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.     

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.     

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.     

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.     

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.     

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.     

Imaging Evaluation of Skull Trepanation Using Radiography and CT

Cranial surgery as practised by the prehistoric and present-day traditional medicine man is the oldest known and one of the highest surgical achievements in the history of medicine. This study examines morbidity and mortality of this ancient surgical procedure by re-examining and reviewing reports of 71 completely trepanned skulls from pre-Columbian Peru by three techniques: gross visual observation and palpation; radiography; and CT. The specimens are located in the San Diego Museum of Man and are part of the Hrdlicka collection. Clear distinction can be made by visual observation between skulls with bone regeneration and those without; that is, between patients who survived long enough to allow bone healing and those who died immediately or within a few days of the operation. 64.8 per cent of skulls had complete healing, 12.7 per cent had partial healing and 22.5 per cent had no evidence of healing. Thus, a post-operative survival rate of 77.5 per cent is noted by gross examination. The meaning of completely trepanned skulls with no evidence of healing is questionable, however, some unhealed skulls may represent post-mortem trepanation, suggesting a lower surgical mortality. Both radiography and CT scan demonstrate with considerable accuracy the presence or absence of new bone formation on trepanned skulls. One skull demonstrated evidence of partial bone healing by CT and radiography but not by our gross examination or by that of some anthropologists. Evidence of osteomyelitis was illustrated by CT scan but not by radiography.     

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.     

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.     

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.     

Cranioplasty in ancient Peru: a critical review of the evidence,and a unique case from the Cuzco area

Cranioplasty is a well‐known procedure in modern neurosurgery. Although some authors have claimed it was also performed by prehistoric trepanners in various parts of the world, there is little hard evidence to support this. Here we review various claims of cranioplasty in Peru, where trepanation was widely practised in Prehispanic times. We find little support for assertions that cranioplasty was common. One recently discovered burial from the Cuzco region, however, provides the first documented case of the reinsertion of a bone plug into a trepanation opening. Copyright © 2008 John Wiley & Sons, Ltd.     

Evidence of interpersonal violence at the Chalcolithic village of Shiqmim (Israel)

Three circumscribed depressed fractures were found on the skull of an adolescent boy recovered from a primary intramural burial at the Chalcolithic site of Shiqmim, northern Negev, Israel dated to (∼4500–3200 BCE). The fractures were located on the left side and back of the skull. They are circular in outline and have sharp margins containing numerous small bone fragments. These indicate that the skull was fractured when the bone was still fresh and were the probable cause of death. The location of the fractured areas is typical of blows inflicted by a right‐handed individual in face‐to‐face conflict. The size and shape of the fractures, suggests that they were inflicted by a blunt instrument, possibly a mace head. The absence of any signs of healing or infection indicates that all fractures occurred within a short space of time and resulted in death. Neither biological characteristics nor burial pattern show any unique features that distinguish this individual from others recovered at this site. 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.     

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.     

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.     

A temporal bone lesion in a modern subject to explain a defect in the Kabwe skull

The skull of a dissection room subject was noted to have a hole in the left squamous temporal bone similar to a lesion in the Kabwe (Broken Hill) skull. Kabwe man has an 8 × 8 mm hole situated 2 cm above and slightly anterior to the left external auditory meatus (EAM). This report describes a possible mechanism for the causation of that lesion, which is illustrated by features on a modern skull. The subject is a 55-year-old man who died from carcinoma of the stomach in 1942. The skull was macerated, defatted and stored after the cadaver had been dissected by medical students. In the squamous temporal bone there was an oval shaped 9 × 8 mm hole. The base of the oval was situated 11 mm above the superior margin of the EAM with the central axis of the hole being in line with the anterior margin of the EAM. This hole forms the base of a larger intracranial pit measuring 21 mm in diameter. The hole has an irregular margin except superiorly where it is smooth and rounded, indicative of healing. Intracranially, the petrous temporal bone displayed a marked exophytic, bony outgrowth suggestive of a chronic infective condition. The tegmen tympani contained a hole 3 mm in diameter in the middle of the exophytic area. No sign of disease in the mastoid process was noted. These findings are compatible with advanced chronic ear disease which has tracked into the extradural space through the tegmen tympani, become loculated, and then eroded the squamous temporal bone. The Kabwe skull shows signs compatible with chronic ear disease. It is suggested that a mechanism similar to the one described in the modern skull could explain the lesion in the left squamous temporal bone of Kabwe man.     

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.     

Signs of meningiomas in a skull of the Mexican colonial period

The skull of a native Mexican from the colonial period is studied. The skull has a nasal trauma, dental pathology and two osteogenic lesions, one situated at the left wing of the sphenoid bone and the other in the infrainion occipital squamous bone, between the left mastoid process and the left occipital condyle. That involving the sphenoid occludes the optic nerve foramen and is evident through the orbit and at pterion. These osteogenic lesions are considered to be secondary to the soft tissue tumour mass, which, at the level of its implantation area, is usually present in meningiomas.     

The Last Domicile of the Iceman from Hauslabjoch: A Geochemical Approach Using Sr,C and O Isotopes and Trace Element Signatures

We present Sr, C and O isotope ratios and quantitative ratios of trace element ratios in the rib and the femur of the Tyrolean Iceman “Ötzi”. The results from the rib and the femur are compared with those obtained from pre-industrial historic human skull bone fragments collected in the late 19th century from charnel houses located on different geological backgrounds throughout North and South Tyrol. Comparison of strontium isotope data from the bone fragments locates the Iceman's domicile, during the last 5 to 10 years of his life, to the crystalline part of the Central Alps. Statistical analysis of the trace element ratios, together with oxygen isotope results, suggests that the Iceman probably spent most of his last years in southern elevated part of the Ötztal. However, the results from Iceman only represent those from a single individual and are not a representative average of a group. It cannot therefore be established with absolute certainty that the original trace element signatures were conserved, especially during the first stage of mummification. Our conclusions should therefore be regarded as tentative, but nevertheless the best possible indication his domicile, and a stimulus for further research.     

Serial craniectomies for intracranial infection 5.5 millennia ago

A skull found in a burial cave near Jericho with evidence of craniectomies dating approximately 5500 years ago had signs of frontal sinusitis and intracranial infection. The location of the three craniotomies in the frontal bone of this skull and evidence of the infection bursting from the sinus intracranially suggest that this is the oldest known cranial surgery performed due to symptoms of a medical aetiology : epidural infection.