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‘Hat on – hat off’: trauma andtrepanation in Kisii, western KenyaSloan Mahonea

a History of Medicine, Oxford University, Oxford, UKPublished online: 03 Apr 2014.

To cite this article: Sloan Mahone (2014): ‘Hat on – hat off’: trauma and trepanation in Kisii,western Kenya, Journal of Eastern African Studies, DOI: 10.1080/17531055.2014.900959

To link to this article: http://dx.doi.org/10.1080/17531055.2014.900959

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‘Hat on – hat off’: trauma and trepanation in Kisii, western Kenya

Sloan Mahone*

History of Medicine, Oxford University, Oxford, UK

(Received 24 May 2013; accepted 25 January 2014)

In 1957, Kenya’s government psychiatrist and director of the colony’s Mathari MentalHospital travelled to western Kenya to investigate the practice of trepanation amongthe Gusii people in Kisii District. Applied to relieve pressure on the brain by scrapingaway a portion of the skull with a hooked knife, trepanation was exceptionally rare bythe 20th century, but remained common in Kisii where the operations are conductedby a group of skilled practitioners. This article uses materials from psychiatristEdward Margetts’ personal papers, including photographs, diaries and clinical notes,to describe and examine the practice of trepanation in Kisii in the 1950s, concludingwith a discussion of the social meaning of trepanation and trauma in modern Kenya.

Keywords: Kenya; medicine; trauma; psychiatry; photography

An unusual case of manslaughter, Kisii District, 19581

In August 1958, when Her Majesty’s Court of Appeal for Eastern Africa convened,Nyachuba s/o Ombati of Kisii District in the west of Kenya had already served seven anda half months in jail on the charge of manslaughter – a charge reduced in the precedingyear from that of murder. The appeal put before the judge was for consideration of thesentence only – the charge of manslaughter itself would stand – this was a charge to whichNyachuba had pled guilty. His arrest resulted from a day in June 1957 when it becameknown that Nyachuba unlawfully killed Kerubo, wife of Sangaka. Nyachuba admitted thecircumstances around Kerubo’s death, pled guilty to manslaughter and was sentenced tothree years in prison. The facts of the case, as acknowledged by the defendant and thecourt, were not in dispute. The story went as follows as described in the court record:

The deceased, Kerubo, used to complain of headaches, due to a head injury incurred in a fall.In June or early July 1957, her husband Sangaka called in the appellant, who was,apparently, some kind of native doctor or medicine-man. He had operated on Kerubo’s headbefore for the same complaint with beneficial, or at least not deleterious, results. There seemsto have been some alleviation of the headaches for a period. Then he was called in agian [sic]and repeated the operation. This (apparently a highly primitive form of trephining) consistedof making an incision in the scalp, pulling the skin aside and scraping or cutting the bone ofthe skull until a hole was caused and the dura mater exposed. Whether the object was toremove pieces of fractured bone or to reduce pressure on the brain does not appear from therecord. The wound was then covered with cow fat and bound with a cloth. No anaestheticwas administered and the instruments used were not sterilized. The patient contractedmeningitis and died some days later.2

*Email: sloan.mahone@wuhmo.ox.ac.uk

Journal of Eastern African Studies, 2014http://dx.doi.org/10.1080/17531055.2014.900959

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The court concluded that Nyachuba’s ‘motive was the relief of suffering’ and that ‘[t]herewas no evidence that he had not acted to the best of his skill and knowledge. He was anelderly man of hitherto unblemished character’.3 With that, the sentence of three yearswas reduced to time already served and Nyachuba was released. The President in theCourt of Appeals, K. K. O’Connor, then wrote to Dr Edward Margetts at Mathari MentalHospital in Nairobi with the result of the appeal. He mused at the end of his letter: ‘Itwould be interesting to see whether a practitioner of this operation would be convicted ofmanslaughter if the case were properly defended. The best that we could do on thisoccasion was to get him out of jail.’4 Nyachuba’s court case and jail time servedpunctuated what had probably been a long and illustrious career as an omobari omotwe –a Gusii head surgeon.5 It is quite possible that he had not seen a death related totrepanning in any previous patient in his care. It is also possible that he had conducted ahundred or more of these surgeries.

This article offers an account of an ancient practice and its intriguing resilience inmodern times in one district in western Kenya. This research represents an offshoot of alarger project on the psychiatry and photography of Edward Margetts, a Canadianpsychiatrist who presided over Kenya’s colonial mental hospital, Mathari, during theturbulent 1950s in the midst of the Mau Mau war and the final years of British rule. Thisarticle is based upon materials from the estate of Margetts, including correspondence,medical records and notes, the doctor’s personal journals and original photographs andnegatives.6 The materials and photographs in the Margetts Collection related totrepanation are significant and themselves form a larger project on the meaning andmodernity of trepanation in Kisii district to the present day. These materials work intandem with interviews I conducted in Kisii. Due to the amount of detail recorded byMargetts, it was sometimes possible to trace family members of individuals who appearin the photographs. I also conducted interviews with a few current ababari, one of whomMargetts photographed at work in the 1990s.

Trepanation from antiquity

Edward Margetts called trepanation of the skull ‘the most fascinating surgical operationin the history of medicine’. It is also one of the most ancient. Evidence of trepanation –usually a hole bored in the head, but sometimes a scraping away of the top of the skull –has existed all over the globe and appears from at least the Neolithic period to the present.In Europe the practice waned before the turn of the 20th century, although with somenotable exceptions – doctors in Cornwall were reported to have trepanned minerssuffering from head injuries well into the 20th century.7 Evidence also suggests that thevast majority of trepanned patients, from all geographic regions and from any period,survived the operation and perhaps had multiple surgeries. In Africa, archaeologicalevidence and historical accounts record some form of trepanning across the continent,from Algeria and Libya, Somalia and Southern Africa.8 Libyan trepanations weredescribed and photographed in modern times during the Cambridge Tibesti Expedition in1957. Somalis were known to carry out trepanations in the treatment of skull fracturesafter the identification of an injury and the presence of other symptoms such assleeplessness, giddiness and headache.9 While western Kenya stands out for the resilienceof modern East African trepanations, the Lugbara of northwest Uganda were said toperform trepanations to ‘let out the evil spirit which was causing an intractableheadache’.10 Some early 20th-century accounts from the Uganda Protectorate describea more ritualistic performance than ‘modern’ surgical trepanning with deep incisions

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made in order extract malevolence with the aid of a cow’s horn filled with human hairand flesh.11 An alternative account by the Revd John Roscoe in Uganda describes theskill of ‘native surgeons’ in Busoga who were often called to operate on head injuriescaused by a favourite weapon: the sling-shot.

As soon as a quarrel becomes serious, men resort to stone-throwing, and the accuracy withwhich they aim these missiles is proved by the dented skulls of many victims. The surgeons,therefore, get much practice in this kind of work, and they have learned how to removesplinters of bone from the brain and thus restore men, who would otherwise die or liveinsane, to life and reason.12

In addition to these traces found in the ethnographic literature, and as a result of thewidespread excavation of trepanned skulls from all over the world, archaeologicalmuseum exhibitions are also ubiquitous. Most museums dealing with anthropological,scientific or medical materials will have had on display, at one point or another, trepannedskulls, and may also have a plethora of them in storage. A skull exhibited in thePitt-Rivers Museum in Oxford was one of many that caught the eye of Margetts. Hecorresponded with the then curator Audrey Butt to enquire after other specimens, tools orbone fragments that he had heard might be housed in Oxford. He had similarcorrespondences with museums all over the world. Margetts’ enthusiasm for the ancientart of trepanation was highly in character with his various global historical interests, hiswide-ranging collections of artefacts and books, and his tireless devotion to becoming atrue polymath. According to his family, he had once aspired to be a surgeon himselfbefore opting for psychiatry with a life-long side interest in the history of medicine. Therumour that the practice of trepanation, already of amateur archaeological interest to him,was alive and well in western Kenya proved to be far too intriguing a project to resist.

The Gusii (Kisii)

Gusiiland, as it was originally known, occupies a lush, highland area to the east of LakeVictoria and to the west of what came to be known as the White Highlands in SouthNyanza District in Kenya. The territory came under British administration in 1907,coming to be known as Kisii District. The land is well-suited for agriculture and showedgreat promise for the key cash crops of tea, coffee and pyrethrum. Women have alwaysdone the majority of cultivation. Men’s traditional roles as keepers of cattle dissipatedover time as the colonial government abolished cattle villages, but this did not result in anincrease in agricultural work for men. In the midst of colonialism, Gusii men migrated forlong periods of time, or sometimes seasonally, in search of work, leaving women to carryon in the fields and run the households at home. Amongst the Gusii, both men andwomen are circumcised, with elder women practitioners carrying out clitoridectomies ongirls.13 Most strikingly, however, the region has always been known for its rampantwitchcraft beliefs, and in more recent times for its tragic and violent association withwitchcraft accusations and vigilante-style lynchings.14

Ethnographers of the region have explored Gusii belief systems and the meaningsattached to misfortune, illness and death, all of which are felt to the locals to be rife inKisii. Emechando (affliction) refers to the experience of pain whether that is due toillness, mourning or economic failures. The appearance of the affliction can be traced toeither natural causes or to mystical causes as a result of the ill-will of another person.15

Ethnographers Robert and Barbara LeVine have outlined witchcraft beliefs (oborogi)from their fieldwork in ‘Nyansango’ with the proverb ‘no one dies without carrying

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someone on his back’, which means that ‘all deaths are traceable back to witchcraft’.They noted, however, that such accusations were often made in haste after an argument oramidst grief during a funeral but were then forgotten.16 Sorcery may be implicated whenone’s misfortune is caused by malevolence that is hired-out from a professional sorcerer,but some forms of sorcery may be brought on oneself as a result of antisocial behaviour –a result similar to the widespread belief that ancestors may punish a transgression.17 Gusiidiviners are diagnosticians and may be called upon to identify afflictions caused byancestors or by witchcraft.

If the first diviner does not give a satisfactory diagnosis, another will be consulted; thus theeventual interpretation of disease is more dependent on the fears and anxieties of the patientand his family than on the arbitrary judgment of the diviner and her oracles.18

While some afflictions are clearly thought to be the result of witchcraft, the LeVines’studies also indicate how much ‘naturalistic’ medicine is practised by the Gusii withpragmatic cures such as potions, pastes, bone-setting and surgeries differentiated frommore supernatural causes of illness and more spiritual means of healing. In the sectionthat follows, I outline a set of case studies brought to light by Margetts during his visits tothe region for the purpose of observing and photographing the unique skills of Kisii headsurgeons.

Trepanation in Kisii

In August 1957, Margetts wrote to Dr John Grounds of the District Hospital in Kisii toinform him that he hoped ‘to investigate, from the psychiatric and anthropologicalviewpoints, the very interesting custom amongst the Kisii of trephining skull [sic]’.19What then ensued was a correspondence between the two doctors – comparing notes onskulls, tools and surgical techniques. By Grounds’ estimation in 1958, there might beapproximately 20 to 30 ababari amongst the Gusii (estimated to have a population of

Figure 1. Trepanned skull with locally made instruments, Kisii. Photograph by Edward Margetts,1958.

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approximately 230,000), and that approximately 500 surgeries were performed each yearwith a death rate of three per year.20 Margetts travelled to Kisii to meet Grounds andspent significant time interviewing various ababari and their patients, observingprocedures and, as was his usual preoccupation, photographing everything he encoun-tered. In addition, he documented and wrote up individual case histories – an invaluablerecord of Gusii men and women’s own accounts of why they opted for such an invasiveform of treatment. What all patients had in common was the claim to severe and chronicheadache, a diagnostic requirement along with the identification of a corresponding pasttrauma or injury to the head, even if such an injury had occurred years before.

Three Kisii case studies

Margetts conducted interviews and examinations and took a series of photographs thatdocumented recent cases of Kisii trepanation. The first case, which Margetts recorded as‘cured’, was that of Marera Nyagenyaro, a tribal policeman working for the DistrictCommissioner’s office in Kisii. He had received a blow to the forehead and experiencedsevere headaches for years thereafter. A trepanation was performed at the site of theinjury which he claimed stopped the headaches. After an examination, Margetts declaredNyagenyaro ‘mentally normal’.21 This first case is fairly unremarkable as it was likely astraightforward intervention to a serious head injury and located at the site of the originaltrauma. Such surgeries were uncomplicated diagnostically and generally consisted ofremoving broken bone and blood clots at the time of the injury, but additional operationsmight be performed at the request of the patient if the headaches persisted or reoccurred.

Margetts then reported on the examination of a second case – a prisoner incarceratedin Nairobi. Omwenga s/o Mukesa, from Kisii, was in jail for 6 months for stock theft, andanother 4 months for an attempted escape. According to Omwenga, a tree had fallen onhim in 1958, and he began to experience headaches. He had three operations conductedby Anthony Ombawa, ‘a very famous doctor, [who] does all kinds of surgery and has a

Figure 2. Askari with right frontal trepanation. Photograph by Edward Margetts, 1958.

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reputation that none of this patients will die’.22 Omwenga’s sister, Muraa w/o Karya ofKeroka, had also had two trepanations by the same doctor. In her case, ‘her husband hadhit her with a stick, which gave her a headache!’ Margetts’ clinical notes describeOmwenga’s assessment of his own condition:

Omwenga does not do any work now – ‘it would spoil my head’ [he claimed]. He appearedsomewhat withdrawn and perhaps slightly depressed. He said he did not feel well because hehad been hit on the head by a policeman on 24th July 1959! He feels something like bloodrunning in his head, and it pains him. He states that the operations cured his originalheadache but now of course he is suffering from the blow given him by the askari (?).23

References to the loss of work and debility in recovery appear frequently in the writtenrecord and in oral histories. In some cases, generally with male patients, staying awayfrom work for a period of a year was not unusual, particularly if the surgeries resulted in asignificant portion of bone removed. Sensitivity to light or noise, continued headache andpain, and fatigue were common complaints. Such debility would not have been conduciveto the hard labour of Kisii’s tea plantations or to farming in general, and the costs towomen in the household due to increased demand for labour and family income weresometimes very significant. Margetts’ scepticism about Omwenga’s personal belief in theefficacy of the trepanation surgeries despite the recurrence of chronic headache isapparent in his personal correspondence and notes. Indeed, in my own interviewsconducted between 2008 and 2011 with former patients, there was often a circuitous routethat connected the initial trauma with the appearance of chronic headaches, and the reliefprovided by a craniotomy (the preferred term in Kisii today). Because an omobari willnot perform a surgery merely because somebody requests one, there must be someevidence or discussion of a past trauma, a process not unlike a means of rooting out thecauses of personal pain or misfortune in cases of sorcery or an intervention by ancestors.

Omwenga described the steps leading up to his surgery. First, he was fed a medicine-laced gruel to clot the blood followed by the application of a powder to prevent pain. Likemost respondents he claimed that while the cutting of the scalp was painful, the actualscraping of the bone of the skull was not. He claimed each of his surgeries lastedapproximately four hours, during which time he ‘lay sandwiched between two European-style beds with his head sticking out, and helpful relatives sat one at each corner of thetop bed, which was upside down over the patient’.24 Finally, the wound was sprinkledwith medicine and packed with fat before being loosely bandaged.

Like all patients, Omwenga described the trepanation as a surgical procedure,outwardly lacking in any direct supernatural connotations of ‘releasing demons’ or othertreatments that might invoke the magical although the need for the surgery may well liewithin a more psychological or spiritual realm. He claimed the procedure was ‘to removesomething that hurts the bone, he took the bad bone out’.25 The presence of headache wascrucial diagnostically, although the spiritual or psychological aspects of experiencingchronic headache is very suggestive, at least in those cases where there is no obviousfractured bone as a result of a traumatic head injury. Omwenga’s sister also claimedchronic headache and a desire for trepanation after being assaulted (most likelyrepeatedly) by a violent husband. As in this case, the proximity of other trepanningpatients (a relative, spouse or neighbour) is a strong marker for potential patients comingforward and requesting a surgery. The proximity of a local omobari omotwe was anotherfactor. Individuals interviewed in Kisii today about their own surgeries frequently had

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stories of the surgeries of relatives, or could point to other houses in their village wherethere resided individuals with the extreme marks of their own craniotomies.

Margetts wrote up his observations of the Kisii trepanation cases for an edited volumeon Diseases in Antiquity. The published chapter as well as the psychiatrist’s clinical notes,correspondence and personal journals are invaluable for the first-hand experiencespatients, and an understanding of what it was like to undergo a modern trepanation. Whilethe Margetts and Grounds reports seem to be the first detailed published accounts of thewestern Kenyan practice, Kisii trepanation appears in the published record from the1960s to the 1980s, usually as a medical curiosity of some interest to physicians ortravellers who happened upon the practice. One article published in the Guy’s HospitalGazette recounted the West Kenya Medical Department’s cautious respect for the Gusiisurgical specialization and its ancient pedigree, claiming the skill ‘has developed overnine thousand years, a secret inherited from the early Persian surgeons and closelyguarded by the tribe. They evade the law because of their near perfect results’.26 Suchclaims have little historical evidence behind them, but authors routinely tried to makesense of the surprising modern appearance of an ancient practice that was documentedprimarily outside of Sub-Saharan Africa. Another reference to the unbroken longevity ofthe practice suggests that this ‘neurosurgery’ dates back at least 5000 years, and claimsthat ‘primitive’ peoples ‘without modern instruments, appear to have achieved surgical

Figure 3. Omwenga s/o Mukesa after multiple trepanations. Photograph by Edward Margetts, 1958.

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results not duplicated by Western medicine until after the turn of the [20th] century’.27This is also an inaccuracy. European physicians in the 16th to the 18th centuries manuallyoperated specially designed drills to create perfectly round holes in their patients’ heads.

Observations from the late 1970s to the 1990s document modernizing shifts in Kisiicraniotomies, with Gusii ababari replacing the cruder home-made knives and chisels withrazor blades, scalpels and syringes of lidocaine, although the more traditional instrumentsmight be used in tandem with the new.28

As a physician practising in the 1950s, Margetts marvelled at the extent to whichsome of the surgeries were carried out. In some cases he commissioned X-rays ofpatients’ skulls at the King George VI hospital in Nairobi.29 In Omwenga’s case hereported that ‘both tables of the vertex of his skull [were] absent over nine squareinches’.30 However, the last patient in this series of case studies was one for which thedoctor clearly felt a strong fascination and affection – calling it ‘the most spectacularcuriosity that one would ever hope to see’.31

‘Hat On–Hat Off’

When they met in Kisii district in 1958, Nyachoti was approximately 50 years old. Hestated that in 1940 he was working as a tribal policeman.32 Upon entering his house oneday, he hit his head on the door lintel, and thereafter experienced chronic headaches.

In 1945 he had his first trepanation, and over the next seven or eight years he had fourmore.33 Although he initially claimed having five surgeries, this number was eventuallyexaggerated to nearly 30. Margetts wrote up this particular case in a number ofpublications. The Nyachoti surgery also appears in a 1985 study conducted by plastic

Figure 4. ‘Hat On’ – Nyachoti and his omobari omotwe, Siparato Ondiecki. Photograph by EdwardMargetts, 1958.

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surgeon, David Furnas, although it appears that by then Nyachoti’s story had shifted tothe extent that rather than having been injured by a door jamb, he had been attacked witha machete during the Mau Mau emergency.34 Margetts nicknamed this particular case,and Nyachoti himself, ‘Hat On–Hat Off’.

The spectacle of Kisii trepanning attracted a fair amount of very specialized attentionin the 1950s and 1960s. It was unique surgically for obvious reasons, but also for the factthat it was a common occurrence in Kisii and nothing more than an archaeological relicanywhere else. Nyachoti’s omobari, Sipirato Ondieki, approximately 70–75 years old,related to Margetts that he had apprenticed as an adolescent under the tutelage of hisfather and had since taught his own two sons.35 Father to son was the most commontrajectory for this training, although there were apparently no objections for those outsidethe family to take up the profession. The only restriction seemed to be that all Gusii headsurgeons to this day are men. Ondieki claimed that the only reason to do a trepanationwas to treat headache after a head injury. He remarked that he would expect to find afracture of the skull at the site of the blow, knowing that he was in the right place due tothe presence of ‘black’ (clotted) blood. However, Margetts postulated that ‘many of theskulls opened probably never did show an actual fracture line, and the extensive amountof bone removed in some of the operations might have been the result of seeking forsomething that did not exist’.36

The results of Nyachoti’s surgeries were so severe that he was fitted with a hardplastic skull cap, upon which was painted ‘Hatari – Ngonjwa’ or ‘Danger – sick person’.Margetts claimed that X-rays indicated a hole in the vault of the skull of approximately30 square inches.37 Nyachoti’s appearance was altered so dramatically that the primaryreaction to him in the community was fear. According to his widow, most people wouldlook at him and run away assuming that ‘he was about to die’.38 As his spiritual angstwas a precursor to seeking repeated surgeries, his extreme physical pain and debility waschronic thereafter. His wife said that he lived in terror for years feeling he had beenbewitched, the worsening headaches a clear indication to him that his affliction was other

Figure 5. ‘Hat Off’ – Nyachoti. Photograph by Edward Margetts, 1958.

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worldly, causing him to flee to Tanzania to live in exile for many years. When handlingphotographs of her husband, she demonstrated her technique for caring for him, brushinghis wound with a feather while blowing air on his head through a straw.

Gusii ethnography and gender relations

The anthropological record yields some additional insights into modern Gusii trepanation,including a gendered aspect that relates directly to the domestic violence and maritalantagonism that has been well-documented in the region. Sarah LeVine’s ethnography ofGusii women, based upon fieldwork conducted in the 1970s, recounts the life story ofZipporah Bochere who remarks upon the frequent trepanations performed on her husbandMakori – himself a violent drunk who suffered ‘excruciating headaches’, but defied thedemands of his omobari that he stop drinking while his surgical wounds healed.39 In thiscase, Zipporah relates how her husband’s demands for repeated surgeries affected herown life.

Yesterday people laughed at him in his rags at the beer party, and so at last he agreed to takeoff that thing he was wearing. His shirt I got in payment of a chicken. As for that cloth on hishead, he wears that to hide the place where he had his operation. The wound is not yethealed. He talks of having another operation, but even now I cannot manage him. Usually Icannot sleep here because he gets so drunk at night. He drinks heavily to help the pain. Whatwould happen if he had yet another operation?40

Zipporah Bochere’s story as a wife and caretaker is one of despair and weariness, thethreat of on-going violence and, as appears in many stories, the role played by alcohol inthe initial injury or in the slow and complicated recovery afterward. AnthropologistMargrethe Silberschmidt has documented the increasing role of men’s violence againstwomen as a means of enforcing their sometimes tenuous positions within the household.Her findings in Kisii ‘suggest that those [men] unable to meet their obligations face majorproblems of male identity and self-respect that have consequences for women and theasymmetric gender relations’.41 According to Silberschmidt, the use and abuse of alcoholincreased with alarming rapidity after independence, particularly with regard to thelocally brewed changaa with its alcohol content reaching 70%, and this has had direconsequences for women and sky-rocketing rates of domestic violence.42

Brett Shadle’s study of 20th-century marriage in Gusiiland similarly depicts genderantagonism and frequent violence as an accepted norm. Divorce or cases of wives simplyfleeing the relationship occurred only in cases of excessive violence, which might resultfrom men using something other than their hands or fists in an assault, or as a result ofwives being accused of witchcraft, a dangerous claim in Kisii.43 The fact that mostvictims of witchcraft accusations were and are older women also speaks to their increasedvulnerability to violent assault and even death.44 Anthropologist Robert LeVine hasoutlined the rampant aggression built into Gusii unions due to the hostilitiesaccompanying inter-clan tensions that invariably disadvantage the bride.45 With collaps-ing economies and shifts in traditional divisions of labour from the mid-colonial era to thepresent, women have shouldered more of the economic burden, which has in turnprompted greater conflict within the home.46

Returning to the ethnographic study of Gusii wives and mothers, Sarah LeVinerecounts a second case study of Sabina Nyangige. Sabina was assaulted with a hoe by aman who was angry with her for winning a court case. The long-running feud betweenher husband and her brother-in-law resulted in extreme hostility shown toward her when

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her husband was away. As a result of a beating, Sabina suffered a fractured skull. Thedistrict hospital did nothing for her, so three days later her brothers took her to Motanya,a local omobari:47

When he cut my scalp, they brought forked sticks and held back the flaps of skin for him sohe could work inside my head. He scraped out blood and gristle and filled up several littlecooking pots with it. Then when he finished he used different kinds of leaves to stop thebleeding. Afterward I stayed in my mother’s house for a month. … But when the bandageswere taken off and the cuts had healed and I went home again, I knew I was not altogetherwell. When I work hard in the shamba my head hurts me. I think this is because Motanya cutme twice above my left temple but only once above my right. He must operate again on theright side, and if the scars are equal on both sides I think I shall be well again.48

Sabina’s description of on-going headache resonates with other patient accounts, andexplains the rationale for repeated surgeries over time, as the assumption is that the firstsurgery either wore off or had not been quite extensive enough. In some cases, theresulting disfigurement, as well as chronic pain and debility, provided, intentionally ornot, an eventual opportunity for discussion of a past trauma, which in the case of womenwas almost always the result of an assault. Just the same, tradition in Kisii dictates thatGusii women do not need an excuse to complain bitterly about men, and LeVine felt thatSabina was nonchalant about her surgery as she recounted the assault multiple timesbefore disclosing she had undergone the operation. Despite the frequency with whichGusii individuals opted for a trepanation, LeVine writes the surgery was still highlytraumatic, and exacerbated the ‘extraordinarily precarious nature of the physical andemotional conditions under which [Sabina] lived’.49

Discussion: headache as metaphor

There are many cases of this nature in Kisii, and they all tend to say very similar things.Recollections of violence, injury and trauma were frequent and the normative response inthese cases was frequently trepanation, or indeed multiple surgeries. While the presenceof ‘headache’ is required for all trepanations in Kisii, its diagnosis and practice fits wellwithin the corpus of both modern and ancient trepanning globally. For the ancient period,the literature refers to trepanations being performed for any number of reasons related tothe head, including:

fractures, inflammations, localizations of pus and blood, epilepsy, madness, idiocy, moraldegeneration, various head symptoms (headache, vertigo, deafness, etc.), the removal offoreign bodies from inside the head (real or faked, as in ‘stones of insanity’ or pierres de tête)and the release of pressures, airs, vapors, humors, and demons and evil spirits.50

In modern times, Margetts allowed for equally diverse approaches (within the rareexamples available), claiming that the Kisii motive ‘is to relieve headache after a blow.Yet a few hundred miles away, the Lugbara motive is to let out an evil spirit’.51 Whatthese diverse approaches have in common is the removal of something. According toMargetts: ‘If all the “reasons” for trepanation are put together, the common mechanismbehind all the conditions … is to remove something. There is a continuum, fromimmaterial to material, from magic and thaumaturgy to science …’.52 Sarah LeVine’sobservations corroborate the necessity to remove ‘something’ – including the physicalmatter of bone which may correspond to the removal of ‘pain’.

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The principle involved in this surgery is simple: when someone has migraines or dizziness asa result of a beating or head injury, the Gusii believe that by cutting the sufferer’s scalp andremoving some of his blood, bone, and ‘surplus’ matter, the pain will be alleviated.53

Margetts also noted the striking lack of fear or anxiety in patients undergoing theprocedure, and this calm confidence was clearly mirrored by the omobari who, with veryfew exceptions, were medicine men of high standing in their communities who wereworking for the benefit of their patients rather than for personal gain. Margetts attributedthe ababaris’ beliefs as ‘based partly on rational pathophysiology [and] partly magic’.54The physical effect of boring a hole in the skull to relieve ‘pressure’ felt by a patientmight work in tandem with the unwavering belief that the trepanation – or multipletrepanations – will provide a cure for the headaches and distress. Indeed, in those rareinstances where a trepanation might go wrong, such as the death from meningitis in the30-year-old local woman, her husband did not blame the omobari, but claimed thatmalaria had killed her.55 The actual incidence of chronic headache as a result of a blow tothe head or even bumping the head in a doorway is debatable. Only those incidents of aviolent or traumatic injury resulting in the fracture of the skull where bone fragments areremoved seem to be particularly straightforward. However, some speculate that Kisii’swell-known history of violence goes hand in hand with the resilience of trepanning.Regardless, in the vast majority of cases the visible marks of a craniotomy allowed thepatient to describe a past or ongoing trauma. There was no stigma attached to wearingsuch a mark on the body, nor was there shame in describing the violence that precededthe treatment. In LeVine’s description of her discussions with Sabina the talk of headacheovertook the description of the original act of violence although the two issues wereinextricably linked.

Two months later she mentioned (so casually that for a moment I thought I must have alreadybeen told and had forgotten) that she had been beaten almost to death by Marco’s [herbrother-in-law] son. She talked of the operation which followed and of her aching head, butnever again of the beating.56

For Furnas and his team it was the public act of the surgery itself that allowed for anacknowledgement and discussion of the patient’s trauma and misfortune.57 If thepostoperative mark is at least one of the key factors in opting for a trepanation, it maylend some credence to the frequent observation that an omobari is less engaged with moremagical aspects of personal healing than he is a surgeon with a very significantcommunity presence. The long and sometimes equally traumatic recovery period after atrepanation is another factor in its visibility and importance.

The Kisii accept as common knowledge that recovery from a craniotomy is a prolongedmatter, and the patient is not expected to return to work for at least six months. If a patientreturns to work too soon, it is feared that the operation could be ‘spoiled,’ and symptomsmight return, necessitating a repeat operation. Some patients risked an early return to workrather than lose a job, and others took as long as a year off.58

Our historical understandings of one of the most ancient surgeries on record are perhapsovershadowed by the allure of the archaeological digs that have turned up trepannedskulls with a fair degree of regularity. This is coupled with the physical evidence thatsuggests that the majority of these ancient patients survived what we might think of as aninvasive and traumatic procedure.

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The various rediscoveries and representations of trepanning, as described in thispaper, also serve to highlight a degree of wonder that such an ancient and extremepractice has survived to modern times.

The stated clinical reason for the existence of the surgery in East Africa – for therelief of post-traumatic headache – has remained constant. The rhetoric of trauma,recognition and visibility is always present even when physical signs of a prior injuryare not. The presence of trepanning in Kisii, of all places, adds a dimension ofthe medically exotic to an already ‘exoticized’ region within the country. Newspapersall too frequently report on another extreme for which Kisii is tragically famous eventoday – that is for witchcraft, or more specifically, for witchcraft accusations ending inthe stoning, lynching or burning of the accused. What has remained consistent is theneed for relief and, as observed in the 1950s, the removal of something, and theunmistakable visible mark that allows for an ongoing acknowledgement of Gusiitrauma and misfortune.

FundingThis research was supported by a grant from the Arts and Humanities Research Council (AHRC),Trauma and Personhood in Late Colonial Kenya, [Grant # 119246].

Notes1. The terms ‘Kisii’ and ‘Gusii’ can be used somewhat interchangeably, but in general ‘Kisii’

refers to the town or district and ‘Gusii’ is used to describe the people. It is not unusual,however, for an individual to be described as ‘Kisii’.

2. Papers of Edward Margetts, Criminal Appeal no. 108 of 1958, Nyachuba s/o Ombati andRegina, August 21, 1958.

3. Ibid.4. Papers of Edward Margetts, Letter from K. K. O’Connor, August 25, 1958.5. Omobari is the Gusii term for ‘surgeon’ of any sort. Omobari omotwe refers specifically to a

head or skull surgeon. For convenience I will sometimes use the broader term ‘omobari’ aswell as the plural ‘ababari’.

6. The photographs, negatives and corresponding materials, including correspondence and diaries,are in the possession of the author, having been either purchased from the estate of EdwardMargetts or provided by his family. These materials are not, as yet, deposited in a library orarchive.

7. Margetts, “Trepanation of the Skull,” p. 677.8. The wide-ranging literature on trepanation is extensive. Select references for Africa include:

Drennan, “Some Evidence for a Trepanation Cult”; Hilton-Simpson, “Some Arab and ShawiaRemedies”; Akester, “Tibesti – Land of the Tebou”; and Steele, “Trephining in Tibesti”.

9. Brotmacher, “Medical Practice Among the Somalis,” p. 216.10. Margetts, “Trepanation of the Skull,” p. 10.11. Fisher, Twilight Tales of the Black Baganda, p. 61.12. Roscoe, Soul of Central Africa, p. 300.13. Gwako, “Continuity and Change.”14. Ogembo, “Cultural Narratives, Violence and Mother–Son Loyalty”; Ogembo, Contemporary

Witch-Hunting in Gusii. See also the newspaper reportage: BBC News, “Kenya ‘Witch’ CaseMass Arrests”; Nyasato and Gitau, “Five Lynched Over Witchcraft Claim”; Odhiambo, “Horrorof Kenya’s ‘Witch’ Lynchings.”

15. Ogembo, Contemporary Witch-Hunting in Gusii, p. 32.16. LeVine and LeVine, Nyansongo: A Gusii Community, p. 97. ‘Nyansongo’ is a fictional name

used by the LeVines for a set of communities they interviewed.17. LeVine and LeVine, Nyansongo: A Gusii Community, p. 99.18. Ibid.19. Papers of Edward Margetts, Letter to John Grounds, August 6, 1957, re: trepanation.

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20. Papers of Edward Margetts, Letter to John Grounds, March 25, 1958, re: trepanation. Also,Grounds, “Trephining of the Skull Amongst the Kisii.”

21. Margetts, “Trepanation of the Skull p. 686.22. Papers of Edward Margetts, Letter to Officer-in-charge, H.M. Prison, Nairobi, August 8, 1959,

re: Omwenga s/o Mukesa, Prison no. 293 R.23. Ibid.24. Margetts, “Trepanation of the Skull,” p. 686. This method would have been highly unusual.

Most patients sat upright while leaning forward to allow copious amounts of blood to fall into abasin on their laps.

25. Margetts, “Trepanation of the Skull,” p. 688.26. Coxon, “Kisii Art of Trephining,” p. 263.27. Mueller and Finch, “Kisii Trepanation,” p. 11.28. Ibid., p. 12.29. X-rays were performed by Dr Leslie Whittaker of the King George VI Hospital (now Kenyatta

National Hospital) on behalf of Margetts.30. Margetts, “Trepanation of the Skull,” p. 688.31. Ibid., pp. 688–90.32. Nyachoti’s widowed third wife indicated that he was not a policeman but had always been a

labourer (2011).33. Personal journal of Edward Margetts, February 17, 1958, p. 359.34. Furnas et al., “Traditional Craniotomies of the Kisii Tribe,” p. 551.35. Margetts’ personal journal, February 17, 1958.36. Margetts, “Trepanation of the Skull,” p. 691.37. Ibid., p. 690.38. Interview with Marta Nyabaiga Nyachoti, September 2, 2011.39. LeVine, Mothers and Wives, p. 218.40. Ibid., p. 225.41. Silberschmidt, “Have Men Become the Weaker Sex?,” p. 239.42. Silberschmidt, “‘Women Forget that Men are the Masters’”, pp. 120–3.43. Shadle, “‘Girl Cases’”, p. 157.44. Ogembo, Contemporary Witch-Hunting in Gusii, p. 164.45. LeVine, “Gusii Sex Offenses,” p. 967.46. Silberschmidt, “Have Men Become the Weaker Sex?,” p. 237.47. LeVine, Mothers and Wives, pp. 279–80.48. Ibid., p. 280.49. Ibid., p. 282.50. Margetts, “Trepanation of the Skull,” p. 691.51. Ibid., p. 692.52. Ibid.53. LeVine, Wives and Mothers, p. 280.54. Margetts, “Trepanation of the Skull,” p. 693.55. Margetts’ personal journal, February 17, 1958.56. LeVine, Mothers and Wives, p. 316.57. Furnas et al., “Traditional Craniotomies of the Kisii Tribe,” p. 546.58. Ibid., p. 548.

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Coxon, Ann. “The Kisii Art of Trephining.” Guy’s Hospital Gazette 76 (1962): 263–266.Drennan, M. R. “Some Evidence for a Trepanation Cult in the Bushman Race.” South AfricanMedical Journal (1937): 183–191.

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Mueller, Michael D. and Charles S. Finch, III. “Kisii Trepanation: An Ancient Surgical Procedurein Modern-Day Kenya.” Explorers’ Journal 72, no. 1 (1994): 10–16.

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Odhiambo, Joseph. “Horror of Kenya’s ‘Witch’ Lynchings.” BBC News. June 26, 2009. http://news.bbc.co.uk/1/hi/world/africa/8119201.stm/.

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Roscoe, John. The Soul of Central Africa: A General Account of the Mackie EthnologicalExpedition. London: Cassell, 1922.

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