A RetRospective study on tRepAnAtion in AnAtoliAyilmAz selim eRdAl

AbstrAct

Forty trepanations in 23 settlements were observed in Anatolia up to now. All off the known techniques were used in the cranial surgery in Anatolia. Early case of trepanation, dated to the aceramic Neolithic period in Anatolia, put into practice with drilling techniques. Scraping and rectangular sawing techniques were first applied in the Early Bronze Age. It is observed that boring-and-cutting technique was only applied in Iron Age. However, a very similar case of this technique was found in the Roman period, Perge. Trauma was the main motive for trepanations in Anatolia. Reasons other than cranial trauma were also taken into consideration for trepanation in Anatolia, i.e. tumor and training.

IntroductIon

Trepanation is defined as the removal of a bone piece of the skull of a living individual without penetration of the underlying soft tissues.1 Trepanation is accepted as the oldest form of surgical operation.2

With its oldest examples encountered in Africa and the Middle East, cranial trepanation among ancient populations3 was independently practiced in many areas of the world, manifesting the highest concentrations in Peru, Bolivia.4 Since the year 1958, when the first publication on trepanation in Anatolia was made, the examples have reached to an important number in the last 20 years. However, the information on trepanation in Anatolia is generally based on the description of single cases.5 In this study, techniques and possible reasons of trepanations in ancient Anatolia were discussed from a historical perspective.

MAterIAl And Methods

Forty individuals from 23 different Anatolian settlements are identified to have been subjected to trepanation (Fig. 1). In this study, four main techniques of trepanation

1 Lisowski 1967; Steinbock 1976; Özbek 1993.2 Crubezy et al. 2001.3 Özbek 1992; 1999.4 Gomez 1973; Rifkinson-Mann 1988.5 I.e. Şenyürek 1958; Angel 1971; 1972; Alpagut 1986; Angel, Bisel 1986; Özbek 1992; 1999; Güleç,

Açıkkol, 2001; Erdal 2006: 2007; 2008.

include: (1) drilling, (2) scraping, (3) cutting, and (4) boring-and-cutting.6 Motives of the trepanations are discussed with signs of diseases together with the trepanned skulls.

technIques of trepAnAtIon In AnAtolIA

One of the most widespread techniques of trepanation in Anatolia is drilling. The frequency is about 32.5%. The oldest examples of this technique were observed on Aşıklı and Çayönü skulls. The cases from Aşıklı and Çayönü (Fig. 2) were a circular hole about 11.5 on occipital and 8-10 mm on parietal, respectively.7 Another case dated to the Neolithic period from Çatal Höyük,8 trepanation, was performed as two set-back circular holes 6 mm in diameter, belonged to a sub-adult female.9 On the right parietal bone of the Kuruçay skull from Early Chalcolithic Age levels, three holes were identified.10 Neolithic and Chalcolithic Age trepanations were generally quite small in size and ranged from six to 11.5 mm in diameter.

The only case on which drilling technique was performed in Bronze Age was from the Acem Höyük. The trepanation 30-40 mm in diameter was made using the drilling technique on the right parietal of this case, near the bregma. The Acem Höyük case was distinguished from the drilling techniques in Neolithic and Chalcolithic ages by its bigger dimensions.

The drilling technique commonly used in the Roman Period also (71.4%). On a skull unearthed from the Western necropolis of the Perge (no. M6-4 B4), a trepanation 38.5 mm in diameter was identified on right parietal tuber (Fig. 3). On the three individuals from the Cevizcioğlu Çiftliği, trepanations were made with the drilling technique. Two holes were found on the left side of the cranium belonging to an old female individual (CÇ M 13). Similarly, in the other case, two trepanations were attempted on a skull belonging to a male individual. The first attempt was bored on the left parietal; the other attempt was an incomplete trepanation close to the first hole (CÇ M 35/1). The last case of surgical intervention performed by the drilling technique from Cevizcioğlu was observed on the young adult male individual (ÇC M 23).

The drilling technique was used in the two of the trepanations dated to the medieval period. In the Kovuklukaya case, the trepanation made on the right frontal tuber was performed through the external table and diploë (Fig. 4). In Allianoi, a site which served as a healing center during the Roman period, one of graves that were excavated at the layer dated to the Byzantine period. Trepanations of small dimensions were observed on the left parietals of the two males unearthed from the Late Ottoman graves located in the

6 Lisowski 1967; Campillo 1984; Knaufman et al. 1997.7 Özbek 1992; 1999.8 Angel 1971.9 Angel 1971.10 Güleç, Pelin 1998.

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Karacaahmet Cemetery, Istanbul.11 Drilling was the oldest technique in Anatolia, but it was used until the Ottoman period and it continues to be used nowadays in neurosurgery in modern clinics.

trepAnnIng wIth scrApIng

Scraping is defined12 as removing the required area of bones by gradually scraping away bone tissues. With 12.5 per cent, scraping is the least frequently used technique in Anatolian cases. In the light of the most recent data, the İkiztepe individual (SK 404) constitutes the earliest example of scraping technique (Fig. 5). On this individual, an oval shaped opening was identified on the parietal tuber.13 On the middle aged female from Bakla Tepe,14 there was a circular lesion, on the middle of the sagittal suture. Although the external table and diploë were affected with the appearance of a broad crater, the internal table was an incomplete or symbolic trepanation. On one male individual from Cevizcioğlu Çiftliği (ÇC M8), an oval shaped trepanation was observed on the left frontal tuber.

Two scrapped trepanations were detected in Nicaea Roman Amphitheater that used a cemetery in the Byzantine period. The first case of the trepanations found on the adult male, located on the left parietal (İTK 93). The other case had an oval shaped opening on the left side of the lambdoid suture (İTK 81/10). These trepanations have beveled margins all around the orifice.15

The scraping method with large rings of abrasion around opening, easily permit the differentiation of this procedure from the other techniques.16 Some of the researchers believe that the oldest technique of trepanning is scraping. This technique has been used since the Neolithic until the present day.17 However, this technique was first observed in Anatolia after the first half of 3rd millennium BC and continued to be used until the medieval period.

trepAnnIng wIth sAwIng

Sawing technique can be described as a series of cuts drawn and redrawn on the skull with a sharp instrument, until a piece of bone in a circular, ovoid or rectangular form between the grooves becomes loose and can be removed. Sawing was the most common technique that was seen in Anatolia (37.5%).

11 Güleç 1995.12 Lisowski 1967.13 Erdal 2005.14 Erdal 2006.15 Özbek 1988; 1994.16 Campillo 1984; Lisowski 1967; Mays 2006.17 Piggot 1940; Lisowski 1967; Vlček 1972; Meschig, Schadewaldt 1981; Prioreschi 1991; Piek et al.

1999; Arnott et al. 2003; Weber, Wahl 2006.

A Retrospective Study on Trepanation in Anatolia 3

The earliest examples with irregular shaped or un-described form were unearthed from Kurban Höyük and Kültepe. Alpagut18 grooves on the right side of the occipital bone of a skull from an Early Chalcolithic layer of Kurban Höyük. The trepanation recovered from Kültepe/Kaniş, dated to the Assyrian Trade Colony period, was described ‘a section of bone has been cut and extracted from the left side of the squama of os occipitale’.19

A case of trepanation in İkiztepe consisted of a triangular opening starting from the obelion on the sagittal suture (Fig. 6) and continuing towards the occipital (SK 409). With the size (102x87 mm), this individual had the largest trepanation opening discovered in Anatolia with healing.

Trepanning with Circular or Ovoid Plan

This cutting procedure in a circular or ovoid shape is same to grooving described by Lisowski.20 There exist examples on which the cutting procedure was done in a circular or ovoid plan in Anatolia. The trepanation gathered from Küçük Höyük21 consisted of three adjoining orifices that started from the lambdoid suture on the right parietal and continuing to the baseline of the skull. It is measured more than 100 mm in one side. On another individual from İkiztepe, an oval trepanation was observed on the bregma (SK 420). Other examples showing an area cut in the circular plan were dated to the Byzantine period. The trepanation on an individual (İTK 85 32/2) was in the ovoid form on the frontal and parietal bone including bregma.22 In another case from İznik (İTK unnumbered), an oval shaped area on the right side of the frontal bone was cut out. The last case which was dated to the medieval period was unearthed from the ancient city of Van.23

Rectangular Sawing

The cutting technique in which four straight incisions are made, intersecting at right angles and the in-between fragment is removed.24 In the light of the present data, the earliest examples of the rectangular sawing technique were encountered in the Bronze age as well; its typical examples were represented by two individuals from İkiztepe (SK 536 and SK 603)25 and one individual from Çavlum.26 Hundreds of scratches that related to the cut out the borders and the skin, run either parallel or partly perpendicular to margins of trepanation were observed on İkiztepe individuals (Fig. 7). The latest skeletal remains which were trepanned by the rectangular sawing technique were dated to the Ottoman

18 Alpagut 1986.19 Şenyürek 1958: 52.20 Lisowski 1967.21 Güleç, Açıkkol 2001.22 Özbek 1994.23 Gözlük et al. 2004: 56.24 Lisowski 1967.25 Erdal 2005; 2007.26 Güleç et al. 2004.

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period.27 The case was distinguished from the Bronze Age cases. The frequency of this technique among the Anatolian trepanations was 10%.

It is believed that rectangular sawing is the most ancient surgical procedure in a part of South America, especially in Peru.28 In Eurasia, a case of rectangular trepanation was found in France29 and two others dated to the Iron Age were discovered in Tell Duweir, Plastine (7th-8th century BC).30 It was also used among the traditional populations in Algeria and Kenya. However, this type of trepanations was not commonly found in Eurasia, Anatolia notwithstanding.31 Rectangular sawing was used in the Early and Middle Bronze Age population in Anatolia.

borIng-And-cuttIng

In the boring-and-cutting technique, the bone is perforated by a drill of closely adjoining perforations, which are then connected by cuts a sharp instrument.32 This technique was observed on five individuals (12.5%) in Anatolia. Two middle adults were identified from Karagündüz in the Province of Van.33 On one of these cases nine or ten circular holes on the right parietal were observed. Another example of the trepanation was made on the frontal of an adult female that was recovered from a chamber tomb in Hakkari.34

Two other examples were identified in a chamber tomb in Van-Dilkaya.35 The first case belonged to a young adult individual whose parietal bone had five adjacent perforations. On another case belonging to a young adult female, the surgical intervention was performed with 13 holes on the right parietal. The bone flap was also discovered in the same chamber tomb where the skull was unearthed. The histological analysis done on the bone flap suggested that this individual survived after the operation.

From the examples at hand, it can be said that the boring-and-cutting technique was restricted to the Eastern Anatolian during Iron Age. Boring-and-cutting technique was known in South America in ancient times36 and might have been used after the rectangular sawing and drilling techniques in Peru.37 Some examples of the technique were found in Monte Albán Mexico.38 stewart39 suggested that this technique is a somewhat uncommon procedure. In a review of trepanation, Parker40 suggested that this technique was unknown

27 Güleç et al. 1999.28 Lisowski 1967; Gerszten et al. 1998.29 Piggot 1940; Stewart 1957; Lisowski 1967.30 Starkey 1936.31 Vlček 1972; Gomez 1973; Piek et al. 1999.32 Lisowski 1967.33 Sevim et al. 2002.34 Gözlük et al. 2004.35 Güleç 1989; 1995.36 Rytel 1956; Stewart 1957; Lisowski 1967; Wilkinson 1975; Campillo 1984; Jørgensen 1988; Verano

2003; Nystrom 2007.37 Rytel 1956.

A Retrospective Study on Trepanation in Anatolia 3

in Europe. Only a case of multiple drill holes found in Austria similar to this technique was related to extraction of amulet that found with a child burial.41

On one of male cranium from the Western Necropolis in Perge (M6 4.1), a trepanation similar to boring-and-cutting techniques was discovered (Fig. 8). On the right frontal, two arching rows, each consisting four orifices are observed. All of the holes were identical in their dimensions and shape: each hole is 6.5 mm in diameter and truncated cone shaped. There are a lot of scratches both around and inside of the holes related to mechanical intervention were observed. This case is similar to Celsus’ definition for boring-and-cutting technique. This indicates that the technique described by Celsus was in use in Anatolia 1000 years before his day. Another example resembling this uncompleted trepanation was found also on a child that was included in Son Real (Alcudia, Mallorca, 5th century BC), Spain.42

MotIves of trepAnAtIons In AnAtolIA

In many studies based on archaeological and ethnographic research, and historical writings show that there are traditionally two main motives of trepanations: therapeutic or magical or ritual purposes.43 Many studies done on skeletal remains pointed that therapeutic motive was important among ancient populations. Studies examining cranial surgery in different parts of the world conclude that trepanations with therapeutic motives were mainly associated with traumatic lesions. In the 20 out of 40 trepanations in Anatolia it was determined that treatment was the purpose for surgery. The most important motive stood out as cranial traumas.

Judging from the healed and unhealed cranial injuries from the Early Bronze Age cemetery in Karataş, Angel stated44 that clear marks of battle was observed and it was considered that two male individuals were trepanned due to cranial injuries. Examples carrying apparent signs of trauma during the Early Bronze Age were found in İkiztepe.45 Lateral border of trepanation opening on male individual had sign of cranial trauma (SK 420). The unhealed trapezoidal-shaped trepanation on another individual (SK 536) bore the undisputable marks of trauma, providing proof for a trauma induced motivation for surgery. On this individual, small cut marks which occurred during the cutting procedure on the anterior, medial, and lateral borders of the opening were observed. In addition, scratches were observed around the mentioned borders on the external table. However, on the posterior border of the trepanation, no cut marks or scratching were detected. Whereas

38 Wilkinson 1975.39 Stewart 1957.40 Parker et al. 1986.41 Breitweiser 2003.42 Campillo 1993.43 Piggot 1940; Lisowski 1967; Margetts 1967; Parker et al. 1986; Jackson 1988; Jørgensen 1988;

Rifkinson-Mann 1988; Grmek 1989; McKinley 1992; Mariani-Constantini et al. 2000; Gross 2003; Powers 2005; Mays 2006; Weber, Wahl 2006; Rubini 2008.

44 Angel 1972.45 Erdal 2005.

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the internal surface of the trepanation no fracture or depression was detected on its three borders, an irregular fracture mark was present on its posterior border. It is concluded that cranial defects caused by sharp edged injury tend to show internal beveling at its posterior border.46

In a study done on 445 well-preserved skulls from İkiztepe, it is found that 43.4% of the male individuals had cranial trauma. It is the highest frequency among the ancient Anatolian populations. High frequency of cranial trauma and perimortem death of 17 male individuals suggest that a battle had taken place in İkiztepe. The trepanation on this individual considered as a treatment of the trauma related to wounds result from the battle.47

Trauma-induced trepanations were also present on the cases from Gordion,48 Perge and Cevizcioğlu Çiftliği (CÇ’95 M8), all dated to the Roman period. On the Perge sample (M6 4 B4), a circular type of trepanation opened with a modiolus, as described by Celsus. A trauma was present on the lateral edge of the orifice on the right parietal. In Celsus’ descriptions,49 it was stated that cranial injuries were treated not only by using the modiolus and trepan but also by cutting or scraping the region around the injuries. These data indicated that, in the Roman period Anatolia, all the techniques described by Celsus were utilized, particularly in Perge and Cevizcioğlu Çiftliği necropolises.

Traces of surgery that obviously point to trauma were also observed on the İznik dated to the Late Byzantine period.50 On the cranium belonging to male individual, there was an opening in the middle portion of the left parietal (İTK 81/10). On the anterior and posterior border of the trepanation from İznik case, healed fracture lines were also observed.51 The fracture lines observed around the ovoid opening on the right parietal of another İznik case were associated with a trauma induced by a blunt weapon (İTK un-numerated). On the third individual from İznik, there was an injury on the posterior borders of the trepanation (İTK 85 32/2). This trepanation must be resulted from a sharp-edged incision related to axe or sword (Fig. 9).

In a study done on 558 Byzantine individuals buried in the Roman Amphitheater in İznik, 90% of them were identified as males. Most of the individuals’ age-at-death distributed between 20 and 40 years old. When the demographic data were considered together with 20% cranial traumas related to projectile points and blunt and sharp-edged weapons, it is understood that this cemetery was not belonged to ‘common people’ but belonged to ‘warriors’.52

Examples pointing to surgical intervention for therapeutic motives other than trauma were also discovered in Anatolia. A trepanation opened with the rectangular sawing technique on a male individual from İkiztepe (SK 603) was mentioned earlier. On this

46 Erdal 2005.47 Erdal 2005.48 Güleç 1995.49 Celsus, De Medicina Vol 3: Part 8, pp. 501-503.50 Özbek 1988; 1994.51 Özbek 1988; 1994.52 Erdal 1996.

A Retrospective Study on Trepanation in Anatolia 3

individual, a meningioma was encountered on the internal surface of the left parietal tuber, probably on the motor and sensory cortex. The trepanation was performed not in the region where the tumor was located but on the right side of the sagittal suture. This trepanation is not evaluated as a truly therapeutic operation but as a magical therapeutic reasoning to remove the negative effects of the tumor.53 The fact that the trepanation was not performed on the same area as the tumor led it to be evaluated not as a truly therapeutic operation but as a magico-therapeutic reasoning to remove the negative effects of the tumor.54

It is generally accepted that religious or magico-therapeutic motieves is also important for trepanations.55 It is known that trepanation was made use of with the aim of relieving the evil spirits from the head,56 taking out the stone in the head,57 perforating the head for lengthening life,58 obtaining magical medicine,59 and treating cases like headaches, to treat madness, melancholy, epilepsy and evaporate the humor and air inside the head.60 However, it is very difficult to distinguish magic from treatment procedures since they have been intertwined with each other in prehistoric and modern traditional societies.61 For this reason, in cases where no accompanying evidence are found on the cranium, the majority of explanatory assumptions do not go further than being mere speculations. In half of 40 trepanations gathered from Anatolia, no definitive evidence with respect to the motives for the surgical intervention was available.

It is accepted that some of information related to brain anatomy was gathered by dissecting and vivisecting cadavers during antiquity.62 On an individual from Perge, whose right side of the frontal bone had eight orifices on the two arching rows, as mentioned before. The holes were bored in such a way that would have formed two circles if they had been completed, a characteristics that showed resemblance with boring-and-cutting technique described earlier. Campillo63 described an example from Son Real, Spain (dated to the 5th century BC) as a trepanation made postmortem using the drilling technique. On the basis of the structural similarities of these trepanations as well as the information available on the surgical operations provided by antic writers, it is possible to obtain some clues about the motives for them. Wilkinson64 emphasized that cases of uncompleted trepanations would have suggested that the surgery was experimental. This example

53 Erdal 2007.54 Lisowski 1967.55 Margetts 1967; Lisowski 1967; Steinbock 1976; Zvanovic 1982; Campillo 1984; Capasso, Di Tota

1996; Holck 2008.56 Margetts 1967.57 Holck 2008.58 Lisowski 1967.59 Janssens 1970; Ortner 2003.60 Moodie 1923: 97-113; Lisowski 1967; Margetts 1967; Steinbock 1976; Parker et al. 1986; Gross

2003.61 Roberts, McKinley 2003.62 Jackson 1988; Celsus, De Medicina.63 Campillo 1993: 62, Fig. 1.

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along with the antic texts indicated that training purposes might have also been a likely reason.

conclusIon

At the end of this study it can be concluded that:- All of the known techniques were used in the cranial surgery in Anatolia- Early cases of trepanation were put into practice with drilling- Scraping and rectangular sawing techniques was first applied in Early Bronze

Age.- Boring-and-cutting technique was only applied in Iron Age. However, a very

similar case of this technique was found in the Roman period, in Perge.- Half of the trepanations operated due to cranial trauma.- Reasons other than cranial trauma were also taken into consideration for

trepanation in Anatolia, i.e. tumor and training.- Trepanation techniques are similar to South America and the Mediterranean

region rather than Europe.

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A Retrospective Study on Trepanation in Anatolia 3

Fig 1: Distribution of trepanation in Anatolia.

Fig 2: Trepanation with drilling in Çayönü.

Fig. 3: Trepanation with drilling in Perge.

Fig. 4: Incomplete trepanation in Kovuklukaya.

Fig. 5: Trepanation with scraping in İkiztepe (SK 404).

2 Yılmaz Selim Erdal

Fig. 6: Trepanation with sawing in İkiztepe (SK 409)

Fig. 7: Trepanation with rectangular sawing in İkiztepe (SK 603)

Fig. 8: Trepanation similar to boring-and- cutting technique in Perge (M 6.4 B4).

Fig. 9: Trepanation with trauma in İznik (İTK 85 32/2).

Fig. 10: Meningioma and trepanation on İkiztepe’s skull (SK 603).

A Retrospective Study on Trepanation in Anatolia 3