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 Table of Contents  
MEDICAL HISTORY
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 126-131

History of trepanation and the Indian connection


Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission04-May-2022
Date of Decision10-May-2022
Date of Acceptance09-Jun-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Prof. Girish Menon
Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_96_22

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  Abstract 

Trepanation refers to scraping, cutting, or drilling of an opening (or openings) into the cranium and is believed to be one of the earliest surgeries performed on and by man. Fossil evidence of trephined skulls has been found in separate continents throughout ancient history and such discoveries continue to be made even from geographic areas or time periods from which the practice was not previously known. Equally interesting is the evolution of this practice from ancient times to the modern neurosurgical era. This review seeks to define a framework around the history of cranial trepanation and tries to understand the various different interpretations of the origin and etiology of the art of cranial trepanation, starting in the prehistoric era. The contribution of ancient Indian medicine toward the progress of this branch of surgical expertise is also discussed.

Keywords: Craniotomy, history, trepanation


How to cite this article:
Pai A, Menon G. History of trepanation and the Indian connection. Arch Med Health Sci 2022;10:126-31

How to cite this URL:
Pai A, Menon G. History of trepanation and the Indian connection. Arch Med Health Sci [serial online] 2022 [cited 2022 Aug 17];10:126-31. Available from: https://www.amhsjournal.org/text.asp?2022/10/1/126/347977


  Introduction Top


Trepanation refers to the practice of making a hole into the human skull (by scraping, cutting, or drilling into it) with or without surgical removal of a piece of the skull. Trepanation, provide the earliest proof of surgery being performed on humans. Reports of trepanation performed back from the stone ages have been reported from multiple pockets across all major continents.[1],[2],[3] Samuel Morton is thought to be the first to describe a trepanned skull, in 1839; however, it was a detailed scientific analysis done by Broca on a trepanned skull brought from Peru which brought to light the practice of trepanation in ancient times.[4] Even more surprising than the fact that ancient men were skilled in the technique of trepanation is the evidence, that many of these patients survived after the procedure.[5] India had a great surgical tradition from prehistoric times and there is unverified literary evidence of trepanation and removal of brain tumors by Jivaka, the surgeon to Lord Buddha.[6],[7],[8] This short review narrates the history behind trephination, early indications and its evolution. The review also analyses the contribution of ancient Indian physicians in the evolution of this important surgical practice.


  Background Top


In 1865, Ephraim George Squier an explorer and archaeologist received a skull as an unusual gift. It was sourced from an old Inca burial ground in Peru.[4] The skull had a rectangular opening near the top [Figure 1]. On detailed inspection, Squier was convinced that it was “a clear case of trepanning before death, the opening having been made with a burin, or tool like that is used by engravers on wood and metal.”[9] His observation was met with scepticism at the scientific meeting in New York. This was not unusual considering the fact those days even craniotomies done in specialized hospitals used to carry a high risk of mortality, mostly due to infection. This Peruvian Inca skull was sent to Paul Broca, physician and anatomist at the University of Paris. He confirmed that the trepanation was indeed a proof of advanced surgery from the ancient time and that the patient had survived for a while. Broca presented his findings to the Anthropological Society of Paris in the year 1876, where again, it was not readily accepted.[9] Almost a decade later, a discovery was made in central France that confirmed Broca's interpretation of trephination being successfully being performed by the “primitives” of the Neolithic era. Later, excavations in a Neolithic burial site in Peru revealed a number of skulls with circular holes 3–5 cm wide with scalloped edges. Alongside these skulls, skull pieces the same size as the holes were also found. These small skull pieces had evidence of piercing inside, probably for stringing as amulets. It is possible that some of these pieces were removed postmortem. However, at the edge of these wounds, scarring was noticed which indicated that many of these skull pieces were removed when the patient was alive and that the time duration between procedure and death must have been months to years. These findings categorically proved that trephination was being successfully performed in Neolithic era. The indication for trepanation, however, was unclear and Broca assumed that this practice had a religious or therapeutic background. Apart from Paul Broca, De Blasio, an Italian anthropologist is renowned for his careful study and analysis of trepanned skulls. De Blasio considered analyzing the skull as the best way to investigate the different aspects of human life and often challenged the strict bio-medical paradigm of the period.[9] His publications added further proof to the ability of the ancient man to perform trepanations.[9]
Figure 1: The trephined Inca skull given to Ephraim George Squier which now resides in the American Museum of Natural History. Reference: Gross CG. A Hole in the Head: More Tales in the History of Neuroscience. Cambridge (Massachusetts): MIT Press; 2009[4]

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Following Squier's finding of the Inca skull, trepanned skulls have been excavated all-round the globe with reports dating back from the Mesolithic to the ethnographic present.[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30] The largest numbers of trephined skulls were found in South America. About 15000 skulls were discovered in Peru and Bolivia and nearly 5% of these skulls had evidence of trepanation.[10],[11],[12] The earliest skulls with trepanation found from Paracas in Peru were estimated to be from 5th century BC.[10] Evidence of trepanation has been found in a Mesolithic skull discovered in Morocco, skulls from the burial grounds in Ukraine, and an Alsatian burial in Ensisheim, all dating back to about 5000–7000 years BC. Similar discoveries dating to Neolithic period in Europe, South America, and some African and Pacific tribes have also been made. The skulls when examined showed signs of inflammation and healing of the bone around the trephine site, which indicate that the individual survived for a reasonable period after surgery. It is thus safe to presume that these procedures can be considered as forerunners to the practice of therapeutic drilling performed in the Greco-Roman period in Europe and to modern neurosurgical practice.[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37] Ancient trephined skulls have been reported from India as well and reports suggests that such operations were indeed performed in India at almost the same time and in a similar manner as was done in other parts of the world.[6],[28],[29]


  Etymology: Trepanation versus Trephination Top


The terms trepan and trephine are now used synonymously but have different origins. In ancient Greece, during the time of Hippocrates, the instrument used for “boring” holes in the skull was called “terebra and trepanon” -from the Greek “trupanon, a borer.” The word trepan probably originated from this instrument which resembles the present day trephine. A second etymological source relates to a triangular instrument called “tre-fines” used in the 16th century by Fabricius ab Aquapendente for boring holes in the skull. It had three arms with different-shaped edges. Each of the points could be applied to the skull using the other two as handles. It is believed that “tre- fines” became trafine and then trephine. Later, by 1656, trephine was being used as a synonym for trepan. Yet another version is that a London surgeon, John Woodall invented a similar triangular instrument in 1639 for boring holes in the cranium and named it as “tres fines.” It is believed that this “tresfine” evolved to become trephine.[4]


  When and Who Started the Practice of Trepanation? Top


Trepanation was reportedly practiced in almost all major continents since stone age.[5],[30],[31],[32],[33] The exact location and time span in which the first trepanation was done is however controversial. Evidence of trepanation being performed is widespread in terms of time and geographical area and the findings of healed or healing trepanation is seen right from the Mesolithic period to the ethnographic present[5],[25],[30] The earliest proven evidence for trepanation comes from Neolithic times probably in Andean South America and Africa. Squier and Broca were probably among the first to draw attention to the antiquity of this practice in Peru. It was prevalent in Europe around 5000 years ago according to Piggott. In Asia, there is fossil evidence of trepanation from around 4000 years ago in Palestine.[34] In Europe and North Africa, trepanation was performed most often in the Mesolithic and Neolithic period.[5],[16],[26],[30] In Europe, it continued through bronze and iron age but declined and disappeared altogether shortly after the Medieval period.[5],[16],[26] Evidence of the practice of trepanation in the Indian subcontinent has been found from the Neolithic period.[6],[28],[29] A Neolithic skull excavated in Kashmir, skulls excavated from Harappan sites, and skull retrieved from Maski, Karnataka, provide ample evidence about the practice of trepanation in ancient Indian subcontinent over 4000 years ago. In the absence of accurate dating, it is safe to assume that the practice of trepanation existed from the early stone ages and was probably practised in multiple parts of the globe at around the same time.


  How did the Practice of Trepanation Evolve? Top


The instruments and techniques used for trepanation have varied over time and place. Several different methods have been described for trephining and these include scraping, grooving, boring, and cutting and making rectangular intersecting cuts[4],[5],[30],[31],[32],[35],[36],[37],[38] [Figure 2].
Figure 2: Different methods of trephining: (1) scraping; (2) grooving; (3) boring and cutting; (4) rectangular intersecting cuts. Reference: Gross CG. A Hole in the Head: More Tales in the History of Neuroscience. Cambridge (Massachusetts): MIT Press; 2009[4]

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Scraping involves repeated rubbing by sharp, oval object, often a stone (flint) over the intended area. Commonly found in skulls retrieved from France, this was a common practice and was being carried out in Italy even up to 14th century. Broca attempted to reproduce that same and found that these openings can be made even in a thick skull by scraping with a piece of glass in less than an hour.

In grooving, a pointed instrument etches a round or oval groove. This action is repeated until the instrument digs through to the diploe and then the disc of bone is lifted off. This was another commonly used method, especially in African countries like Kenya until recently.[39] This technique is the predecessor of the later-day circular trephine or crown saw. First used by Hippocrates and described in detail by Celsus the trephine is a hollow cylinder with a toothed lower edge, a retractable central pin, and a transverse handle used for making circular holes in the skull.[40],[41] Hippocratic texts also mention the use of an instrument called a prion, a sort of pointed drill. Celsus has described this technique in detail as follows “The surgeon, after exposing the bone and controlling the hemorrhage through sponges soaked in vinegar, delimits the cranial area that must be removed by making small holes at a close distance from each other, whose joining segments are subsequently sectioned with a chisel, opening a piece in the cranial vault.”[35]

Boring or drilling is done by repeatedly rotating a sharp thin instrument in circular motion to cut through the bone. The current day practice of using a Hudson brace and the present day drills have all evolved from this principle of “boring “into the skull.”

Cutting is when a sharp, oval stone is used at right angles to the skull, to make four linear grooves in the form of a rectangle. Initially, stone knives were used, but with time were replaced by metal ones. Peruvian Inca's used a curved metal knife called a “tumi” for this job. “Tumi” is considered as a symbol of good luck in Peru and the “tumi has also been adopted by the Peruvian Academy of Surgery as its emblem [Figure 3]. The use of this technique has been also found in skulls found in Europe, Middle East, and Africa.
Figure 3: (a) The ancient form of “Tumi,” the instrument believed to be used by the Inca tribes to perform trepanning, (b) The modern-day version of the ceremonial knife Tumi which is made of bronze, gold, silver or copper and usually made of one piece. This decorated ornamental version of the Tumi has been adopted by the government of Peru as a symbol to promote tourism and as a symbol of good luck

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The fifth technique was to drill a circle of closely-spaced holes and then cut or chisel the bone between the holes. This method suggested by Celsus was also practised by the Arabs and became a standard method in the Middle Ages. It was in vogue in Peru and, until recently, in North Africa. It resembles the modern method in which a sharp-edged wire (Gigli saw) is used to saw between a set of small trephined or drilled holes to raise a bone flap.


  Why Was Trepanation Done? What Were the Indications? Top


It is presumed that in the stone age and Iron age trepanation would have been practised either following traumatic brain injuries or for sociocultural reasons. The exact indications, behind the practice of trepanation, however, is unclear and is limited to various postulates.[41],[42],[43],[44],[45],[46],[47],[48],[49] Broadly, trepanation was carried out mainly for two indications – therapeutic and cultural. The primary therapeutic indication was for the management of fractures and war injuries.[31] Hippocrates in his treatise “Wounds in the Head” writes about the use of trephination in the management of head injuries. He believed that collected blood would get spoilt and turn into pus. Thus, trephining was done for the movement of blood out of skull before it decayed. By Galen's time, trephining was being done to treat fractures of skull, for reducing pressure, for drainage and to extract fracture fragments that threatened the dura. Till the end of 18th century, it was standard practice for the treatment of depressed fractures and penetrating head wounds. The Hippocratic practice of “prophylactic trephination” after head injury even when there was no skull fracture continued to be performed postrenaissance.

Trepanation, reportedly, has been subsequently tried for multiple other aliments including convulsions, headaches, epilepsy, and infections.[31] There are reports of trepanation being suggested for refractory headache from ancient China set in at the time of end of Han dynasty. Hua Tau, a reputed physician of those times is believed to have recommended opening the skull to release air and fluid from emperor CaoCao's skull to relieve his headache.[24] Trephining among the Kisii tribe in Kenya was done to reduce headache after injury to head.[24] According to Margetts, it was done “to let out the evil spirits which were causing an intractable headache.”[31]

In the European medical tradition, trephining played an important role in the treatment of epilepsy and mental illness. In the surgical text “Quattuor magistri,” trephining the skull of patients suffering from epilepsy is advised so “that the humors and air may go out and evaporate.” It was often thought as the last step is highlighted in Riverius, “The Practice of Physick” (1655) “If all means fail the last remedy is to open the fore part of the Skull with a Trepan, at distance from the sutures, that the evil air may breath out. By this means many desperate epilepsies have been cured, and it may be safely done if the Chyrurgeon be skilful.[50] By the end of 17th century, the use of trephination for epilepsy had come down fortunately.

Trephining was also done to treat mental diseases. Roger of Parma (ca. 1170) writes in “Practica Chirurgiae:” “For incision is made in the top of the head and the cranium is penetrated, to permit the noxious material to exhale to the outside.[51] Robert Burton, in “Anatomy of Melancholy,”(1652) recommended boring a hole in the skull for madness, a view which was shared by physician Thomas Willis.[52] One of the most famous depiction of trephining for mental disease is seen in the Dutch painting., Hieronymus Bosch's “The Cure for Madness (or Folly),” also known as “The Stone Operation,” which shows a surgical incision being made on the scalp as a cure for madness [Figure 4].
Figure 4: Hieronymus Bosch's The Cure for Madness (or Folly), also known as The Stone Operation The Extraction of the Stone of Madness or The Cure of Folly, is a painting by Hieronymus Bosch, displayed in the Museo del Prado in Madrid, completed around 1494 or later. The painting depicts a surgeon, wearing a funnel hat, removing the stone of madness from a patient's head by trepanation. An assistant, a monk bearing a tankard, stands nearby. A woman with a book balanced on her head looks on. (lsink, Matthijs et al. (2016). Hieronymus Bosch: Painter and Draughtsman – Catalogue raisonné. New Haven: Yale University Press Hieronymus Bosch: Painter and Draughtsman). Reference Gross CG. A Hole in the Head: More Tales in the History of Neuroscience. Cambridge (Massachusetts): MIT Press; 2009.[4]

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Cultural theories for trepanation are linked to religion, rituals, and to other ethno-medical practices. Trepanation was believed to “to allow for the exit or entrance of spirits believed to cause illness.”[36] Herodotus depicts Libyans as “cauterizing the heads of their children to prevent them being plagued in their afterlives by a flow of rheum from the head.” Yet another unverified postulate suggests that trepanation would have been done to collect skull disks, called roundels, for charms or amulets.[25]

Surprisingly, even today, trepanation continues to be practised for unconventional reasons. The International Trepanation Advocacy Group propagates trepanation as a “do it yourself: surgery for enlightenment and enhanced consciousness in patients with depression and chronic fatigue syndrome. Their rational is fusion of skull sutures in childhood “reduces brain pulsations causing a loss of dreams, imagination, and intense perceptions.” Making a small hole in the skull “restores the intracranial pulse pressure which leads to a permanent increase of the brain-blood volume which leads to accelerated brain metabolism and more areas of the brain functioning simultaneously” resulting in “increased originality, creativity and… testosterone level.”[53] The group points to the historic, extensive, and sustained practice of trephining in other cultures as support for their idea. Considering the dangers involved with this practice the British Medical Journal was quick in issuing warning against this hazard.


  The Indian Connection Top


Proven scientific evidence of trephination in the Indian subcontinent dates back to the Bronze Age (ca. 4300 BC) Indus Valley Civilization. Archaeological finds from Harappan sites like Lothal, Kalibangam revealed skull of child with a square shaped hole, some skulls with circular holes; all suggesting that trepanation was practised in India since ancient times[6],[28],[29] [Figure 5]. Skull excavated from Maski in Karnataka, dated to iron age era also showed two round holes on either side of the midline suture of skull indicating practice of trephination in that era.[6],[28],[29] A skull dated to the Neolithic era was found at Burzahom in Kashmir showing proof of trepanation being performed since ancient times.
Figure 5: Sketch of the trepanned skull from approximately 2350–2050 BC (4300–4000 BP) found in Burzahom, which is located approximately 10 km north-east of Srinagar in the Kashmir Valley. The skull, belonging to a female aged between 26 and 30 years, shows a total of 11attempts at trepanation. Reference: Sankhyan, A. R. and G. H. J. Weber. Evidence of Surgery in Ancient India: Trepanation at Burzahom (Kashmir) over 4000 Years Ago. International Journal of Osteoarchaeology 11 (2001): 375-80

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Indian mythological scripts abound with narratives of brain surgery. Lord Ganesh with a transplanted elephant head is the most notable example. Transplantation of horse's head on the body of Dadhyancha, repair of the excised head of Yagyana by Rudra are less popular examples. These mythological stories have no documentary proofs though. Ancient Indian scriptures and Ayurvedic texts also speak about brain surgery. The Sanskrit work Bhoja Prabandham narrates how King Bhoja's headache was cured by two Brahmin surgeons from Ujjain who performed cranial surgery on him apparently under some form of herbal anesthesia. Jivaka, surgeon to Lord Buddha, is considered as father of ancient neurosurgery in India and is reported to have performed complex surgeries on a routine basis [Figure 6].[54] The Jivaka Sutra describe Jivaka as having performed trephination on a patient and removed intracranial mass.[6],[7],[8] These descriptions of surgical procedures follow the template as laid in works of Charaka and Susruta.[8] The master surgeon Susruta considered as father of Indian surgery is said have performed basic neurosurgery procedures. He considered the head as the centre of all functions and in his works, he describes various surgeries involving the skull such as trephining, excising, probing, puncturing, suturing, and draining of “collected” “fluids especially in relation to warfare injuries. However, unequivocal evidence of brain surgery in ancient Indian literature is still not confirmed.
Figure 6: Jivaka: The great physician and surgeon of ancient India, shown here with some of his surgical instruments. Reference: Kashyap A. Jivaka: The great surgeon and physician of ancient India. Indian J Colo-

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  Conclusion Top


Trepanation of skull probably is one of the earliest surgical procedures attempted by humans on fellow human beings. Available evidence suggests that right from stone ages humans attempted trepanation both for therapeutic and socio-ritualistic indications. Evidence also suggests that such surgical procedures were indeed successful and the patients lived for long after the surgical procedure. Further studies are required which could throw more light on the techniques, indications, and outcome of trepanation done in the stone ages. Such insights may also provide invaluable tips helpful in the current day practice.

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    Figures

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Abstract
Introduction
Background
Etymology: Trepa...
When and Who Sta...
How did the Prac...
Why Was Trepanat...
The Indian Conne...
Conclusion
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