Introduction

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 in ancient times

Trepanation has been practiced since thousands of years. It is possibly one of the earliest forms of surgical intervention on the head of which we have any authentic record and its practice is widely spread in space and time. Trepanation of the human skull is the removal of a piece of calvarium with out damage to the underlying blood-vessels, meninges and brain. In some parts of the world it is still practised in its early form by native medicine men. Trepanation as performed by man in prehistoric and early historic times shows an astonishing degree of technical skill. And certainly the number of survivals of this operation testify to the competence of the early surgeons. For a long time medical science doubted the existence of healed prehistoric trepanations, since eighteenth and nineteenth century surgeons of the pre-antiseptic era rejected this procedure owing to the almost one hundred per cent mortality (Schröder, 1957). However, as evidence of trepanation appeared in the South Sea Islands and in North Africa, these doubts were gradually removed. According to Rytel (1962) the first reference to trepanation dates from 1849 (Atlas de Morton, Cranea Americana). Bartucz (1964) claims that Dr. E. Kovaces of Hungary was the first to describe in 1853 an actual trepanation found at Vereb. Another of the earliest to be recognized as such was noted by E.G. Squier on a skull from Cuzco during his tour of 1863-65 through Peru (Stewart, 1958). He consulted Paul Broca, the noted French physical anthropologist of the time whose interest led to the recognition of Neolithic trepanations in France. And thus gradually more skulls came to light showing this early surgical interference. The realization that this practice has survived until the present day has greatly increased our knowledge of this operation. The most important contributions on this subject are the study by Guiard (1930), the survey of European trepanations by Piggott (1940) and the more recent general review by Stewart (1958). This particular account will deal with the prehistoric and early historic aspects of trepanation and note certain of its mediaeval features.

A summary of the distribution of the various sites so far found in the world is given below together with the names of some of the main authors. The list is not fully comprehensive since the literature is rather scattered and new discoveries are frequent but it does indicate how wide spread the practice was. In each case the name of the country is followed by the number of sites found and the authors referred to. With regard to ceratin countries, although no actual case of trepanation has as yet come to light, there is strong presumptive evidence from the literature that it was practised. .

Here only the main outlines will be given together with certain additional information that has become available in recent years. Moodie considers that the earliest European trepanations occurred some ten thousand years ago and Forgue (1938) too places the beginnings at the end of the Palaeolithic period. All these estimates, however, are hypothetical. It has been accepted by Broca, Lucas-Championnière (1878), Horsley (1888), Ruffer, Guiard, Parry (1923), Piggott and Oakley et al. That this operation was practised during the Neolithic age. Piggott and Oakley et al. State that trepanation was performed occasionally by early Danubians (c. 3000 B.C.) and frequently by "battleaxe" people who constructed the chambered tombs in the Seine-Oise-Marne area of France (c. 2000 B.C.). So many skulls showing this trait were discovered in these tombs that it is probable that the operation had some ritual significance (Oakley et al). I t seems that circa, 1900 to 1500 B.C., the south of France was a major centre for trepanation (Sudhoff, 1929; Stewart). Examples of this practice have also been reported from many regions of Neolithic Europe, and in particular, Denmark, England, Germany, Italy, USSR, the Balkans have revealed quite a large number of skulls. In Europe trepanned skulls became rare after the Neolithic era, partly because in the later Bronze age and La Tène period the dead were mostly cremated (Regnault, 1936). Nevertheless a few examples are available from France (Guiard), Scandinavia (Piggott), Germany (Brunn, Breitinger), Czechoslovakia (Matiegka), Hungary (Bartucz), Rumania (Russu and Bologa), Bulgaria (Boev), USSR (Bobin) and other countries. The Iron Age, early Historic, Greek, Roman and Mediaeval times all indicate that trepanation continued to be performed in Europe. This is known from actual specimens of those days, and from the relevant literature of the later period. Mediaeval evidence comes from England (McKenzie, Parry, Brothwell), Ireland (Martin, Fleetwood), France (Piggott), Germany (Brunn, Karolyi), Italy (Castiglioni, 1941), Czechoslovakia (Piggott), Hungary (Boev), Rumania (Russu and Bologa), Bulgaria (Boev) and other areas. According to Rytel, however, the frequency of this operation never reached the proportions nor the universality during Mediaeval times that it enjoyed in the Neolithic age. To this one has to add that skeletons of the former period unfortunately have aroused less interest than those of older burials and thus our knowledge in this respect is rather scanty. In Greece, Hippocrates (c. 460 to 355 B.C.), advises trepanation for wounds of the head in one of his six treatises of his surgical classic (Littré). The account is detailed and meticulous and shows some experience, and although little or nothing is known of any actual specimens it is highly likely that this operation must have been performed fairly often. Roman examples of this surgical interference are known from Gaul and also from Trier in Germany (Piggott). And from Rome we have the account by Celsus (c. 25 B.C. to 37 A.D. ) of a method of operation which became standard in the surgical books of the Middle Ages. This apparently was adopted later by the Arabs. Celsus, whose method differed from that of prehistoric times, advises trepanation for head wounds and gives careful and precise instructions on methodology in his treatise De medicina (Spencer, 1948), and part of his De artibus, written between 25 and 35 A.D. Although Spencer believes that Celsus was a medical practitioner, Castiglioni (1941) considers that he was neither a physician nor a surgeon but a compiler from the works of others. Which ever he was, his text undoubtedly influenced the surgical world for many centuries. Much later Rogerius Frugardi (c. 1170 to 1200 A.D.), otherwise known as Roger of Salerno, one of the greatest of the Salernitan surgeons, produced his text in which he deals at length with wounds of the head and brain, even giving the differential diagnosis of injuries of the skull and indications for trepanation (Castiglioni). However, his method was not dissimilar from that of Celsus. From Ireland several interesting examples are available. A trepanned skull of a thirteen-year-old child, probably early Christian, was recovered from Collierstown in Co. Meath (Martin, 1935). Two further trepanations each of late Mediaeval date, one from Ballinlough (Co. Laois) and the other from Maganey Lower (Co. Kildare), were found during recent excavations. A fourth specimen was discovered in a stone-lined grave at the Abbey of Nendrum on Mahee Island in Strangford Lough (Martin). The abbey was destroyed in 974 A.D. by fire. It is highly likely that in those days "major surgery" was performed in monastic institutions (Fleetwood, 1951). Legend has it that Cennfaeladh, whose skull was fractured by a blow from a sword during the battle of Moyrath in Co. Down (637 A.D. ), was operated upon by St. Bricin, the Abbot of Tuaim Drecain, an accomplished surgeon and scholar (Fleetwood). In Yugoslavia, especially the south-western part, and also in northern Albania there is a long history of the practice of trepanation which persisted as late as the nineteenth century (Giot and Desse, Boev). The folklore of this region is rich in accounts of these operations (Leskin, 1919). Thus, the story is told of the physician who was secretly watched by his apprentice as he trepanned the forehead of the daughter of the Czar and extracted a beetle from her brain. Outside Europe and apart from South America, the evidence of examples and historical accounts is more scant. This may be due to the fact that fewer exhumations have been carried out in these parts and further excavations may reveal more information. In Asia the examples from Palestine are of some interest. There the oldest trepanation found so far comes from Jericho (Oakley et al.) and dates to the Bronze Age (c. 2000 B.C. ). Risdon who excavated Tell Duweir (Lachish) discovered three Iron Age (c. 8th cent. B.C. ) skulls, which were reported on by Parry and Starkey (1936). Giles (1953) reported a further case of trepanation belonging to that period. From Roman Syria there is, for instance, indirect evidence by way of China (Needham, 1954). Ouyang Hsiu and Sung Chhi in their Hsin Thang Shu (New history of the T ang dynasty) in 1061 A.D. state that the people of Ta-Chhin (Roman Syria) have physicians who can cure blindness by opening the brain and removing worms. Needham believes this to be "the solitary instance of any attention consciously paid in Chinese writing to early Western medical science." Going further east one finds that both in ancient and recent times this type of skull surgery was performed in the region comprising present day eastern Afghanistan, northern Pakistan and Kashmir (Giot and Desse 1950; Roney, 1954). Although actual specimens of the earlier periods are rare, the lore of trepanation was very much current around c. 400 A.D. in that part of the world (Müller, 1959) and in the Tibetan region (Jungbauer, 1923). One of the accounts mentions that in ancient times students went to Takkasil_ (Greek Taxila) in the north-western part of the Indian subcontinent to learn the arts and sciences. At that time a famous teacher _treya, king of the physicians, lived there, to whom prince J_vaka went as an apprentice so as to learn the art of opening skulls. He watches his master extract a worm from the brain of a patient. And later when J_vaka returns to his own country he trepans, using an "opening instrument" and thus removes centipedes. Legend has it that he later became the medical adviser to Buddha. J_vaka is certainly famous in old Buddhist tests and in folklore. It is also known that these stories were carried eastward by Buddhist missions. However, in China these tales received certain additions, such as the use of acupuncture and feeling the pulse, which were not practised in ancient India. Thus the folklore became Chinese by adaptation. On the other hand the Tibetans took over the original stories and translated them without alteration. Müller feels that these folktales, and there are many, are based on fact and that trepanation must have been practised in this in this area. So far the main part of China has not revealed any trepanations (Woo, 1964), though a few have been found in her peripheral provinces. Thus there is evidence from Tibet (Boev 1959), quite apart from the folklore traditions (Jungbauer 1923). Here medical knowledge probably came into the region through Kashmir. Tallgren (1936) reports a skull with an occipital opening from Oglakty in southern Siberia which was found in a cemetery dating to the Han dynasty (202 B.C. to 220 A.D. ). And Montandon (1926) found another example from the Far East in a museum in Vladivostok; however, date and site are doubtful. These two regions at one time, of course, belonged to the northern part of the Chinese empire. Although there are only these few skulls, classical Chinese literature does mention trepanation. In ancient times (c. 2700 to 1100 B.C. ) there is supposed to have existed a physician Yü Fu who is alleged to have been able to expose the brain (Wong and Wu, 1936). However, he is a very ancient legendary character associated with surgery and, according to Needham, one of the interlocutors in the great classic of medicine Huang Ti Nei Ching, Su Wên (c. 2nd cent. B.C. ). Wong and Wu also mention Hua Tho (c. 130 to 220 A.D. ), the famous surgeon and discoverer of the use of anaesthetics. Legend has it that he offered to cure the headaches of the Wei emperor Tshao by opening the skull, an offer which was declined. Another account supposes that Hua Tho suggested trepanation to a famous warrior who thought the surgeon wanted to murder him and therefore had him beheaded. Reference already has been made to the Buddhist missions. However, for the more detailed information on classical China given below, the author is indebted to Dr. Joseph Needham F.R.S. who kindly made this available. The Pao Phu Tzu book, by the famous physician and alchemist Ko Hung, written circa 300 A.D. , is quoted by late scientific encyclopaedias as saying that Thai Tshang Kung (Shunyü I 205 to 150 B.C. ) "used to cut open skulls of patients and arrange their brains in order." Here it is rather difficult to trace the original passage. Although there is some uncertainty, it s probable that the trepanation account of Hua Tho occurs in the Yuan period novel San Kuo Chih Yen I (The three kingdoms story) by Lo Kuan-Chung (c. 1364 A.D. ). Nor is it known whether there are any more ancient accounts of this operation nearer the time of Hua Tho himself among the unofficial literature of the San Kuo or Liu Chhao periods. In 1040 A.D. there was published a history of medicine entitled Li Tai Ming I Meng Chhiu (Brief lives of the famous physicians of all ages) by Chou Shou-Chung. He quoted two descriptions of trepanations from an earlier book, the Yü Thang Hsien Hua (Leisurely conversations of academicians) written between 960 and 1040 A.D., i.e., during the Sung dynasty. This was also quoted in a later florilegium, the Lei Shuo by Wang Jen-Yü in 1136. The first account is of a metal worker who performed an operation for the extraction of a worm from a patient previously pronounced incurable. The other tells of a Taoist adept who was condemned to death for alleged arson, but who wished to demonstrate his skill at surgery before dying; a leper was therefore fetched, and the adept opened his skull and removed a cupfull of worms or parasites. During this period too, the Hsin Thang Shu, quoted above, was published and this mentions the surgical practices in Roman Syria. All this seems to indicate that trepanation was probably practised during tenth and fourteenth centuries in China. Later in 1366 the Cho Kêng Lu (Talks while the plough is resting) by Thao Tsung-I appeared, in which it is said that Arabic physicians, of which there had been many in China since T ang times, could open the skull and extract worms. Thus we have the classical literary references, but no actual skulls showing this operation. It is therefore conceivable that in time the skeletal evidence will be forthcoming. The Ainu people in Hokkaido, northern Japan, are also supposed to have practised trepanation (Boev, 1959). Certainly Rytel (1962) mentions five Ainu skulls showing resection of the foramen magnum and of the alveolar process, and this evidence of surgical interference may indicate that other techniques, e.g., trepanation were not unknown. Turning to Africa, one finds that so far in Egypt only six trepanations have been found, although more Egyptian skulls have been examined than of any other population. Chronologically the excavations have revealed the following: the oldest find is from Sesebi, Sudan (Lisowski, 1954) and belongs to the XVIIIth to XIXth Dynasty (c. 1200 B.C. ), Batrawi (1935) reported one from Sakkara dating to the XXVth Dynasty (c. 600 B.C. ); a bilateral trepanation was found in Sakkara (Lisowski) of possibly Ptolemaic date (c. 323 to 30 B.C. (, a Meroitic skull (c. 50 to 200 A. D. ) was reported earlier by Batrawi. Ruffer (1918) mentions one of circa 200 A.D. found near Alexandria, and Elliot Smith and Wood Jones (1910) described a Byzantine (395 to 638 A.D. ) trepanation from Hesa near Aswan re-examined and also reported by Parry. In mentioning the above examples one has to consider the possible connexions between the practice of trepanation in Egypt and that practised in neighbouring regions. The Egyptian specimens roughly fall into three historic periods. To the first of these belong the Sesebi and the earlier Sakkara individuals who were more or less contemporary of the Palestinian trepanations. It is difficult, however, to relate these two centres since they are some eight hundred miles apart. The later Sakkara specimen, which dates to the Ptolemaic period, may be an example of the influence of Greek surgery. The other trepanations belonging to the period 50 to 600 A.D. are probably due to Roman influence. From North Africa there is evidence that the technique this type of skull surgery has survived to the present day. Sudhoff (1929) gave reports from Libya, Hilton-Simpson (1913) and Forgue (1938) described the operative procedure from the Aures mountains in Algeria, and Oakley et al. Gave a contemporary account of trepanation among the Tibu in Tebesti (Sahara). It might be argued that here one finds a degenerate form of Greek or classical surgery, though it is more likely that this practice dates to Islamic times. In Kenya too trepanation is still performed to this day (Sood, 1960; Margetts, 1962) where it may well have been introduced by the Arabs. It is appropriate at this juncture when dealing with Asia and Africa to mention trepanation in the old Islamic world, a period during which their science and medicine flourished from the western borders of China right across Persia to Egypt, North Africa and Spain. It appears that the method of operation described by Celsus was adopted by the Arabs, for it is advocated in the treatises of the tenth to eleventh century surgeons Ali-abbas and Abdul-kassim (Piggott, 1940). In this connexion mention is made already that Thao Tsung-I wrote in 1366 of the skill of the Arabic physicians. In fact many of the latter had been in China since T ang times. With regard to South America the centre for trepanations was restricted largely to the central and southern parts of Peru and to the neighbouring part of Bolivia (Cabieses, 1957). It appears that more trepanned skulls have been found in this area than in all the rest of the world together (Stewart, 1958). According to Stewart the oldest specimens date to the period of c. fifth century B.C. to fifth century A.D. , although Rytel (1962) considers that the oldest evidence of trepanation in Peru dates to circa 3000 B.C. It is also known that the Indians of this particular region continued these operations into post-Columbian times (Bandelier, 1904), and even today the practice of trepanation is not unknown (Oakley et al.).

Since science and magic are in their early stages indistinguishable (Needham, 1954), it is difficult to differentiate between ritual or magical and therapeutic motives underlying the practice of trepanation. Dealing first with the performance of this operation in the living, one finds that various authors emphasize different aspects of the motivation. Broca (1876) decided that trepanations were performed for the relief of certain intracranial maladies and Horsley (1888) considered that all these surgical interferences were therapeutic. According to Lucas-Championnière (1912) the operation was done in order to cure a disease supposed to have its seat in the head or to remove splinters from a fractured skull---in the latter practicing cerebral decompression. Ruffer believed that Neolithic people may have trepanned for injuries, but as most of the operated skulls show no signs of trauma, headache was probably the chief indication. Lucas-Championnière also mentioned that "according to the theory usually accepted, the operation was first performed from time immemorial on sheep for the relief of staggers, and later man extended the application of the veterinary method to his species." However, Ruffer felt that this was pure speculation. Russu and Bologa (1961) also mention the practice of trepanation in connection with staggers in sheep, and how the shepherds in Rumania thereby removed the larva of the Multiceps multiceps since ancient times. Thus it could be that the accounts in folklore of the extraction of beetles (Yugoslavia) and centipedes (Tibet) from the brain in man might be based on the trepanation of sheep, and may not be so far fetched as they might seem at first sight. Moodie (1923), Piggott (1940), and Russu and Bologa consider that the majority of operations were performed as a definite surgical treatment, either to repair a fracture of the skull or to alleviate headache. Guiard (1930), Regnault (1936), Forgue (1938) and Thompson (1938) believe that in prehistoric times various intracranial diseases were ascribed to evil spirits and therefore cure was obtained by letting these out of the skull. And since these operations were often followed by improvement in the patient s condition, the primitive surgeons persisted with this surgical intervention (Forgue). Castiglioni (1941) considers that trepanation owes its origin to a demonic or magic concept more than to the idea of therapy. In view of the Peruvian evidence, Stewart believes that trepanations were mainly performed in cases of skull fracture, though he does not exclude other motives for this operation. However, Guiard considered that since the procedure was such a frequent custom among the pre-Inca and Inca inhabitants of Peru and Bolivia, it bordered on a cult. Oakley et al. who described a skull from Tarkhan with a parietal craniotomy and which also shows signs of otitis media and mastoid inflammation, believed that in this case the operation must have been undertaken for clinical reasons. More recently Rytel stated that the surgical indications were both therapeutic and superstitious. Owing to the large number of trepanned skulls found in the chambered tombs in the Seine-Oise-Marne region of France Oakley et al. feel that here the operation had some ritual significance, though they consider that in other geographic regions the indications may have been of a clinical nature. Our knowledge of prehistoric trepanation would be very poor indeed were it not for the fact that we know something about the practice of this operation in classical times and in the more recent past, and that it still is performed in widely separated parts of the world. In Hippocratic times medicine in Europe was no longer a branch of magic and religion but had begun to gain its own rightful place (Guthrie, 1958). Thus one finds that for wounds of the head Hippocrates advised early trepanation--- within three days for contusion of bone, and secondary trepanation for infectious accidents---before the fourteenth day in winter and before the seventh day in summer (Littré). In his writings Celsus also notes that for cranial injuries trepanation is indicated (Spencer). And later in mediaeval times Rogerius Frugardi gives the same advice (Castiglioni). At the beginning of the last century Cornish miners insisted on having their skulls opened following injuries to the head (Lucas-Championnière). As late as the nineteenth century trepanations were performed in south-western Yugoslavia and northern Albania (Russu and Bologa) in cases of skull trauma and in nervous and mental diseases; and in the case of a blood feud where a person was marked for revenge the latter could escape by voluntary submission to this operation. From Algeria (Hilton-Simpson) it is known that in certain cases of head injury, usually a fracture resulting from blows from sticks or stones, trepanation is indicated, however, this surgical procedure is more often performed in cases of persistent headache. In present day Kenya where this operation is still practised, the most common indication is headache (Sood). Crump (1901) noted that trepanation was performed in Melanesia not only in cases of headache, epilepsy and insanity, but also as an aid to longevity. Ford (1937) studying this operation in the same group of Pacific islands, says that it was used in cranial injuries due to warfare, and for headaches and in some children of three to five years of age women cut openings into the foreheads to ward off future trouble from trauma---possible an extension of surgical therapy to prophylaxis. And in Bolivia medicine-men still perform trepanation for head injuries (Oakley et al.). As a result of investigations among populations that still trepan Wölfel (1925) believes that injuries caused by blows and stone-slings are the main indications for trepanation. On the basis of Neolithic material in Denmark, Fischer-Møller (1936) comes to the same conclusions and goes on to observe that with the appearance of metallic weapons and helmets the neck proved to be a more vulnerable region for inflicting fatal injuries than the head. Russu and Bologa (1961) are of the opinion that the practice of trepanation may be related to the spread of the stone-sling and that only later on this surgical measure was used in other disease in which the presenting symptoms were similar to those following cranial trauma. The motive for posthumous trepanation was to obtain roundels of human skull bone (Dechelette, 1908). Apparently the object was to remove a piece of bone from the dead skull of one previously trepanned which included a bit of the healed rim from the earlier successful operation (Piggott). This type of trepanation was undertaken in prehistoric Europe and is practised in parts of Africa today (Oakley et al.). These roundels were usually of circular shape and often perforated and polished so as to be worn as a necklace. They had a superstitious significance and were used as charms, or amulets, or as a talisman to counter the demons (Broca, Regnault, Forgue). Even up to the Middle Ages it was supposed that powdered cranial bones possessed curative powers while roundels were worn as late as Gallic times (Ruffer). Thus one may summarize the motives for trepanation in the living and the dead as follows. In the living the indications can be considered under three headings: Therapeutic, certainly in Hippocratic and later times: for head injuries such as fractures, especially depressed fractures, scalp wounds with or without an inflammatory process, concussion; and possibly in cases of lesions of a syphilitic nature in Peru (Rytel). Magico-therapeutic, where in a sense the cause was considered to be evil spirits which had to be let out and the effect could be "therapeutic" at times: headaches, vertigo, neuralgia, coma, delirium, intracranial vascular catastrophies, meningitis, convulsions, epilepsy, intracranial tumours, mental diseases. And prophylactically to ward off trouble such as head injuries and to promote longevity in Melanesia (Crump). Magico-ritual: e.g., as a ritual act in central France (Oakley et al.); in cases of feuds (Russu and Bologa). The indications for post-mortem trepanation seem to have been in order to secure roundels for amulets.

In general craniotomies were performed on the left side (Guiard, Forgue, Piggott, Stewart). The reason for this (Russu and Bologa) was that traumatic lesions of the skull doe to blows occurred in the majority of cases on this side since the adversary, usually right handed, was opposite the victim. Most authorities (Lucas-Championnière, Ruffer, Moodie, Guiard, Forgue, Piggott) consider that in Europe the parietal bone was the most frequently trepanned skull element, followed by the frontal, occipital and rarely the temporal bones. Although Piggott points out that in a high proportion of Czechoslovak trepanations the frontal region was involved. Ruffer suggests that the high frequency of parietal selection was because this region was most easily accessible to the operator. The latter, squatting in front or behind the patient, held the head with his left arm or fixed it between his knees and operated with his right hand. It is of course well known that traumatic subdural haemorrhages can occur following blows in the parietal region. The first detailed side and site analysis was made by Stewart (1958) who, studying a series of 112 trepanations from Peru, found that 48.2 per cent had been operated on the left side, 29.5 per cent on the right, and 22.3 per cent in the median line. Of these, 53.6 per cent had been trepanned in the frontal region, 33.0 per cent in the parietal and 13.4 per cent in the occipital area. The frontal region also was the elected site for prophylactic trepanation in Melanesian infants (Ford). Lucas-Championnière (1912) claimed that the sagittal suture was carefully avoided, implying that the primitive surgeons had some idea of the underlying anatomy of the superior sagittal sinus. Hilton-Simpson (1913) went so far as to state that sutures were never involved in trepanations. He based his views on his studies of the practice of craniotomy in the Aures mountains in Algeria, where the medicine-man observed two rules: that the opening must not involve the sutures and the dura mater must remain intact. That these views are not correct can be seen from observation of trepanned material in which the craniotomies have cut across the sagittal and other sutures and from the work of Stewart who has clearly shown that the sagittal, coronal and lambdoid sutures were quite often involved. Guiard and Maxia and Cossu also stated that the sutures were never respected. For anaesthetic purposes the use of alcohol was not unknown in many parts of the world. Guiard states that the Serbians used grape wine and the people Uganda palm wine, while the ancient Egyptians according to Parry and Sudhoff knew in addition the uses of opium. Similarly the Inca made use of alcohol as well as various preparations from the coca plant (Rytel). Oakley et al. report that for present day trepanations in Bolivia the medicine-men use chicha, a local drink, as an anaesthetic. However, it must not be forgotten that in cases of skull injury the patient often was unconscious thus facilitating sugical intervention, a fact that applied to most cases in Melanesia (Ford). On the other hand the Kabyles according to Hilton-Simpson never use anaesthetics when trepanning. The earlier trepanations were performed most likely with the aid of instruments made of flaked stone, especially flint, of obsidian and of bone (Ruffer, Parry, Thompson, Stewart, Rytel). Probably other materials such as wood were employed also as aids. Later, instruments made of hardened copper were used which were fashioned with a rough edge and shaped like a wedge so as to prevent sudden penetration through the skull bone (Thompson). Russu and Bologa (1961) describe a saw of the La Tène period, discovered in Rumania, which they think was a trepanation instrument. This was found together with a cremation and various ceramics typical of a Celtic burial dating to circa second century B.C. The interment may have been that of a medicine-man. This well preserved saw is 11 cm long, has a half-moon-shaped blade and continues into a swan-neck-shaped stem which ends in a straight handle. The whole instrument is made out of one piece of iron, whose blade is thinner towards the serrated cutting edge and thicker towards the base. This wedge-shape would prevent the saw from cutting deeper than 5 mm to 7 mm into bone. Sudhoff and Ebert (1913) described a number of surgical instruments of the La Tène period which were found in Hungary. One of these is a bone saw while the others are retractors and elevators. The two authors believed that these were amputation instruments. However, Holländer (1915) who re-examined them considered that they were much too fine for such a brutal operation as amputation. He had the saw reconstructed and found that it could only be used on the skull since its blade was wedge-shaped thus limiting the depth of the saw cut. From this Holländer concluded that the instrument must have been employed in trepanning. The trepan was already in use at the time of Hippocrates and was held either between the palms and rotated by rubbing the hands together or rotated by a cross-piece and thong (Littré). Celsus described various trepans, a meningophylax for holding back the meninges when the border of the trepanned opening is manipulated and an instrument for removing the bone fragments following craniotomy (Spencer). Instruments such as these were excavated at Pompeïï (Castiglioni). A more complete outline of the historic evolution of the various trepans from Hippocratic to recent times is given by Thompson (1938). In Algeria a variety of instruments such as scalpers, retractors, drills, saws, screws and elevators, were used (Hilton-Simpson) which will be mentioned when dealing with the methods of craniotomy. Sood has described to me the retractors, saws and elevators, mostly made of flattened nails, still used by medicine-men in Kenya. In Melanesia, the sharp edges of shells were utilized in addition to obsidian for making the skull openings (Crump). Ford further reported that shark s teeth as well as broken bottles and razors were used on these islands in more recent times. In South America during the classical Inca period a special T-shaped knife or "tumi" was employed for trepanation (Cabieses). This instrument has been adopted by the Peruvian Academy of Surgery as their emblem. According to the literature (Littré, Broca, Lucas-Championnière, Ruffer, Parry, Guiard, Forgue, Piggott, Spencer, Stewart, Rytel) several methods of operation have been described, some of which are shown in Figure 1. 1. The scraping technique consists in removing the required area of bone by gradually scraping away, first the lamina externa and diploë, and then with considerable care the lamina interna to expose the dura mater. The resulting opening has of necessity widely bevelled edges and the removed part is in powder form Fig. 1, Number 1). This was probably one of the most common methods used, surviving even into the Italian Renaissance period (Piggott). In Rumania this procedure was practised only in mediaeval times (Russu and Bologa). For illustrative purposes an Egyptian trepanation is shown (Fig. 2). 2. The grooving method, in which a series of curved grooves are drawn and redrawn on the skull with a sharp instrument, until the bone between the grooves becomes loose and can be removed (Fig. 1, number 2). Probably this was the procedure by which roundels were obtained (Fig. 3). This technique was also very frequently used in many parts of the world and is still performed at the present day in Kenya (Sood). Russu and Bologa state that this was the method of choice in prehistoric times in Rumania. In general the orifice in the external lamina is larger than the one in the internal lamina, thus giving a rather bevelled appearance. Ruffer believed that this was always the case, but according to Guiard certain trepanations whose diameter does not surpass 2 cms present practically perpendicular borders to the plane of the surface of the skull and are always circular. 3. In the boring-and-cutting technique the bone is perforated by a circle of closely adjoining perforations extending to the internal lamina, which are then connected by cuts with a sharp instrument, the latter more or less completely obliterating the serrated border. Finally the freed fragment is levered out (Fig. 1, number 3). Lucas-Championnière considered that this type of operation was used in prehistoric times and based his supposition entirely on a single skull from Peru. On the other hand Stewart believes that this method probably was not practised outside Peru and there only occasionally. However, the boring-and cutting procedure was described by Celsus in Roman times (Spencer). He advised in cases of more extensive cranial injuries that a hole is drilled with a trepan at the junction of the diseased and sound bone, close to this a second and a third, until the whole area is ringed by these perforations. Then a chisel is driven through from one hole to the next and so the intervening bone is removed. This surgical operation was later adopted by the Arabs and became standard in the Middle Ages. Thus Rogerius Frugardi recommended that in cases of depressed fractures a number of perforations are made around the affected area with a trepan and then the fractured bone is slowly raised taking care not to damage the underlying meninges. A variation or degeneration of the boring-and-cutting operation existed until recently in North Africa. Hilton-Simpson, studying the practice of trepanation among the Kabyles in Algeria, found that the procedure consisted in removing a circular portion of the scalp with a cylindrical iron punch that had been heated red-hot. Retractors were used to draw away the scalp, and next a small opening was cut in the skull by the confined use of a small drill which was spun between the palms of the hands. With a saw a small incision was made and care taken not to injure the dura mater. Each succeeding day the sawing process was repeated until the piece of bone to be removed was loose, this could take anything from fifteen to twenty days. Finally the part sawn away was lifted from the skull by an elevator. 4. The use of a trepan to remove a disc of bone from the skull (this method is not illustrated here). This instrument seems to have been in current use in ancient Greece and at a later period in Rome. Hippocrates advised its use for a variety of head injuries, and stated that the craniotomy should be so performed that the trepan does not penetrate too quickly to the dura mater and that the cut fragment should be allowed to detach itself. During the operation the instrument was to be plunged frequently into cold water to avoid overheating the bone (Littré). According to Spencer, Celsus recommended the "crown trepan" or modiolus for treating smaller cranial injuries. A modiolus is a hollow cylindrical iron instrument whose lower edges are serrated and down its centre runs a fixed pin which is itself surrounded by an inner disc. As mentioned previously, for more extensive head trauma Celsus suggested the boring-and-cutting treatment. A method in which four straight incisions are made, intersecting at right angles and the in-between fragment is removed (Fig. 1, number 4). This procedure was commonly adopted in Peru, though isolated finds of this type occur also in other parts of the world. Terrier and Péraire (1895) described such an example from Lizières in France dating to the Neolithic period. As already mentioned, from Palestine Parry and Starkey reported on two Iron Age skulls found by Risdon, and Giles described a further discovery from there showing an attempt at such an operation. Forgue notes that this type of procedure was also carried out by the Kabyles in Algeria; and according to Sood one skull from Kenya shows an attempt at such an intervention. Rytel (1962) believes there has been what one might call an evolutionary trend in the methodology of trepanation. He considers that the earliest operative procedure began with rectilinear cranial incisions resulting in rectangular openings. This form of craniotomy then proceeded through the polygonal to the circular type of orifice. It was followed by a method of scraping away the bone with a rotatory technique thus making the hole lenticular, oval or circular in shape. And finally the practice evolved to the boring-and-cutting method described above and recommended by Celsus and adopted later by mediaeval surgeons. Various attempts have been made to assess the time it took to perform a trepanation. Broca, repeating the procedure experimentally on adult post-mortem skulls, found that it took anything from thirty minutes to one hour to perform the operation. About the same length of time was also taken by present-day Peruvian surgeons when trepanning living heads with primitive implements under aseptic conditions (Cabieses). Lucas-Championnière found that the grooving technique took more than one hour to perform and therefore favoured the boring-and-cutting procedure as the method of choice in pre-historic times. At the other extreme is the method used by the Kabyles who, cutting little by little each day, could take up to twenty days to complete the operation. The diameter of the trepanations varies from that of a small drill hole, a few millimeters across, to quite large openings of 82 mm x 62 mm (Regnault) or larger (Boev), thought they are on the average between 30 mm to 45 mm across, one axis being longer than the other. Thus their shapes are frequently oval (in these cases the longer diameter tends to be anteroposterior) or triangular, the smaller openings tending to be round. Quandrangular orifices are produced by four right-angled intersecting incisions. The majority of trepanned specimens show single openings. The skull with the highest number of trepanations so far discovered was reported by Oakley et al. And came from Cuzco in Peru. This has seven healed openings. Examples with two to three or even as many as five craniotomies have been found in various parts of the world. Brief mention must now be made of the postoperative treatment of trepanations. Although Forgue (1938) inferred from analogy with present day practices that the early medicine-men used powdered charcoal, hot sand, cedar wood resin or even cinders from sacrifices for their dressings, this can only be conjecture. With regard to the actual trepanned opening Thompson (1938) considers that this was closed with a plate made from shell or other substances and that in some cases even a lead or other metal (Rytel) diaphragm was used, though Stewart believes that there is no good evidence of this practice. For haemostasis the Inca are reputed to have used extracts from the Ratania root and Pumacbuca shrub of the Andes which are rich in tannic acid (Rytel). Celsus recommended the use of vinegar to stop bleeding (Spencer). Although hardly anything is known of the ancient postoperative treatment of trepanations information on actual practices is available from Algeria and Melanesia. Hilton-Simpson (1913) reports that for dressings the Kabyles used daily applications of heated honey and butter and the stem of leaves belonging to the species of labiatae. This dressing was continued sometimes for as long as a month. Detailed accounts from Melanesia are given by Crump and Ford. The trepanned opening was washed with water of the unripe coconut, plugged with a piece of bark cloth and then covered with part of the inner bark or leaf of the banana palm which had been held over a fire. Then the skin flaps were replaced and stitched with a needle, the latter being made in some cases from the wing bone of a flying fox. And finally the head was bound with dried strips of banana stalks.

Schröder (1957), dealing with the healing of trepanations, found that the endosteal callus produced by the diploë is small in amount and that the periosteal callus of the epicranium grows only very little. Thus the osseous regeneration is rather sparse. Apart from a few osteophytes the reaction at the margins of the opening only amounts to a very few millimeters. Similarly Pritchard (1946) has been able to show experimentally that in skull fractures in rats new bone formation is slight and confined to the fracture site when healing is uncomplicated by widespread haemorrhage or infection. In the latter event there is widespread subpericranial new bone formation with bone resorption. The immediate bony area around the trepanation is radiologically more transparent from the periphery to the margin of the hole (Schröder). The same author warns that radiological differentiation between post-mortem and intro-vitam craniotomy is practically impossible and that Guiard went too far in his claims. The latter believed that he could differentiate radiologically whether an individual had survived the operation for several weeks, months or at least one year. The main diagnosis of healing at the margins is the macroscopic observation of the spongy diploë, the presence of occasional osteophytes and the character of the edges of the external and internal lamina. Healing is indicated by a closed or closing diploë and relatively smooth borders. The region around some trepanations shows a circular area of osteitis surrounding the opening (Stewart, 1956). This takes the form of an osteoporotic pitting which can be seen as a halo around the craniotomy. The borders of the osteitis correspond to the edges of the orifice made in the scalp preparatory to trepanning. According to Stewart the halo indicates that the individual had lived after the operation and that some degree of infection had set in afterwards. Although it has been suggested that this is a chemical osteitis resulting from applications of medicaments to the wound, Stewart believes it is more likely a septic osteitis. Thus when making a detailed study of this operation it is necessary to examine carefully the margins of the trepanation and the surrounding area of bone. The survival rate following craniotomy was remarkably high as evidenced by skulls showing healed openings. Stewart, examining 214 trepanned skulls from Peru belonging to three collections in the United States, found that 55.6 per cent show complete healing, 16.4 per cent early stages of healing and 28 per cent no healing. Rytel too attests to the surgical skill of the Peruvians, of 400 trepanations 250 (62.5 per cent) showed healing. When examining the figures of Russu and Bologa one finds that of the Neolithic material two survived, one lived for a while and four died, whilst of the Mediaeval examples two survived and one died. The figures of Brunn show that thirteen survived and only three died, his material dates from the Neolithic to circa sixth century A.D. And comes from central Germany. And according to Crump the mortality rate was about 20 per cent in New Britain, in fact many deaths resulted from the original injuries rather than from the operation. The remarkable skull from Peru with seven healed trepanations and reported by Oakley et al. Is proof of the skill of the early surgeons. In Kenya quite a number of individuals walk around having recovered from their second or even third trepanation (Sood). The cause of death was very often the original injury. Complications from the actual operation such as haemorrhage, brain damage, sever shock, sepsis and meningitis further contributed to the mortality rate.

Broca erroneously believed that the early surgeons trepanned mainly children and adolescents and he considered that this was due to the frequency of juvenile convulsions. However, the discoveries since have disproved this idea. Certainly children were trepanned and evidence for this is available from Peru (Stewart) and from Melanesia (Ford) where it was also practised prophylactically as cited above. According to Guiard the practice of trepanation coincided with the presence of a dominant brachycephalic element but was absent from countries where a dolichocephalic population predominated. However, a careful examination of the material shows that this operation was also practised in those parts of the world where dolichocephalic and mesocephalic peoples were the dominent element. In connexion with trepanation in man mention must also be made of the practice in sheep. Although Ruffer states that is was done for the relief of staggers, he felt that the theory of the veterinary origin of trepanation in man was purely hypothetical. In Rumania craniotomies were performed on sheep by shepherds since ancient times (Russu and Bologa) for the treatment of staggers. This disease which manifests itself by swaying and an uncertain gait is caused by Coenurus cerebralis, the larva of the Taenia coenurus (Multiceps multiceps) found in the brain of sheep, goats and other ruminants. According to the authors the skull is opened with a knife made of soft iron and the larvae are removed. However, only a few animals recover.

It is a fact that many unusual openings have been reported as true trepanations, although originating in devious ways. Thus the differential diagnosis is of some importance. Admirable attention has already been drawn to this in the exhaustive studies of Guiard and of Giot and Desse. Openings in the skull may be produced by infective processes such as tuberculosis, syphilitic gummata, localized osteomyelitis, or mycoses or as a result of tumours like epidermoid and dermoid cysts, myelomas, secondary carcinomas and sarcomas. Traumatic conditions at birth or during early childhood may also appear as trepanned holes. Bircher (1908) has shown that some so-called trepanations in adults are the results of the use of certain weapons peculiar to the Middle Ages. Brothwell has also drawn attention to the action of beetles and porcupines or other rodents that can produce extensive destruction of bone. Similarly he points out that artefact openings may be due to a pick or other tool used during disinterment, or the cause may be a continual pressure of a sharp stone, or selective erosion of one region of the skull, all or which can give rise to a hole that may bear strong resemblances to a trepanation. There are, however, three conditions that may give rise to mistakes in diagnosis since they occur in association with the parietal bone. These are enlarged parietal foramina, "Fenestrae parietalis symmetricae," and bilateral osteoporosis ("thinning") of the parietal bone. Normally the parietal foramina are very small, but occasionally they may have a diameter or two or three centimetres (Broca, 1875; Spee, 1896; Le Double, 1903), this enlargement being due to a defect in development. According to Spee these sort of foramina are more frequent in males and on the right side. Apart from size, their site and number may vary too (Le Double), and the anomaly may also be hereditary (Weber and Schwarz, 1935). Cave (1928) has even reported two cases with bilaterally enlarged parietal foramina. These types can be easily mistaken for a trepanation. An example of this error is an Egyptian female skull of Roman date (c. 200 A.D. ) found at Shurafa, Lower Egypt, with an enlarged right parietal foramen. This was reported by Derry (1914) as due to a dermoid cyst and considered as a trepanation by Horsley (1888). With regard to "Fenestrae parietalis symmetricae" also known as "Catlin mark" (After an American family in whom this character occurs) quite a different situation obtains. Goldsmith (1941), who has also reviewed the literature, considers that this bilateral anomaly and the normal but highly variable paired parietal foramina are not one and the same thing, but have different origins though anatomically they may fuse. In fact he knows of skulls that show both the fenestrae and the enlarged parietal foramina. The fenestrae are oval to round in adults and have definite "healed" edges, and in the living head they are covered with skin and dura mater, but are clearly demonstrable radiologically. There seems no doubt that this condition may arise as a sport or a mutation. According to Goldsmith a survey of various collections of human skulls shows that the trait is not uncommon and that many supposed cases of trepanation really represent this hereditary anomaly. The third condition which often gives rise to mistaken diagnosis is that of osteoporosis of the parietal bones. Although considered elsewhere in this book by Lodge (pp.405) it seems worth considering the subject a little here since osteoporosis is found fairly frequently in ancient skeletons (Eve, 1889; Elliot Smith, 1906) and can so easily be confused with healed trephine openings. This manifests itself as a rarefaction of bone, due to diminished osteoblastic or increase osteoclastic activity, which results in a reduction in the amount of total bony substance without evidence of mineral deficiency (Schmidt, 1937; Grollman, 1963). Osteoporosis generally commences in those parts of the skeleton that are subjected to the greatest stress, e.g., the thoracic region of the vertebral column. However, ultimately it will involve other skeletal parts and even the skull. There is increased porosity and a decrease in the thickness of the cortex of the bone. Aetiologically the imbalance between osteoblastic activity and osteoclastic dissolution is the consequence of a variety of causes which will be mentioned briefly. (1) Nutritional deficiencies in vitamins, calcium and proteins will result in rarefaction of bone. Thus for example a lack of calcium may be demonstrated in individuals manifesting so called idiopathic, senile or postmenopausal osteoporosis (Grollman). Already long ago Lobstein (1834) and later Paget (1870) and Ferré (1876) suggested that osteoporosis of the parietal bones was due to senile atrophy. (2) Endocrine disturbances such as hyperthyroidism, hyperparathyroidism, acromegaly and Cushing s syndrome are often accompained by osteoporosis (Grollman). (3) Congenital deficiency of osteoblastic function may also give rise ro rarefaction of bone. This may also be hereditary as pointed out by Shepherd (1892) and Roger and Schachter (1941). (4) Reduced mechanical stress according to Grollman can also be a cause of osteoporosis. The characteristic location of osteoporosis in the skull is in the parietal bones between the sagittal suture and the parietal eminence on both sides. In some cases the temporal, or frontal, or occipital bones may be involved bilaterally. The parietal osteoporosis forms a depression which is roughly triangular, quadrilateral, or trough-like in shape (Greig, 1926). There is no sharp line of demarcation between the depression and the adjacent normal external lamina and therefore the margins shelve gradually into the thinned area. Radiologically there is a general reduction in the density of the bone which becomes thin. Greig and Durward (1929) have drawn attention to the fact that the parietal foramina are not involved since the thinning process leaves a margin of bone about one centimetre in width. With regard to the incidence of osteoporosis of the parietal bones, Camp and Nash (1944) found that one in two hundred and seventeen heads showed this trait on radiological examination, with a mean age of over fifty years. And Humphry (1874) found that this abnormality is not confined to the human species only but is also present in the orang-utan. The error in diagnosing a trepanation is due to the fact that in parietal osteoporosis the normal bone shelves into a thinned area which is extremely fragile. The latter then breaks down post-mortem for one reason or another and leaves an opening with a more or less bevelled circumference and apparently healed. This type is exemplified by an Egyptian skull of the twelfth Dynasty (c. 1900 B.C. ) and reported as a trepanation by Breasted (1930), its true condition was later diagnosed by Stewart (1952).

This mutilation, practised in Neolithic times, is in the form of a T or L and consists of a series of cauterizations of the skin affecting the periosteum (Manouvrier, 1895). One line runs antroposterior following the sagittal suture and the other is at right angles and joins the two parietal eminences. In the majority of cases the operation was performed on women. As Stewart rightly points out, any damage to the scalp leading to a loss of blood supply to the bony vault may be followed by osteitis which can result in scarring of the bone. It is known from surviving medical records that in Mediaeval Europe thermal and chemical cauterization was applied to the head in cases of epilepsy and dementia (MacCurdy, 1905). Piggott remarks that there may have been some connexion between these mutilations and the practice of the tonsure. One might even ask the question whether this might not have been a form of baptism or branding. The examples of sincipital mutilation are few in comparison to the number of trepanations. According to Manouvrier (1895) this practice was restricted to a district north of present day Paris between the Seine and Oise. From Hungary Bartucz (1964) has reported one case and Zaborowski (1897) mentions that to the west of the Caspian Sea, the inhabitants of Dagestan practised a form of cauterization of the vertex of the head, similar to the sincipital operation, in order to prevent illness.

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