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NI FEATURE: JOURNEY THROUGH THE EONS - COMMENTARY
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 639-642

Cranial trepanation in ancient India


1 Department of Neurosurgery, Apollo Hospital, Jubilee Hills, Hyderabad, Telangana, India
2 Retired Director of Archaeology, Kerala, India

Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. D Raja Reddy
75-B Journalist Colony, Jubilee Hills, Hyderabad - 500 033, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.263227

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How to cite this article:
Reddy D R, Satyamurthy T. Cranial trepanation in ancient India. Neurol India 2019;67:639-42

How to cite this URL:
Reddy D R, Satyamurthy T. Cranial trepanation in ancient India. Neurol India [serial online] 2019 [cited 2019 Aug 19];67:639-42. Available from: http://www.neurologyindia.com/text.asp?2019/67/3/639/263227






Trepanation is considered as the oldest known surgical procedure that was practiced from the Neolithic period and was reported from North and South America, Europe, Asia, and Africa.[1],[2],[3] India had a great surgical tradition from the prehistoric times and there was literary evidence of trepanation and removal of brain tumors by Jivaka, the surgeon to Lord Buddha.[4],[5] Susruta is acknowledged as the father of Indian surgery, and a study of his ancient Indian surgical treatise namely “Susruta Samhita” does not mention about trepanation.[6] There is only one lone documented report of cranial trepanation from Kashmir.[7] Hence, this report of cranial trepanation was detected in two skulls from Adichanallur, which are preserved in the Chennai archaeology museum. Adichanallur is the prehistoric mining site (8*38'28.5” N Lat. and 77 * 51'51” E. Long.) located in Tirunelveli district of Tamil Nadu state of India. This site was excavated first in 1876 by Andrew Jagor and later by many archaeologists such as Alexander Rea (1899), Louis Lapicque (1903), Henderson (1915), and recently in 2004–2005 by an archaeologist and one of the authors (T.S).[8] This site was first considered as an ancient burial site in view of the presence of skeletal remains in urns, but detailed investigations in recent years confirmed this as an ancient, prehistoric mining site for copper, gold, and iron.[9] The thriving mining activity continued at the site for over 2000 years from 1500 BC to 775 AD. Open mining pits were used in later times for burial practices and hundreds of urns were found in trenches containing human skeletons. Anthropological studies on skeletons surprisingly confirmed that they belonged to people of three races, namely Negroid, Mongoloid, and Caucasian. Each of these nationalities probably participated in different activities of mining. Skeletal remains found at Adichanallur were preserved in 158 urns in the Archaeological Department at Chennai. Some of the skulls were found intact but majority were parts of the skull. A survey of the skulls reveals that some of them sustained trauma and others had evidence of infection: one had evidence of scaphocephalic shape suggesting sagittal craniosynostosis and two had evidence of trepanation, which form the subject of this communication. Two skulls with evidence of trepanation are described first [Figure 1] and [Figure 2] followed by other pathologies detected in the skull bones from Adichanallur [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8].
Figure 1: Square type of trepanation in the left skull just in front of coronal suture in the frontal bone

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Figure 2: Similar trepanation in right-sided image with evidence of fracture in front

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Figure 3: Left-sided skull shows evidence of trauma in the form of a linear skull fracture

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Figure 4: Right-sided skull shows evidence of separated suture and loss of bone

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Figure 5: Left-sided skull is that of a frontal bone showing evidence of osteomyelitis with new bone formation and the gap is suggestive of extruded sequestrum

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Figure 6: Middle specimens are those of osteomyelitic skull bones and right-sided fragment is a sequestrum

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Figure 7: Right-sided skull bone is thickened with evidence of chronic infection

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Figure 8: Intact skull with evidence of scaphocephaly

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  Materials and Methods Top


Description of the Skulls with Trepanation [Figure 1] and [Figure 2]

Clear evidence of healing is not evident. As the entire skull is not present in both cases, it would be difficult to know which type of race to which these cases belonged based on anthropological studies. In the majority of Peruvian skulls, the trepanation was rectangular and the method of removal of skull was by the use of Tumi knife. The most likely method of trepanation in the skulls could have been by the use of surgical instruments, which were described in the ancient Indian surgical treatise “Susruta Samhita”[6] and some of these instruments were found in excavations at Taxila. Thirteen of these instruments are on display in Taxila museum, which consisted of forceps, spatulas, needles, and even complicated instruments such as decapitators used in obstetrics.[10] These surgical instruments are dated from the first to third century BC confirming the great surgical traditions of Ayurveda. Susruta described cataract surgery, abdominal surgery, plastic repair of nose, bladder stone removal and repair of urethral stricture, etc., One more surgery that can be added to this list is trepanation.

Skulls with Evidence of Trauma [Figure 3] and [Figure 4]

Both of these individuals might have died of trauma-related complications.

Skulls with Evidence of Infection [Figure 5], [Figure 6], [Figure 7]

There are skull bones available where bony thickening, osteomyelitis and formation of bony sequestrum indicates the presence of osteomyelitis.

Skull with Evidence of Sagittal Craniosynostos [Figure 8]

It is obvious that craniosynostosis was prevalent in India from the ancient times and the specimen in [Figure 8] is an example.


  Discussion Top


The anthropologist E.G. Squiers obtained a trephined skull for the first time from Cuzco, Peru, dating back to 1863 AD.[3] There was a rectangular opening in the skull in the forehead in that specimen, similar to the trephined skulls depicted above. The world's greatest numbers of trephined skulls were found in Peru and Bolivia and 15,000 mummies were discovered in those regions. Five percent of these skulls had evidence of trepanation. The earliest skulls with trepanation from Paracas in Peru were dated from the fifth century BC to the fifth century AD. Subsequently, trephined skulls were reported from Canada, United States of America, France, and other countries of Europe, Africa, and South Pacific region, and lastly from China.[11],[12],[13],[14],[15] Ancient trephined skulls have not been reported from India so far, and this report suggests that such operations were indeed performed in India similar to other parts of the world.

The indications for such operations are difficult to understand now. The literature suggests that these operations were performed for therapeutic purposes and also for mystical reasons to let out the demons from inside the skull in people with severe psychological disorders.[16] Therapeutic indications appear to be headaches, seizures, and trauma to the head.[17] Primitive tools were used for making holes in the skull, either using a single instrument or multiple numbers of instruments. One kind of a knife known as 'Tumi' was said to have been used for trepanation in Peru and examples of such knives are in museums such as that of American Association of Neurological Surgeons (AANS) in Chicago. Majority of trepanations were round in shape but rectangular and squarish types are known. Moreover, 50–70% of cases survived the operations, though some developed infections causing osteomyelitis.

Evidence of trauma and infection in some of the skulls is understandable and these pathologies must have been responsible for the death of those individuals. The presence of sagittal craniosynostosis is interesting and this is representative of the evidence that this anomaly was present from the ancient times. A detailed study of these skulls including bones from other parts of the body may give clues about the diseases prevalent in ancient times. Trepanation does suggest that this was the oldest surgical procedure and the beginning of neurosurgery should be dated from the time of the Neolithic period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wilkinson RG. Trephination by drilling in ancient Mexico. Bull N Y Acad Med 1975;51:838-50.  Back to cited text no. 1
    
2.
Rifkinson-Mann S. Cranial surgery in ancient Peru-Historical article. Neurosurgery 1988;23:411-6.  Back to cited text no. 2
    
3.
Froeschner EH. Historical vignette—two examples of ancient skull surgery. J Neurosurg 1992;76:55-552.  Back to cited text no. 3
    
4.
Banerjee AD, Ezer H, Nanda A. Susruta and ancient Indian neurosurgery. World Neurosurg 2011;75:320-3.  Back to cited text no. 4
    
5.
Misra BK, Singh VP. Neurosurgery in India. AANS Neurosurgeon 2017;26. Available from: https://aansneurosurgeon.org/inside-neurosurgeon/neurosurgery-in-india/. [Last accessed on 2019 Jun 22].  Back to cited text no. 5
    
6.
Valiathan MS. The legacy of Susruta. Orient Longman, Hyderabad, 2007.  Back to cited text no. 6
    
7.
Sankhyan AR, Weber GHJ. Evidence of surgery in ancient India: Trepanation at Burzahm (Kashmir) over 4000 years ago. Int J Osteoarchaeol 2001;11:375-80.  Back to cited text no. 7
    
8.
Satyamurthy T. Archaeological excavations in Tamil Nadu. J Tamil Studies 2018;153-68.  Back to cited text no. 8
    
9.
Sasisekaran B, Sundararajan S, Venkata Rao D, Raghunatha Rao B, Badrinarayanan S, Rajavel S. Adichanallur: A pre-historic mining site. Ind J History of Sci 2010;45:369-94.  Back to cited text no. 9
    
10.
Marshall J. Taxila (an illustrated account of archaeological excavations). Volume III, Cambridge University Press, Cambridge, 1951.  Back to cited text no. 10
    
11.
Stone JL, Miles ML. Skull trepanation among early Indians of Canada and the United States. Neurosurgery 1990;26:1015-20.  Back to cited text no. 11
    
12.
Epstein JA. Ancient skull surgery. J Neurosurgery 1992;77:657-8.  Back to cited text no. 12
    
13.
Clower WT, Finger S. Discovering trepanation: The contribution of Paul Broca (1824–1880 AD). Neurosurgery 2001;49:1417-25.  Back to cited text no. 13
    
14.
Missios S. Hippocrates, Galen and the use of trepanation in the ancient classical world. Neurosurgery Focus 2007;23:1-9.  Back to cited text no. 14
    
15.
Binello HE. Trepanation in ancient China. World Neurosurg 2016, doi: 10.1016/j.wneu. 2016.10.051.  Back to cited text no. 15
    
16.
Jorgenson JB. Trepanation as a therapeutic measure in ancient (Pre-Inka) Peru. Acta Neurochirurgica 1988;93:3-5.  Back to cited text no. 16
    
17.
Assina R, Sarris E, Mammis A. The history of craniotomy for headache treatment. Neurosurg Focus 2014;36:1-6.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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