaeological" rather than recent, having been dug up on the road and there is no ante-mortem history of the specimen. It may well be a Roman skull. The Hilton-Simpson collection of trepanning instruments from the Aurès and skull fragments from actual operations are in the same museum (Hilton Simpson, 1913-22; Butt, 1961). Skulls and instruments from Algeria collected by French surgeons may be seen in the Musée National d"Histoire Naturelle (Jardin des Plantes) in Paris (Forgue, 1938; Guiard, 1930; Malbot and Verneau, 1897) and the Musée du Val-de-Grâce (védrènes, 1885). The Guanche of the Canary Islands, a now extinct aboriginal people, were probably a Berber group, who trepanned the skull (Beattie, 1930; Hooton, 1925; Meyer, 1896; Schmeltz, 1896; Tillmanns, 1883; Von Luschan, 1896-9) and cauterized or scraped the cranium to make cicatrizations like the Neolithic European sincipital-T. Scarred Guanche skulls may be seen in the Wellcome Historical Medical Museum (Underwood, 1951), and the Museum für Völkerkunde (Von Luschan, 1896-7) and trepanned Guanche skulls in the Museum of Santa Cruz in Tenerife (Hooton, 1925). The scarred and trepanned Guanche skulls described by Beattie (1930) and said by him to be in the Redpath Museum at McGill University are misplaced or lost, or at any rate the present curator has not been able to locate them. The Teds of isolated Tibesti in Tchad and southern Libya, are probably a Berber-Negro mixture. Dalloni (1935) noted information supplied by P. Nöel that the Teda surgeons of Kaouar explored cranial wounds and resected bone. Cline (1950) noted this also, but may have been paraphrasing Dalloni. The Cambridge expedition to Tibesti in 1957 documented the custom of trepanation by Teda native doctors (Akester, 1958-9; Steele, 1958). The one indication for the operation was headache. The technique was to scrape out fragments of skull with a sharp pointed instrument. One trepanned patient had a double operation and carried two pieces of bone about with him. The reports did not comment on the significance of the fragments, but they would certainly be a souvenir or symbol, and most likely an amulet. There is practically no published information about trepanation in West and Central Africa. Talbot (1926) noted in Nigeria, "The only place where trepanning was carried out seems to have been in Bende District, where it is said that recourse was often had to it in case of serious illness. The patients almost invariably recovered, but not all doctors were capable of performing the operation." There is a skull in the Wellcome Museum said to be from Senegal and it does have an unhealed irregular engraved hole in the right frontal bone. There is insufficient history about this skull to report it in any detail as a possibly trepanned specimen. No eye witness account of true trepanation in South Africa has been recorded. There is reasonable evidence from skulls that the operation was practised by the Bushmen (Drennan, 1937 and personal communication 1960). Drennan told me that he and Raymond Dart believed that ante-mortem tampering with the cranium was widespread among the Bushmen, and was probably done with a cautery. Cautery of the scalp (and skull) is common in most primitive tribes of Africa. There is much investigation yet to be done in South African natives so far as traditional medical practice is concerned, and perhaps with particular emphasis on the seeking out of trepanation precedures. Bloom (1962, 1964) has been on the verge of finding out, at first hand, information about this practice in the Zulu around Durban. He wrote (1962), One inyanga suggested that when a patient s head is too hot, and aches severly, and throbs after having suffered a sharp blow, the cure is to make an opening on the area that was struck, and, when the bone is reached, to scrape it and then leave the wound to heal, by which time the headache will have subsided. This operation, similar to trepanning is known as umhlahlo, and the author regrets not having been able to discover the frequency with which it had been carried out by his informants, who were (perhaps understandably) reticent and evasive. The madness caused by a blow on the head is known as ukuphambana.

The field experiences are confined mostly to East Central Africa (Kenya, Uganda, Tanganyika and Zanzibar) and particularly to Kenya, and it is proposed now to present more detail about trepan practices in that part of Africa. A parietal bone showing a trephined hole was reported to have been found in Zanzibar and was said to be in the local museum (Ingrams, 1931). It could not be located by the curator in 1959. The Arab inhabitants and the aboriginals of the island in more recent times denied familiarity with true trepanation (Margetts, field observations 1955-9). Trephining is practised by medicine-men in Somalia (Brotmacher, 1955; Drage-Brockman, 1912). A number of Somali surgeons questioned by me in 1958, near the Kenya-Somalia border in the vicinity of Wajir and Mandera, did not admit familiarity with the operation, but his does not mean the practice was not customary farther north, towards the horn of Africa. Trepanation is reported to be practised in Ethiopia though inhabitants at Moyale did not know about it. The Ganda (Baganda, Waganda), Nkole (Banyankole) and Soga (Basoga) of Uganda treated headache by cutting into the bone and then cauterizing (Fisher, 1911; Roscoe, 1921-3), and for fracture of the skull the Soga were said not to hesitate to operate and to probe, and remove pieces of bone (Roscoe, 1924). These tribes, quite acculturated, are inclined to be particularly reticent about divulging "tribal" information, but so far as could be ascertained, they apparently do not trepan nowadays in the usual sense of perforating the intact skull. The Lugbara, in northwest Uganda, north of Lake Albert, trepanned the head "to let out the evil spirit which was causing an intractable headache." The operation was done with a knife having a four inch handle and a four inch blade with a double cutting edge and awlshaped tip (Hailstone, 1961). The holed skull of a man who died after the operation was donated by Dr. John E. Hailstone to the Wellcome Museum, where it is displayed. In the Sudan, at the Kenya-Uganda border, West West North of Lake Rudolph, live the Topotha made passing mention that he had seen the operation of trepanning carried out by them "most efficiently." Other doctors and anthropologists of experience in Uganda and the Sudan do not seem to be familiar with trepanation by the Lugbara and Topotha.

Since the early days of British and German colonization, and no doubt before, traditional native healers in the hills east of Lake Victoria have operated on the cranium. The colonial service doctors, police and magistrates have documented the practice at length in government files. Trepanation in the narrowest sense, making a hole in the intact skull, is still carried out there by two Bantu tribes, the Kisii (Gisii or Gusii) or South Nyanza in Kenya, and, to a lesser extent, the Tende farther south and into Tanganyika. How the custom of trepanation came to be so frequent in this area of East Africa is not understood. The practice was perhaps introduced by an itinerant patient or native medicine man, and was continued and promoted as a local custom which was encapsulated by the geopraphy and limited migrations in the area. While government officials have always known about the practice of trepanning the skull by native medicine men in Kisii, the custom was apparently not recorded in other than government sources until 1958. The Operation in the Kisii Highlands Trephining in the Kisii highlands is done primarily for the complaint of headache after an injury to the head, with or without fracture of the skull. Trepanation is not ordinarily done for headache without previous head injury, and the operation is not customary for psychosis, epilepsy, dizziness or spirit possession. The operation is a simple but painstaking and sometimes long drawn out procedure, taking one to four hours. The operators are not usually specialized trepanners, but general medicine-men who do the operation as part of their total work. They are usually apprenticed until they are sufficiently skillful and responsible to do the operation on their own. They can learn from a non-relative or may be taught by their fathers. Women apparently do not practise the trephining art. The "head surgeon" (singular omobari omotwe, plural ababari emetwe; surgeon, omobari; head, omotwe) may pray or go through other individualized magical procedures before the operation (okobara), but there is no set ritual. The patient s head may or may not be shaved and washed. He is then placed in a sitting or lying position and restrained. He is usually requested to lie on a bed of leaves with a small log under his head. One operator rather preferred to have his patient lie on a small European style bed with his head over the edge, then to sandwich him by placing another bed upside down on top of him with a relative sitting at each corner of it! The scalp is incised in a linear or cruciate manner over the site of the headache and the flaps if need be are retracted by the fingers of assistants. As a rule nothing is added to the wound, but occasionally, a medicine (unidentified) is sprinkled in the site to assuage pain, and sometimes an agent like charcoal or local pressure is applied for haemostasis. Any fragments of bone, foreign bodies or clotted blood are removed, and any discolored bone or fracture line is removed by scraping the skull (ekeore) with a sharp scraping knife having an acutely curved tip, curved to avoid puncturing the dura and brain. The scraping is usually continued until the inner table is pierced and the brain membranes exposed. Less frequently, a saw is employed to make the hole. Most operators are able to distinguish the cranial sutures from fracture lines, and seem to realize the danger of puncturing the dura, though in ignorance this is sometimes done in the case of subdural haematoma. Usually, both inner and outer tables of the skull are holed, but not always. After sufficient bone has been removed, the wound is washed with water. One omobari is said to have spewed water from his mouth onto the wound---no doubt an effective stream but not very aseptic. Fat or butter may then be applied with a feather or other applicator. Sometimes herbal medicines are added to promote healing. The wound is usually allowed to heal by granulation; the scalp may rarely be sutured, in the common native fashion with figure-of-eight sutures over thorns. The operation is said to cause only very little pain, except initially as the soft tissues are cut and retracted. Anaesthesia is not employed. If any beer is drunk, it is probably taken by the operator, not the patient. "Pain killing" medicines are more likely to have a magical than a pharmacological effect. The omobari omotwe watches the patient carefully during the postoperative period, visiting him regularly until good prognosis is assured. It is not uncommon for a patient to have multiple operations. Care must be taken to ensure the accuracy of claims made by primitives about the numbers of trepannings they have had. The native African is prone to exaggerate when giving his "medical history" (Margetts, 1958). One Kisii (infra) on different occasions varied the number of his borings from five to thirty. Multiple operations in Kisii are more likely to be enlargements of previous openings, rather than additional holes at different sites. The fee paid by the patient varies according to the demand of the omobari, to the circumstances, and perhaps least to the ability of the patient to pay---the amount charged, in money or in staple goods, has been known to vary from 40 to as much as 700 shillings in cash plus goods. The mortality is low, perhaps 5 per cent. The bad results usually end up at government hospitals with local infections or meningitis, or are investigated by the police as deaths. A court case against an omobari usually starts out with a charge of murder, but almost invariably this is modified to one of manslaughter or practising medicine without a license. The courts generally recognize that the operator has no ill-intent in mind and perhaps is ignorant of the law, no excuse in a civilized and educated person, but often mitigating for an African illiterate.

It is now proposed to summarize briefly the case histories of three living Kisii tribesmen who had experienced trepanning operations. They were interviewed and photographed several times between 1958 and 1959. This man was about thirty-five years old. He was a policeman on duty at the District Commissioner s office in Kisii. He suffered a blow to the forehead apparently without fracture. For persistent headaches several years after the injury he went to a native doctor who carried out a trepanation, probably by scraping with a curved knife. The patient was mentally normal, and at the time of examination he had no complaints of headache. Cured! Case two - This man was serving six months for stock theft and four months for escape, in H.M. Prison, Nairobi. A tree fell on his head about 1 March 1958 and this produced a headache. He then had three trepan operations, about 15 April, 15 July and 15 November 1958. The reason given by him for three operations was "to finish the job." A vague answer like this was about all the information obtainable. His omobari was a famous doctor who had an enviable reputation that none of his patients would die. Before the operation, the patient was fed gruel containing a medicine "to stop the blood coming out too quickly." A powder was applied topically "to prevent pain." The patient claimed that only the cutting of the scalp was painful, scraping the bone did not hurt him. He said the operator used a curved scraping knife, and each session took about four hours. During this time he lay sandwiched between two European-style beds with his head sticking out, and helpful relatives sat one at each corner of the top bed, which was upside down over the patient. He said there was not much bleeding. After the procedure was completed, medicine was sprinkled over the wound and boiled fat was applied with a feather. A loose dressing was applied and the wound allowed to granulate. The operation was "to remove something that hurts the bone, he took the bad bone out." The patient had to sell most of his property to pay the omobari s fee. He claimed he paid the doctor 700 shillings, one sheep, one goat, three chickens and three four-gallon drums of millet beer. This patient was somewhat withdrawn and depressed, but maybe this was because he was locked up in "King Georgi hoteli" (the prison at Nairobi). He did no work for fear it would "spoil" his head. He had no defineable physical illness and no diagnosable psychiatric one. X-rays of the man s head revealed a single opening, both tables of the vertex of his skull being absent over nine square inches. The man s sister was also trepanned twice by the same operator. Her husband had beat her on the head with a stick and caused her headaches. The third example of trepanation was the most spectacular curiosity that one would ever hopeto see. The author likes to describe him as "Hat on, hat off." When he had his battered old hat on, he looked unabtursive and "normal" enough. But when he took his hat off, one was amazed to see the whole top of his head missing. X-ray photographs revealed an oval hole about 30 square inches in area in the vault of his skull! This man was about fifty years old. He came to notice because he brought his son to see the European doctor. The son had been absent-minded, was neglecting his work in the father s shop, and was constantly reading the Bible and praying. He recovered without specific treatment. This was perhaps a schizophrenic withdrawal. About 1940, "Hat on" was a tribal policeman. One day, while entering a hut, he hit his head on the door lintel. Subsequently, he developed vertex headaches. In 1945 he had a trepanation, and over the next seven or eight years he had several more operations. The exact number was not known. The fewest claimed by the patient was five---but his story varied and on one occasion he even claimed thirty. Enough of his skull was missing to make either the lower or the higher figure quite possible. This man said his operations were very painful; nothing was given to assuage pain. Because of the extensive deficit in "Hat on s" cranium, it was feared for his safety, so he was fitted with a plastic skull-cap to wear under his hat. At last report he was wearing this and quite proud of it. The omobari who trepanned this patient was an interesting old fellow of about seventy or eighty years (Fig. 6 f). He had been doing the operation since he was a young man of twenty, and he could not recall how many patients he had trepanned, certainly well over a hundred. He was taught the technique by his father, and claimed he had never lost a patient. According to this operator, the only indication for trephining was headache following a blow. He used a curved scraper and disapproved of the saw. He expected to find a fracture at operation. He would know he was in the right place because the blood there was black (i.e., clotted). Many of the skulls opened probably never did show an actual fracture line, and the extensive amount of bone removed at some of the operations might have been the result of seeking for something that did not exist.

The operation of trephining the cranium is of importance to archaeology, to anthropology and to medicine. There are few other subjects of study which integrate so well the interests of all these three specialties. From the point of view of the medical sciences, trepanation is fascinating from the aspect of surgery, but perhaps even more so it is intriguing because of the psychology of the motives which lead to it. To gain some understanding of these motives, it is necessary to examine the psychological and psychopathological makeup, firstly of the cultural milieu in which the operation is done, secondly of the patient and thirdly of the native surgeon. While the custom of trephining seems a strange and particularly fascinating one to a stranger, it is commonplace and not considered to be a curiosity within the East African culture framework where it is practised. The basic mechanisms of thought, logic, emotional expression and behavior are the same in all cultures, and they are determined by genetic, instinctual and possibly by racial sources. These mechanisms vary in a fluid, secondary manner from culture to culture, depending on the advancement of the culture and on the opportunities and needs presented. These secondary mechanisms are determined by the differing impacts of the specific local culture, and by culture contact and exchange, i.e. the process of including within the social framework those values imposed or offered from outside societies and those requested or demanded by the specific inside society concerned, and of excluding by suppression, replacement or rejection some or all of the local values of the particular society under scrutiny. The values of civilization" in actual fact are very artificial, and consist mostly of added stresses and repressions which serve to mask the basic mechanisms common to all groups of mankind. The basic mechanisms of the mind would appear to be the same all the world over. Groups of men differ from their neighbors (which include the primitive and the more "evolved" or "involved" cultures) primarily because of the secondary factors, which can change within a chronological variable. This is the variable which is not taken into sufficient consideration in this day of world conflict. For people to change requires time. From historical writings over the centuries, it is known that trepanation has been carried out for a variety of medical-surgical reasons. The indications included practically everything relating to the head---fractures, inflammations, localizations of pus and blood, epilepsy, madness, idiocy, moral degeneration, various head symptoms (headache, vertigo, deafness, etc.), the removal of foreign bodies from inside the head (real or faked, as in "stones of insanity" or pierres de tête) and the release of pressures, airs, vapors, humors, and demons and evil spirits. When Neolithic European and pre-Columbian American trepanned skulls were studied, from the middle of the nineteenth century, the motives for the operation in prehistory had to be guessed at, since there were no writings available to explain why the procedure was done. It can be assumed that the motives in the prehistoric period were the same---multiple---as the ones that followed in historical times. It is known also that the reasons offered for trephining in present day primitive cultures are not always the same. For instance, the Kisii motive is to relieve headache after a blow. Yet a few hundred miles away, the Lugbara motive is to let out an evil spirit. If all the "reasons" for trepanation are put together, the common mechanism behind all the conditions in the list is to remove something. There is a continuum, from immaterial to material, from magic and thaumaturgy to science---evil spirits and demons, vapors, humors, air, hypothetical "pressures," actual pressures, real and fictional foreign bodies, "unknown substances," pus, blood and finally, pieces of bone. A given culture may utilize any one or several of these "reasons"---at the same time or at different chronological periods. The reasons chosen depend on the psychomental evolution of the individual and of his specific society at the particular time under observation. The reasons may vary whenever there is regression of the individual or his culture. Moreover, the custom may have "epidemic" significance, becoming a fad and a folly within the culture, depending on publicity and on the degree of regression. There is only one motive for the operation which is not aimed at the "removal of something." This is the interesting modification of trepanning as an amulet, to protect the patient against developing a disorder which trepanning is known to "cure." Such was the "prophylactic" trepanning done in the Bismarck Islands (supra). While not a motive to do the therapeutic operation, the obtaining of cranial amulets or rondelles has either magical, protective value or perhaps to a lesser extent a "curio" or "relic" significance. Amulets of trephined crania are not common in present day cultures where the operation is done. Murder with post-mortem breaking of the skull in order to get brain matter and bone for witchcraft purposes and as ingredients of magical medicine is well known throughout Africa. Any regularly outlined opening, particularly a circular one, is more likely ante-mortem trepanning than post-mortem smashing so the cranium. If the edges of the opening are smooth, pending microscopic and X-ray analysis, and excluding disease and weathering, it is almost certain that the opening is the result of ante-mortem trepanning. Intact skulls are used all over Africa for various magical purposes. Skulls may be holed post-mortem also for magico-religious purposes, as in West African ancestor cults (Stéphen- Chauvet, 1936). The psychological makeup of the patient seeking a trepanning operation may now be summarized. The patient can demand relief because he believes that evil spirits are in his head ("spirit intrusion"), plaguing him as a result of his personal slight to a decreased relative, or to his transgression of a tribal prohibition or "taboo." He may believe that foreign bodies, such as stones, pieces of glass, or other material objects, have been projected into his head ("object intrusion") by an evil-working practitioner of black magic. This belief may exist in quite a normal person of a culture which customarily believes in this kind of magic, or it may be in a person who has paranoidal ideas relating to his head. His mental aberration may press him to seek and demand action by a medicine man. Such patients are not necessarily masochistic at all. They have some sort of belief about the head relating to the presence there of something, and their magical explanation of it leads to the seeking of a magical cure. Even a natural illness causing headache, such as malaria, is explained on a magical basis of something in the head, which might be let out or removed through a hole. There is a striking lack of overt anxiety and fear in the patient seeking a trephining. The reason would appear to be security generated by the forceful and positive suggestion and promise of cure by the native surgeon. The patient does not think in terms of possible mortality, he is secure in his hope or belief that the complaint will be relieved. And now to review the possible motives of the trepanner himself. In modern primitive culture groups, he is usually a medicine man of reputation and high standing. His ministrations are meant to be for the good of his patient. On occasion, of course, he may be a deceitful and dishonest person, but this is unusual. He believes that he can cure his patient. The average medicine man and practitioner of white magic must be differentiated from the psychopathic minority who are cunning and dishonest, and who seek gain and personal gratification without regard to the patient s welfare. The trepanner s beliefs are based partly on rational pathophysiology, partly on magic. He proceeds because he knows that in most cases the patient is relieved of his complaint, whatever it may be. He may, on rational surgical grounds, remove bone fragments, bad blood, and the like. He may likewise erase a fracture line. A sick person complaining of feelings of pressure (variously described) may be cured by relieving this pressure. Thus any spheriodal organ, like the head, leads to the boring of a hole in it in order to afford an exit for the pressure-inducing agent. The other visible spheroidal organ, the eye, has for a similar reason been trephined within highly evolved cultures having developed a more elaborate surgical technology. Similarly, swellings resembling spheres may be punctured, as in case of the urinary bladder, ascitic abdomen, and the like. In many primitive psychologies, the head is the dwelling place of the intellect and of the soul. The skull is a home, a house. The emotions and vital principle are located elsewhere, usually in the heart. It is reasonable then, to think of a hole in the head as an exit for the soul, or an inhabiting foreign spirit, as the door in a house. Mental activity associated with the head (thinking, perception) are located in the head and brain. Any abnormality of this mental activity may perhaps be treated by utilizing the natural orifices to put medicines into the interior of the cranium or to draw illness out of it. The primitive may believe that the auditory canals and the nostrils particularly lead directly to the brain. Even a better way in or out of the skull would be to make an artificial hole in it. Not all culture groups who believe in the entrance of a maleficent spirit into the head, or the projection of foreign bodies, or semi-rational illnesses like "water in the head" or "maggots in the head" trepan the skull to seek relief, even though their basic theories of psychopathogensis may be similar. This can only be explained by chance and by scattering as a result of migration. As in the patient, the experienced native trepanner seems to be relatively free of anxiety about the outcome of his operation.

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