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Prehistoric Skull Trepanation in China

Xianli Lv1, Zhenguang Li2, Youxiang Li1

The term trepanation describes the removal of sections of bone from thecranium. Although others may have made earlier reference to trepanation, in1995, Chinese archeologists discovered a skull at the Neolithic site Fujia fromapproximately 3000 BC (the Dawenkou Cultural Period), Guangrao, Dongying,Shandong, China, and after careful examination of the specimen, the archeolo-gists suggested that the procedure had been performed on a living patient whosubsequently survived. Archeological evidence supports that the practice oftrepanation was widespread.

Key words- Prehistory- Skull- Trepanation

From the 1Beijing Neurosurgical Institute andBeijing Tiantan Hospital, Capital Medical

University, Beijing; and 2Shandong Provincial Institute ofCultural Relics and Archaeology, Shandong, People'sRepublic of China

To whom correspondence should be addressed:Youxiang Li[E-mail: ttyyzjb@sina.com]

Citation: World Neurosurg. (2013) 80, 6:897-899.http://dx.doi.org/10.1016/j.wneu.2012.08.009

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter ª 2013 Elsevier Inc.

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Figure 1. Stone artifacts (A) and bone needles (B) made using a borer. These archeological artifactswere found at the Early Neolithic site Dawenko, Taian, Shandong, China, in 1959.

INTRODUCTION

The term trepanation describes the removalof sections of bone from the cranium (6).The instrument used to accomplish thisprocedure is the trepan, which derivesfrom the Greek word trypanon, meaning“borer” (Figure 1). The term trephinationrefers to the specific creation of a circularsaw, a trephine, or a more moderninstrument (10). At the present time,there is almost universal acceptance ofthe existence of antemortem cranialsurgery in prehistory; archeologicalevidence supports the theory that thepractice was widespread, with skullspecimens found in Europe, Asia, Africa,North America, Central America, SouthAmerica, and Oceania (3, 5-7, 9-13).Previous authors believed that there wereno skull specimens of trepanation in theFar East and China until the report byApuzzo et al. (1). Nevertheless, moretrepanned skulls have been found in thisregion than in the rest of the worldcombined. Presumably, the Chinesereports are not well known in the Westbecause most have not been translated; itis hoped that this article corrects thisproblem (2). The present article would bea much more important contribution if it

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placed more emphasis on the availablereports from China.

SKULL DESCRIPTION

This skull, which was found in the gravenamed M392, was found in a review ofmore than 400 graves of the Neolithic siteFujia (Figure 2). It is a round skull ofa man, found in a rectangular tomb 1.9meters in length, 0.6 meters in width, and0.3 meters in depth. The only funeraryobject is a pottery tripod. The skull showsa circular defect 3.1 � 2.5 cm2 in diameterin the right parietal region, 2.0 cm fromthe interparietal suture and 2.3 cm fromthe occipital suture. The edges of theopening are clearly defined, and the adja-cent bone surfaces are smooth and do notshow alterations. It is particularly inter-esting that the hole has been firmly sealedby a dense cortex of bone. The sutureshave a normal appearance, and nothingunusual can be seen on the floor of thebase of the skull. The sella turcica and theclinoid processes are normal. A computed

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tomography scan confirmed this analysis(Figure 3).

DISCUSSION

To date,>1500 specimens have been foundand examined. The oldest examples oftrepanation, dating back to 10,000 BC, maybe specimens found in North Africa.Excavations in the Jericho area in the NearEast and Asia have produced specimensfrom approximately 8000 to 6000 BC. Theearliest European examples are >10,000years old, dating perhaps to the latePaleolithic period but certainly to theNeolithic age (6, 10). Early Danubians wereperforming cranial surgery in 3000 BC, andancients from the Seine-Oise-Marne area ofFrance were similarly active in 2000 BC.Based on the number of skulls that havebeen found in France, it is probable thata veritable “surgery center” existed therebetween 1900 BC and 1500 BC. Trepanationspecimens have also been found in otherregions of Neolithic Europe, the Balkans,and Russia. New World specimens of

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Figure 2. (A) Skull specimens found at the Neolithic site Dawenko, Taian, Shandong, China, in 1959.(B) Map showing the Neolithic sites Fujia, Guangrao, Dongying and Dawenko, Taian, Shandong,China.

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XIANLI LV ET AL. PREHISTORIC SKULL TREPANATION

trepanation aremuchmore recent, with theoldest examples dating to 400 BC, found onthe southern coast of Peru.Previous authors believed that there were

no skull specimens of trepanation in the FarEast and China until the report by Apuzzoet al. (1). Nevertheless, trepanned skulls

Figure 3. Skull (A) and computed tomography scan oftrepanation. Despite primitive instrumentation and crsurprisingly successful.

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have been found in this region. Chinesearcheologists discovered trepanned skulls atthe Early Neolithic sites of Liuwan, Fujia,Shanshan, Shangnan, and Chifeng fromapproximately 3000e1000 BC (3000e5000years up to this time) in 1974, 1995, 1998,2006, and 2007 (Figure 4) (4, 14-17).

skull (B) showing evidence of bone healing afterude methodology, prehistoric surgeons were

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Despite the plethora of physical evidenceof prehistoric trepanation, insight intothe motivation to the practice has beenmuch more problematic and controversial(6, 8, 10). In the absence of written records,scholars are left to speculate, invokinga combination of motives as varied astherapeutic,magic-therapeutic, andmagic-ritual. Given the tendency of Peruvian,Danish, and Chinese skulls (Figure 3) tohave openings in the left temporoparietalregion, it follows that trepanations wereperformed therapeutically for injuries fromblows by a right-handed assailant. Ritualwas believed to be an important motivationfor the development of the trepanation“center” in Neolithic France. In somepostmortem operations, roundels ofcranial bone were presumably obtained foruse as charms, amulets, or talismans.These speculations are supported byobservations of the practice of modern-dayEast African tribes, in which the Kisii tribeperforms trepanations primarily to alleviateheadache after a blow, whereas the nearbyLugbara tribe desires to release evil spirits.A novel speculation proposes that opera-tions on the head were aimed at resurrect-ing the dead (8). Prioreschi (8) argued thatNeolithic man appreciated the contrastingoutcomes of “fatal” blows by piercingweapons to the chest or abdomen and bluntinstruments to the head. For example,“death” by piercing the chest or abdomenwas generally permanent, whereas victimsoften recovered from ostensibly fatal blowsto the head. Thus, Neolithicman attemptedto revive the dead by surgically manipu-lating the head. However, this eleganttheory suffers from lack of concreteevidence and has faced the same criticismas earlier speculations.In regard to the skull described in this

report (Figure 2), we speculate that thera-peutic trepanation was performed fora man with brain disease. He was a poorand ordinary member of the tribe becausehis tomb is small with only a small funeraryobject. Also, if the trepanned skull is anexample of a magic-ritual motive, it shouldnot be the sole skull found among the Fujiagraves.However motivated, prehistoric

surgeons used essentially four differenttechniques to remove pieces of cranialbones: (i) scraping, (ii) grooving, (iii)boring and cutting, and (iv) rectangularintersecting incisions (6, 10, 13). The

dx.doi.org/10.1016/j.wneu.2012.08.009

Figure 4. Map showing that the practice of trepanation spread from east to west in China between3000 to 5000 years up to this time.

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earliest instruments were made of flakedstone, flint, obsidian, and bone. Later, theancient Peruvians used curved tumi bladesto incise soft tissue and make rectangularcuts in the bony cranium. Sharp instru-ments were used to make grooves and drillholes, which could then be connected. Flatscrapers were also used with good effect,and in Mexico, a bow and obsidian drillmay have been used. Although the primi-tive surgical instruments have survived tothe present day, specific evidence of theuse of anesthetics is lacking. Scholars havespeculated that alcohol, narcotics, or cocoproducts were administered to alleviatepain. However, contemporary East Africanpatients undergo trepanation withoutanesthesia, and a survivor in Boliviaadmitted that although the incision of thesoft tissue is painful, analgesia is not anoverriding issue once the bony cranium isstripped of the pericranium (3).Despite the primitive instruments and

lack of fundamental medical knowledge,prehistoric surgeons were surprisinglysuccessful (3). Evidence of healing in thearcheological specimen indicates thatpatients survived (Figure 3). In some groupsof ancient skulls, 80% of Neolithic andMelanesian patients survived the operation.In present-day Africa, operators claimmortality rates of <5%. Ancient Peruvians

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faced >50% mortality. However, it isbelieved that many of their patients werevictims of trauma, and the confoundingcontribution of the traumatic injury couldaccount for the poorer results (1).

CONCLUSIONS

This article confirms that more trepannedskulls have been found throughout China,dating earlier and more widely spread thanprevious reports indicated.

REFERENCES

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2. Arnott R, Finger S, Smith CUM, eds. Trepanation:history, discovery, theory. Lisse, Netherlands:Swets & Zeitlinger; 2003.

3. Aufderheide AC: The enigma of ancient cranialtrepanation. Minn Med 68:119-122, 1985.

4. Dongmei W: Puzzle of skull trephination inShanshan. Available at: http://www.tianshannet.com.cn/GB/channel8/923/200512/14/208959.html.

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6. Lisowski FP: Prehistoric and early historic trepa-nation. In: Brothwell D, Sandison AT, eds.Disease in antiquity. Springfield, Charles C.Thomas; 1967:651-672.

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7. Marino R Jr, Gonzales-Portillo M: PreconquestPeruvian neurosurgeons: a study of Inca and pre-Columbian trephination and the art of medicinein ancient Peru. Neurosurgery 47:940-950, 2000.

8. Prioreschi P: Possible reasons for Neolithic skulltrephining. Perspect Biol Med 34:296-303, 1991.

9. Rifkinson-Mann S: Cranial surgery in ancientPeru. Neurosurgery 23:411-416, 1988.

10. Saul FP, Saul JM: Trepanation: old world and newworld. In: Greenblatt SH, ed. A history of neuro-surgery in its scientific and professional contexts.Park Ridge: AANS Publications Committee; 1997:29-35.

11. Stone JL, Miles ML: Skull trepanation among theearly Indians of Canada and the United States.Neurosurgery 26:1015-1020, 1990.

12. Velasco-Suarez M, Martinez JB, Oliveros RG,Weinstein PR: Archeological origins of cranialsurgery: trephinations in Mexico. Neurosurgery 31:313-319, 1992.

13. Wilkinson RG: Trephination by drilling in ancientMexico. Bull N Y Acad Med 51:838-850, 1975.

14. Willow bay skull puzzle. Available at: http://www.gs.xinhuanet.com/gansucaitao/2006-05/16/content_6990679.html.

15. Xuan MA: Is skull trephination a magic ritual oroperation?Available at: http://www.swcf.cn/epaper/hswb/html/2007-09/07/content_20265.html.

16. Yantao Z: Prehistoric “little giant” skull with 3holes found in Shanxi. Available at: http://www.jcrb.com/pic/xinwentupian/201009/t20100909_416891.html.

17. Wei D: The riddle of skull boring in Shanshan.Available at: http://www.tianshannet.com.cn/big5/culture/content/2005-12/14/content_208959.htm.

Conflict of interest statement: The authors declare that thearticle content was composed in the absence of anycommercial or financial relationships that could be construedas a potential conflict of interest.

Received 06 October 2011; accepted 11 August 2012;published online 25 September 2012

Citation: World Neurosurg. (2013) 80, 6:897-899.http://dx.doi.org/10.1016/j.wneu.2012.08.009

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter ª 2013 Elsevier Inc.All rights reserved.

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