Lorenz Heister and the challenge of trepanation: a neurosurgical case study from the 18th century

In the 18th century, medical practice was essentially based on communication. Cranial trepanation, however, was usually performed on an unconscious person. Here the dialogue ceased. It was the only operation which had to be attempted without the positive consent of the patient. Thus trepanation challenged the surgeon's skill not only with its intricate surgical practice, but also with its unusual social setting. The present paper illustrates possible ways out of the "trap of trepanation" by interweaving two points of view. On the one hand, a general account is given on the basis of surgical publications written by Lorenz Heister and his contemporaries. On the other, the unpublished sources of the Heister correspondence serve to reconstruct the case of Heinrich Wilhelm Bachmann, a German merchant who fell victim to a traffic accident and underwent trepanation in 1753. The case study shows how the physician in charge counterbalanced the patient's inability to communicate by strengthening the remaining network of professionals, and ultimately confirming his decisions by use of the post-mortem.     

Trepanation in Italy: A Review

This paper reviews and discusses cases of skull trepanation in ancient Italy on the basis of information provided by the literature. A total of 54 individuals from 43 different Italian archaeological sites were found to have evidence of trepanation. The analysis of evidences of trepanation in Italy has demonstrated that no differences can generally be perceived between the trepanned individual and the social context of the burial, leading to exclude a special role of the former within the group. Trepanation in Italy covers a time span of approximately 7000 years, the most ancient cases dating back to the fifth millennium bc and the most recent to the 18th–19th centuries ad . The geographic distribution appears quite homogeneous, with a prevalence of cases in Central Italy and abundant evidence from prehistoric Sardinia. The majority of individuals show a single trepanation, whereas others present skulls with multiple holes. Trepanation in Italy was reserved to adult individuals, except for some rare cases, and shows a relevant preponderance for the male sex. The most diffused technique is scraping; cutting and drilling are less attested, especially as unique techniques for trepanation, but they were used more frequently in combination with scraping. Trepanation could in some cases be hypothesised as therapeutic intervention for the treatment of a traumatic wound or of other pathologies, whereas in other cases, a number of evidences are attested of trepanation performed as probable ritual intervention or as experimental surgery; in the remaining cases, the reasons for trepanation are unclear or not determinable. A high percentage of long‐term healing associated with trepanation has been evidenced. Copyright © 2017 John Wiley & Sons, Ltd.     

Ante Mortem Cranial Trepanation in the Late Bronze Age in Western Siberia

We report a case study of cranial trepanation in a male subject 30 to 40 years of age from the Nefteprovod II burial ground in the Anzhevsk archeological site. This burial dates back to the Late Bronze Age, in particular the Karasuk culture located in the Minusinsk Basin on the Yenisei River and on the upper reaches of the Ob River. The left parietal bone had an opening with evident signs of bone healing, as well as signs of inflammatory reaction from both bone plates of the calvarium. The strongest signs of inflammation were located around the trepanation opening at the exocranium, suggesting that it occurred after, rather than before, the operation. Although trepanation was the main cause for the development of the changes noted in the preceding texts, there are no reasons to believe that the subject died from complications arising from infection after trepanation. The patient survived and later died for reasons that may never be determined. Medical necessity was the most likely justification for trepanation. Immersion in altered states of consciousness may also have been a necessary part of the trepanation process as a mode of sedation, along with other shamanic practices, such as consumption of psychotropic substances or ecstatic dance. These data, together with reports of other ante mortem burials, raised questions about the application of anaesthesia and possible techniques of cranial trepanation. These issues and possible postoperative complications are discussed in the following text. Copyright © 2016 John Wiley & Sons, Ltd.     

A scientific analysis of cranial trepanation from an Early Iron Age cemetery on the ancient Silk Road in Xinjiang,China

This study uses multiple scientific methods to analyse a case of trepanation from a cemetery located at the westernmost point along the ancient Silk Road in China dating back to the Early Iron Age. The skull of interest belonged to a middle-aged male; the opening is located on the left posterior side of the skull in the occipital bone. Computer tomography (CT) and microscopic observation show that the incision was unhealed, indicating an immediate death either during or after the operation. The procedure of trepanation might have been used to treat a depressed fracture from inflicted trauma on the individual’s right parietal bone, suggesting the presence of surgical trepanation in early Western China.     

An interesting case of prehistoric trepanation from Poland: re‐evaluation of the skull from the Franki Suchodolskie site

The skull described here was excavated in Central Poland (archaeological site Franki Suchodolskie) in 1951, and was known as one of the oldest cases of healed trepanation. This skull, with later excavations from the Ukraine (cemeteries of Vasilyevka II and Vasilyevka III), was the basis for dating the beginning of the practice of trepanation in the Mesolithic period. The skull was never comprehensively described and dated, although it was scientifically extremely important. The skull has been reassessed by the authors of this paper has brought thorough verification of the knowledge concerning this excavation. According to radiocarbon analysis it is much younger than previously thought and has now been dated to the Late Neolithic or the Bronze Age. Earlier opinions about the healing and survival after the operation have not been confirmed: the hole in the squama of the frontal bone made by scraping and then by grooving has no evidence of healing. Radiological studies as well as computer tomography indicate lack of any healing processes in the bone tissue around the trepanation opening. The results of the analysis significantly modify ideas regarding the earliest skull operations in Central Europe, and change the time of the first trepanation to the Late Neolithic, as for most of the continent. Copyright © 2005 John Wiley & Sons, Ltd.     

Trepanation in the Chachapoya region of northern Perú

This paper discusses trepanation frequency data from the Chachapoya region of the northern highlands of Perú. New data from three skeletal samples are presented: Kuelap, Laguna Huayabamba, and Los Pinchudos, as well as isolated crania housed at the Chachapoya Museo Instituto Nacional de Cultura. The vast majority of the trepanations are circular in shape, except for one individual exhibiting as many as three roughly square trepanations. Evidence for healing is prevalent, with examples of both associated periosteal reaction of nearby outer table bone, as well as for healing of the insult itself. Only one case demonstrates a clear association between a traumatic injury and a trepanation event. The purpose or function of the remaining cases of trepanation, however, remains elusive. Copyright © 2006 John Wiley & Sons, Ltd.     

Short Report: Evidence of Trepanation on a Female Individual from the Middle Bronze Age Necropolis of Casas Velhas (Melides,Portugal)

Recent reanalysis of the human remains unearthed from the grave cists of the necropolis of Casas Velhas (Melides, Portugal) from the Southwest Iberian Middle Bronze Age, with a minimal number of 25 individuals (23 adults and 2 non‐adults), allowed relevant anthropological data. This culture, although widespread in southern Portugal and nearby areas of southwest Spain in the Middle Bronze Age, is characterized by the paucity of preserved human remains and thus the anthropological knowledge of these human populations. The adult female skeleton exhumed from cist 30, the last interment of this double burial, exhibit a complete perforation on the right parietal bone. The aim of this paper is to present and discuss this defect, which most probable diagnosis is trepanation. The hole is oval shape exhibiting long term healing. A shallow remodelled area is visible around the defect, which suggests scraping method. No complications or evident reasons for the intervention were observed. In terms of mortuary practices no clear distinction was observed between this individual and others from this cemetery. The features of this trepanation fit in the major points summarized by Silva ( 2003 ) for prehistoric Portuguese trepanation. These data sustain the existence of an old tradition of this procedure is this region of Iberia, present, at least, since the Middle Neolithic. Copyright © 2016 John Wiley & Sons, Ltd.     

The Ciempozuelos Necropolis skull: a case of double trepanation?

The focus of this study is the analysis of a trepanation performed on the skull of an adult male from the famous Bell Beaker necropolis of Ciempozuelos (Madrid) excavated at the end of the 19^th century. The unusual characteristics of the pottery and other associated grave goods gave rise to the use of the name ‘Ciempozuelos’ to define the regional Bell Beaker style; this refers to similar finds from other sites on the Meseta of central Spain. Although trepanations from Chalcolithic contexts in the Iberian peninsula are not infrequent, they are unusual in Bell Beaker inhumations. Furthermore, this skull is exceptional not only for the type of trepanation performed, but also for the subsequent cranial deformation apparently resulting from the operation, as well as evidence of a second subsequent trepanation which indicates a very short post‐surgical survival period for the individual. Copyright © 2003 John Wiley & Sons, Ltd.     

Trepanations from Oman: A case of diffusion?

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

Neurosurgical aspects of trepanations from Neolithic times

Trepanation of the cranial vault is the oldest known surgical procedure and has often been reported in the literature. We present two skulls with trepanations from Neolithic excavations in southwestern Germany. One skull exhibits a healed fracture in association with the trepanation. Both skulls show clear signs of healing without evidence of osteolytic inflammatory reaction. We discuss conditions relating to survival from trepanation in Neolithic times and some potential complications such as intraoperative bleeding and wound infection, in the context of modern neurosurgical knowledge. We conclude that neolithic skull surgery was probably mainly extradural. Copyright © 2006 John Wiley & Sons, Ltd.     

A review of trepanations in Anatolia with new cases

In this study, trepanations in ancient Anatolia were discussed from a historical perspective. Trepanations were studied in respect to temporal and spatial distribution, sex and age distribution, techniques and reasons, completeness, healing and number of holes. Forty individuals from 23 different Anatolian settlements are identified to have undergone trepanations. Cranial trepanations in Anatolia show a distribution over a period of 10 000 years ranging from the Aceramic Neolithic period to the Late Ottoman period and spread to whole Anatolia. The greater majority of the individuals had single trepanation orifices while only four individuals were identified with multiple holes. It is observed that the surgical procedure was predominantly carried out on males in Anatolia. Main techniques of trepanations used in Anatolia are drilling and cutting. Early cases of trepanation were made by drilling; however, this technique has been used for cranial surgery until the Ottoman period. Scraping and rectangular sawing techniques first applied in the Early Bronze Age. The boring‐and‐cutting technique was only applied in the Iron Age. More than half of the trepanations practiced due to cranial trauma. Training and treatment besides of cranial trauma are also considered as likely causes of trepanations in Anatolia. It is concluded that trepanation techniques are similar to South America and the Mediterranean region rather than Europe. Copyright © 2010 John Wiley & Sons, Ltd.     

A case of cranial trepanation in a Roman necropolis (Cassino,Italy, 3rd century BC)

The aim of this study was to investigate an individual from a Cassino necropolis of the 3^rd century BC. The inhumation shows a rectangular wound between the sagittal and lambdoid sutures of the cranium. Furthermore a series of pathological traces on the post‐cranial skeleton are present. The trepanation of the skull seems intentional: probably a healed surgical procedure to treat a sword wound. Copyright © 2007 John Wiley & Sons, Ltd.     

Multifocal eosinophilic granuloma with a possible trepanation in a fourteenth century Greek young skeleton

Multiple lytic lesions in the cranial remains of a young adolescent from medieval Corinth in Greece, display characteristics best associated with multifocal eosinophilic granuloma. Some of the lesions have marginal sclerosis indicative of healing. The lesions vary in size from less than one centimeter in diameter to over two centimeters. The larger lesions, in particular, appear to be the result of confluence between two or more lytic foci. These lesions, rarely described in archaeological skeletal material, result from a pathological disturbance within the reticuloendothelial system. One of the cranial lesions has a different appearance from the other lesions and may have been produced by a therapeutic trepanation. © 1997 John Wiley & Sons, Ltd.     

Two medieval ‘trepanations’ – therapy or swindle?

During the 1991–1992 excavation of the ruins of the medieval cathedral in Hamar, Norway, the broken skull of an elderly man was found, showing evidence of an incomplete trepanation. The ‘surgeon’ had obviously tried to penetrate the skull surface around bregma in an irregular circle of 23 × 21 mm. Upon investigation, the skull revealed a reactive‐pathological area of the internal surface of the occipital bone, which probably represents a respite after a meningeal disorder (a tumour or an infectious process), causing us to suggest that the trepanation was meant to cure the patient's increasing headache. However, as a second skull with similar marks was found in the same churchyard, another explanation seems possible. Because the brain tumour in the first case may have altered the patient's mental state, we may surmise that these incomplete operations were an attempt to remove from these patients' heads the ‘Stone of Madness’, which was then commonly considered to be the reason for psychiatric diagnoses as well as persistent headache, and often depicted in European art, most notably in the 16^th and 17^th centuries. The second skull, revealing an even more incomplete attempt, did not show any skeletal pathology at all. Copyright © 2007 John Wiley & Sons, Ltd.     

Evidence of surgery in Ancient India: trepanation at Burzahom (Kashmir) over 4000 years ago

The article describes a neolithic skeleton with multiple‐trepanated skull found in Kashmir, the archaeological circumstances of the find, the dating, the background, the skeletal evidence, the details of the trepanation and possible affiliations of the Indus civilization. It speculates briefly about possible medical grounds for the surgery. Copyright © 2001 John Wiley & Sons, Ltd.     

Cultural policy in the United Kingdom: Collapsing rationales and the end of a tradition 1

The aim of this article is to critically assess the content and rationale of the French 2003 law on private patronage and foundations. More specifically, it investigates the extent to which this law can truly encourage companies to become more involved in arts support. Before reviewing and explaining the major aspects of the reform and the advantages it is meant to bring to corporate donors, a short historical account is offered to demonstrate that even though the involvement of the private sector in the support of the arts has been on the agenda of various Ministers of Culture over the last forty years, the development of adequate and effective measures to encourage such an involvement has been difficult and erratic and, above all, has been met with little success. The third part of the article questions the relevance of a law largely based on tax reductions to support the arts in France and wonders whose interests it will really serve.     

Mortuary behaviour reconstruction through palaeoentomology: a case study from Chachapoya,Perú

This paper explores the contribution that applied forensic entomology can make to our understanding of prehistoric mortuary behaviour. Samples of insect remains were recovered from a mummy bundle that has been attributed to the Chachapoya people who occupied the northern highlands of Perú from ca. AD 800 to ca. AD 1532. The insects were identified to the family level and used to create a hypothetical timeline of post‐mortem interval before the construction of the mummy bundle. The individual in question suffered from a number of blunt force insults to the head, followed by two and possibly three trepanation events. We speculate the initial insect colonisation to have taken place almost immediately following injury and subsequent surgery, occurring before the individual's death. Insect succession patterns and timing estimates for the appearance of periosteal reactive bone suggest that the individual was wrapped shortly following death. The application of such modern forensic techniques holds vast promise for addressing issues concerning Chachapoya mortuary behaviour and, further, these results can expand our understanding of mummy studies in general. Copyright © 2005 John Wiley & Sons, Ltd.     

Scurvy as a factor in the loss of the 1845 Franklin expedition to the Arctic: a reconsideration

In 1845, an expedition, commanded by Sir John Franklin, set out to discover the Northwest Passage. The ships entered the Canadian Arctic, and from September 1846 were beset in ice off King William Island. A note left by the expedition in May 1847 reported all was well, but by April 1848, 24 of the 129 men had died. The ice‐locked ships were deserted in April 1848, but the 105 survivors were so weakened that all perished before they could reach safety. The causes of the morbidity and mortality aboard the ships have long been debated, and many commentators have argued that scurvy was an important factor. This study evaluates the historical evidence for the likely effectiveness of anti‐scorbutic precautions taken on polar voyages at that time, and investigates whether the skeletal remains associated with the expedition provide evidence for scurvy. Skeletal remains available for study were carefully examined for pathological changes, and lesions potentially consistent with scurvy were subject to histological analysis. Where remains were no longer accessible, use was made of published osteological work. It is argued that the anti‐scorbutic measures customarily taken on mid 19^th century British naval polar voyages were such that there is no a priori reason to suppose that scurvy should have been a problem prior to the desertion of the ships. The analysis of the skeletal evidence provided little in the way of bony lesions consistent with the disease, and cannot therefore be used to support the presence of scurvy. Factors other than scurvy may been the main causes of morbidity and mortality in the 11 months prior to the desertion of the ships. Copyright © 2012 John Wiley & Sons, Ltd.