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A TREPHINED SKULL FROM IRAN ROBERT MALLIN Department of Anthropology and Sociology

TED A. RATHBUN, Ph.D. Assistant Professor of Anthropology University of South Carolina Columbia. S.C.

TREPHINATION of the human skull is a widely practiced procedure among prehistoric, historic, and some modern groups. The surgical removal of part of the calvarium has been documented through the neolithic age.71'1' The skill with which prehistoric man performed these procedures is evidenced by an impressive survival rate, generally agreed to exceed 50%.4,10,16,18 Stewart23 reports a survival of 5 5.6% in a series of 214 trephined skulls from Peru. In studying 400 Peruvian trephinations Rytel20 found that 62.50% showed signs of healing. Trephination also is a widely distributed phenomenon among ancient populations. Although the majority of trephined skulls have been excavated from South America2'20 and Europe,3 Lisowski'0 has documented cases from Asia,9 Africa, 19, 24 North America,, 13, 22 and Melanesia.7 The motives for trephination are not clear, and most hypotheses are controversial.'1724 One of the most widely accepted proposals is that the procedure sometimes was used for the treatment of depressed fractures.'7 This explanation is supported by the number of healed fractures of the skull found in skulls that have been trephined. MATERIALS The skull under study is that of a person I I to 12 years of age from Dinkha Tepe in northwestern Iran. The specimen was disinterred in I966 by the combined efforts of the Hasanlu projects of the University Museum of the University of Pennsylvania Museum, the Metropolitan Museum of Art of New York, and the Iranian Archaeological Service. ]\luscarella'- assigned the specimen to the Iron Age II period, which dates to approximately iioo to 8oo B.C. The cranial remains include the major portion of the vault, the entire maxilla with attached portions Bull. N. Y. Acad. Med.

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of the zygomatic bones, and portions of the mandible. Approximately one half of the left parietal bone, most of the sagittal suture, and a small portion of the right parietal bone are missing.

Posterior view of the trephined skull.

DESCRIPTION

The oval aperture occurs on the posterior third of the right parietal bone, immediately lateral to the midline. Almost two thirds of its borders are intact. The remaining portion of the aperture is 14 mm. wide and 17 mm. long. Visual extension from the remaining borders suggests Vol. 52, No. 7, September 1976

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that the perforation originally was oval and measured about 25 mm. by 14 mm. The medial borders appear to be close to the sagittal suture. A slightly raised area of disturbed bone which extends 8 mm. laterally and 5 mm. anteriorly and posteriorly surrounds the border of the aperture. On both visual and radiographic examination the disturbed bone appears to be more compact than the rest of the skull. This may be seen more clearly in the denser and more compact diplo,, which is exposed on the medial borders of the perforation. A small amount of pitting is visible on the anterior and posterior surfaces; there is little on the lateral surface. The edges of the aperture are beveled. They are smooth but irregular and have small grooves resembling cuts on the edges. Longer grooves of the same appearance occur on the external surface surrounding the aperture. The internal edges of the borders are somewhat less beveled and the area of disturbed bone is less distinct. Under Io-power magnification of the outer surface, the border of disturbed bone is defined more clearly, and more pitting becomes evident on the posterior border. Magnification confirms the denser appearance of the diploe and accentuates the grooves on the borders of the aperture. Radiographs were taken to help determine the condition of the bone immediately surrounding the aperture. An anterior-posterior view, a superior view, and an angled anterior-posterior view were taken. The angled anterior-posterior view shows the edges of the border to be thinner than the surrounding area. The superior view confirms the thinness of the edges and clearly shows the bone around the perforation to be disturbed and denser than the surrounding bone. DIAGNOSIS To confirm the authenticity of this trephination, a number of other possibilities must be ruled out. Three parietal conditions that could confuse diagnosis are enlarged parietal foramina, fenestrae parietales symmetricae, and bilateral osteoporosis of the parietals.10 Parietal foramina may, on rare occasions, have diameters of 3 to 4 cm. This condition is thought to be a genetically transmitted defect of development. Unusually large parietal foramina are generally found in males on the right side but they are sometimes bilateral. It proved difficult to rule out this possibility completely. Since parts of the left parietal bone are absent, it is impossible to cite two normal-sized parietal Bull. N. Y. Acad. Med.

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foramina as evidence against the condition. However, the evidence of osseous regrowth around the lesion clearly rules out a nontraumatic anomaly such as enlarged parietal foramina. The smoothed, although slightly uneven, edges with beveling also indicate the regrowth of bone.'18 Fenestrae parietales symmetricae, or Catlin marks,8 is a known hereditary condition that may be found separately or in conjunction with enlarged parietal foramina. Lisowski10 reports that the fenestrae are oval or circular, located on the parietal bone, and may have edges that appear healed. The appearance of healed edges makes this condition difficult to rule out. The anomaly is hereditary, however, and it seems unlikely that only one individual in the population of Dinkha Tepe or the closely related population at Hasanlu would display this condition (154 were examined) *25 Also, the cut-like grooves along the borders of the perforation suggest trauma rather than heredity as the cause of this lesion. The probably inflammatory osteitis, as evidenced by the fine pitting around the borders, also supports this conclusion. The evidence here is overwhelmingly against Catlin's mark. It was simple to rule out the third possibility, bilateral osteoporosis of the parietal bone. This lesion is manifested by a rarefaction of the bone with an increase in porosity and a decrease in the thickness of the cortex.3 These conditions may result in perforation of the parietal bone, which may lead to a mistaken diagnosis of trephination.10 Both radiographically and under magnification the specimen shows none of the typical manifestations of osteoporosis-the area around the perforation being dense and thick, rather than porous and thinned. Thus, osteoporosis is the least likely possible cause of the perforation. DISCUSSION Regeneration of bone provides the strongest argument for trephination, since very few other perforations of the skull involve regrowth of damaged bone. In the present case the regrowth is documented by the dense diploe, the beveled but uneven edges, and the raised and disturbed area of bone surrounding the aperture. The fine pitting around most of the perforation suggests osteitis, a common finding in trephined skulls.24 Finally, the cuts or grooves on the borders of the perforation suggest trauma similar to that caused by a trephining instrument. These observations are supported by examination under io-power magnificaVol. 52, No. 7, September 1976

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tion and radiography. A similar example was found among the skeletons of Lerna, Greece from a comparable time.' If the dense diploc is indicative of the amount of osseous regeneration, annular regrowth of up to 5 mm. may have occurred. This would indicate prolonged survival, since bone regenerates slowly. The large area of disturbed bone, the oval shape of the aperture, and the cut-like grooves suggest that scraping rather than boring or sawing was used.16 Without the lateral or the medial border of the aperture, it is difficult to state whether the sagittal suture was involved. Although involvement of the sagittal suture would be dangerous because of the subjacent blood vessels, several healed trephinations involving the suture have been reported.4"0 Great skill must have been required to carry out such a procedure successfully. Since there is no direct evidence of fracture in the area of trephination, the reason for the operation is not clear. It may have been a ritualistic procedure, but if this is the case why were other examples not found in the same population? If the procedure was therapeutic, was it done for relief of traumatic subdural hematoma, chronic headache, epilepsy, or some other malady? The skeletal material does not provide the answer. SUMMARY We have described the skull of a subadult from the Iron Age in Iran. It exhibits a fairly large perforation of the right parietal bone. Trephination seems the most probable diagnosis. The patients survived the operation for some time. The purpose of the procedure was not ascertained.

ACKNOWLEDGMENTS We thank Robert Dyson and Oscar White Muscarella for the opportunity to study the skeletal remains from Dinkha Tepe, the student health center at the University of South Carolina for the radiographic work, and the Institute of Archaeology and Anthropology at the University of South Carolina for the photography.

Bull. N. Y. Acad. Med.

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REFERENCES 1. Angel, J.: The People of Lerna. Washington, D.C., Smithsonian Institution Press, 1971. 2. Bandelier, A. F.: Aboriginal trephining in Bolivia. Amer. Anthrop. 6:440, 1904. 3. Brothwell, D.: Biparietal Thinning in Early Britain and Evidence for Neoplasms. In: Diseases of Antiquity, Brothwell, S., editor. Springfield, Ill., Thomas, 1967. 4. Cave, A.: The surgical aspects of the crichel trepanation. Prov. Prehist. boc. 6:131-32, 1928. 5. Cosgrove, C. B.: A note on a trephined Indian skull from Georgia. Amer. J. Phys. Anthrop. 13:353, 1929. 6. Derry, D.: Parietal perforation. J. Anat. 48:417-29, 1914. 7. England, W.: Trephining through the ages. Radiography 28:301-14, 1962. 8. Goldsmith, W.: Trepanation and the "Catlin mark." Amer. Antiquity 10:348,

1945. 9. Hilton-Simson, M. W.: Some Arab and Schawia remedies with a note on trephining. J. Roy. Anthrop. Inst. 43:71522, 1913. 10. Lisowski, F. P.: Prehistoric and early historic trepanation. Amer. Anthrop. 49:25, 1947; also in Diseases of An-

tiquity, Brothwell, S., editor. Springfield, Ill., Thomas, 1967. 11. MaCurdy, G.: Prehistoric surgery: A neolithic survival. Amer. Anthrop. 7:17, 1905. 12. Malcolm, L.: Prehistoric and primitive surgery. Nature 133:200, 1934. 13. McGregor, J. C.: A trephined Indian skull from Illinois. Amer. Anthrop. 53:

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148, 1951. 14. Moodie, R.: Ancient skull lesions and the practice of trephining. Surg. Clin. (Chicago) 3:481-96, 1919. 15. Muscarella, 0. W.: Excavations at Dinkha Tepe, 1966. Metrop. Mm. Art Bull. 27:187-96, 1968. 16. Podolsky, R.: Skull surgery in prehistoric man. Med. Ann. D.C. 31:268-74, 1962. 17. Popham, R.: Trepanation as a rational procedure in primitive surgery. U. Toronto Med. J. 31:204-11, 1954. 18. Rogers, S.: The healing of trephined wounds from pre-Columbian America. J. Phys. Anthrop. 23:321, 1964. 19. Ruffer, M. A.: On osseous lesions in ancient Egyptians. J. Path. Bact. 16: 439, 1912. 20. Rytel, M.: Trephinations in ancient Peru. Bull. Pol. Med. Sci. Hist. 30: 365, 1962. 21. Salib, P. Orthopedic and traumatic skeletal lesions in ancient Egyptians. J. Bone Joint Surg. 44b :944-47, 1962. 22. Smith, H.: Trephined aboriginal skulls from British Columbia and Washington. Amer. J. Phys. Anthrop. 7:447, 1924. 23. Stewart, T. D.: Stone age skull surgery. Smithsonian Inst. Rep. 1957:469, 1958. 24. Wells, C.: Bones, Bodies and Disease, London, Thames and Hudson, 1964. 25. Rathbun, T. A.: An Analysis of Physical Characteristics of Ancient Inhabitants of Hasanlu, Iran. Study No. 68, Field Research Projects. Miami, Field Research Projects, 1972.

A trephined skull from Iran.

7 82 A TREPHINED SKULL FROM IRAN ROBERT MALLIN Department of Anthropology and Sociology TED A. RATHBUN, Ph.D. Assistant Professor of Anthropology Un...
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