Trephination Trepanation

Trephination, one of the earliest surgical procedures involving the skull, was first reported in prehistoric skeletal remains during the nineteenth century (Squier 1877; Rytel 1956; Lisowski 1967; Steinbock 1976; Ortner and Putschar 1981). E. Squier's early description of trephination in Peruvian remains led to the recognition that this procedure was frequently practiced in pre-Columbian South America (Stewart 1958; Steinbock 1976). The success rate of this surgery, which exceeded 50 percent in the South American examples (Stewart 1958), is particularly significant for the history of medicine. It far exceeded recovery predictions for individuals subjected to brain surgery in eighteenth- and nineteenth-century Europe, where death was the expected result (Schroder 1957, cited in Lisowski 1967).

The removal of a segment of skull without injuring the underlying meninges and brain is an exceedingly delicate operation. Commonly practiced in South America during the millennium between



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Figure V.8.3. Different methods of trepanation. 1, Scraping; 2, grooving; 3, boring and cutting; 4, rectangular intersecting incisions. (After Lisowski 1967, with permission, Charles C. Thomas, Publisher.)

Figure V.8.3. Different methods of trepanation. 1, Scraping; 2, grooving; 3, boring and cutting; 4, rectangular intersecting incisions. (After Lisowski 1967, with permission, Charles C. Thomas, Publisher.)

1500 and 2500 B.P., trephination encompassed several distinctive techniques with various results. One of the most extensive descriptions is that of M. Meyer (1979), who reports 10 different types of surgical method in his study of 374 trephined crania from Peru. Most common were the scraping and grooving procedures (Figure V. 8.3, after Lisowski 1967), which had been performed on more than 61 percent of this sample. Meyer (1979) attributes the popularity of the scraping technique to its high success rate (85 percent). Given that the key problem in surgery of this type is the removal of bone without penetrating the dura, the finer control afforded by the scraping technique rendered it maximally effective (Ortner and Putschar 1981).

The overall recovery frequency reported by Meyer (1979) is 61.9 percent, which compares quite favorably with the rate of 62.5 percent reported by J. Tello (1913) in a sample of 400 Peruvian skulls. Meyer also reports similar figures for researchers dealing with smaller series. Thus, fewer than half of these ancient Peruvian patients died as a result of skull surgery.

Various motives have been attributed to those who performed trephination, ranging from the utilitarian to the spiritual. Meyer (1979) observed cranial pathology, due either to infection or to trauma, in association with 42.0 percent of his trephined sample. As he notes, the rate would undoubtedly have been higher, given the fact that either the operation itself or subsequent healing would have obliterated symptoms visible at the time of surgery. He also reports that fractures were more commonly, but by no means exclusively, associated with men in his sample, with infection appearing more frequently in trephined women. There tended to be a larger number of healed trephinations among men than among women, which contributes to Meyer's observation that relatively few young men appear in his trephined sample. He attributes "ritual practice" to this pattern, but male survival rates must also be considered.

Meyer also suggests, on the basis of observation of stains and osteoporotic pitting in the trephined region, that Peruvian surgeons used antiseptics. Unlike earlier observations by T. Stewart (1958) on a less extensive series, Meyer's (1979) observations revealed that most trephinations in his sample occurred on the parietal bone. The left side of the skull was more commonly trephined than the right, which may reflect the agonistic origins of many cranial fractures.

Contemporary examples of trephination using primitive technology include the African cases cited by E. Margetts (1967) and Bolivian examples reported by K. Oakley and colleagues (1959). The African techniques were similar to prehistoric methods, whereas in Bolivia a young man was operated on with "a rusty nail and a stone" (as cited in Meyer 1979). The African operations were quite successful; in one instance of multiple trephinations, for example, the subject continued to live a "normal" life. Clearly, ancient peoples had discovered a surgical strategy that was remarkably successful, even in the absence of modern antibiotics.

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