Ancient Cranial Modifications with Medical and Cultural Significance

ANCIENT CRANIAL MODIFICATIONS WITH MEDICAL AND CULTURAL SIGNIFICANCE

A thesis submitted to the Kent State University Honors College in partial fulfillment of the requirements for University Honors

Emily A. Brahler

May, 2015

Thesis written by

Emily A. Brahler

Approved by

______, Advisor

______, Chair, Department of Anthropology

Accepted by

______, Dean, Honors College

TABLE OF CONTENTS

LIST OF FIGURES...... iv

ACKNOWLEDGMENTS...... v

CHAPTER

I. CRANIOFACIAL RECONSTRUCTION...... 1

II. INTRODUCTION...... 15

III. SKULL DEVELOPMENT...... 18

IV. ARTIFICIAL CRANIAL DEFORMATION...... 21 Artificial Cranial Deformation...... 21 Types of Artificial Cranial Deformation...... 23 Health Implications of Artificial Cranial Deformation...... 25 Artificial Cranial Deformation in Peru...... 27 Instances of Artificial Cranial Deformation Globally...... 30

V. TREPHINATION...... 32 Trephination (Trepanation) Surgery...... 32 Health Implications of Trephination Surgery...... 34 Trephination Surgery in Peru...... 36 Instances of Trephination Surgery Globally...... 44 Cranioplasty...... 46

VI. CONCLUSION...... 50

LITERATURE CITED...... 53

iii

LIST OF FIGURES

Figure

1. Skull Cast for Craniofacial Reconstruction………………………………..…4

2. Tissue Depth Markers……………………………………………………..….5

3. Preliminary Layers of Clay…………………………………………………...6

4. Preliminary Sculpted Face……………………………………………………8

5. Construction of the Bust………………………………………………………9

6. Musculature of the Bust……………………………………………………...10

7. Completed Sculpture…………………………………………………………11

8. Completed Reconstruction…………………………………………………...12

9. Completed Reconstruction Outfitted in Tunic……………………………….13

ACKNOWLEDGMENTS

To begin I want to thank Dr. Linda B. Spurlock, my primary thesis advisor. You have been a perpetual source of new knowledge and ideas. You have served to strengthen my passion for anthropology and have shown me the kind of professional, and person, I hope to become. Regardless of your never-ending responsibilities, you always made yourself available for guidance, laughs, or to simply indulge our mutual love of all things ghoulish and gruesome. Without your assistance, support, and great edits this thesis and the accompanying facial reconstruction project would never have been possible.

To Dr. Evgenia Fotiou, my secondary thesis advisor, it has been a true pleasure to work with someone as knowledgeable and passionate as you. You have introduced me to an entirely new aspect of anthropology that not only greatly contributed to the well- roundedness of this thesis, but has also forever changed how I look at medicine and human health.

To Dr. Mary Ann Raghanti, my tertiary thesis advisor, I want to thank you for your endless kindness and support, and for always providing such an admirable example of professionalism. Although this thesis process has had its share of ups and downs, I found myself trying to think of what you might suggest to make sure my work, and its presentation, was the best possible. I feel truly privileged to have had the opportunity to learn from you.

And finally to Dr. Paul Sampson, the final member of my defense committee, thank you for taking the time out of your immense schedule to assist me in this process and attend my defense. I very much enjoyed having you on my committee and I was delighted that you seemed to be so interested in my topic. Your enthusiasm and positivity greatly helped to calm my nerves during my defense.

vi 1

CRANIOFACIAL RECONSTRUCTION

The process of craniofacial reconstruction is identified as artistically recreating the face of a past individual by utilizing the osteological architecture of the skull that is left behind (Lee et al. 2014; Taylor 2001; Duan et al. 2014). This process is often conducted in a forensic context, as a means of recreating the face of unknown human remains (Taylor 2001; Lee et al. 2014; Wilkinson 2010; Duan et al. 2014). However, this method has also been used in other anthropological contexts, most commonly as a way to reconstruct what extinct hominids or ancient peoples may have looked like in life (Lee et al. 2014; Wilkinson 2010; Duan et al. 2014).

In terms of the latter use, this technique can provide not only a striking visual representation of what the face of ancient peoples may have looked like in life, it also provides a more meaningful look into the overall identity of a person who is no longer alive (Lee et al. 2014; Wilkinson 2010; Duan et al. 2014). Originally in a landmark text on forensic science, and reiterated in a prominent text on forensic art by Karen T. Taylor,

Dr. Wilton Marion Krogman described the potential of this method:

A skull may tell of age, of sex, of race, and thus in part contribute to

cranial identification. But it may do more: it may provide a further

individualization, for it may give clues as to cephalic identification. This is

to say that the dead skull is, in a sense, the matrix of the living head; it is

the bony core of the fleshy head and face in life. Upon the cranial

framework (which is really subjacent to all soft tissues) we may build bit

by bit, until details of physiognomy take shape, and a reasonably

acceptable facsimile of a living human head emerges (Taylor 2001 p

419; Krogman 1962).

This sentiment of “individualization” is what is most important in this particular analysis

(Taylor 2001 p 419; Krogman 1962).

A 3-dimensional craniofacial reconstruction was completed, by hand in clay, as part of this overall undertaking. The skull cast used was of a male individual from the

Inca Empire in the Andean region of Peru who displays characteristics of artificial cranial deformation and a wound from a healed trephination surgery. This reconstruction is of particular interest not only because it has provided a telling visual representation of what people of this area, at this time in the past may have looked like, but also, it provides a unique look into the individual life, and individual face of this specific past person. This reconstruction is significant for the remainder of this analysis based on the unique cranial conditions present on this individual’s skull, in addition to this overall idea of how impactful physically, and conceptually, recreating the faces of the past can be for anthropological, and most specifically bioarchaeological study.

Facial reconstructions are completed in several stages (Taylor 2001). The two main stages of development of this kind of a project are the “technical phase” and the

“artistic phase” (Taylor 2001 p 422). Although the facial landmarks are all present on the skull, it is not clear until the reconstruction begins and progresses through each phase

what the unique face will look like; each step uncovers more aspects of identity (Taylor

2001).

The “technical phase” of reconstruction includes, connecting the mandible to the rest of the skull, placing the skull on the appropriate armature in “Frankfort horizontal plane” position, and applying what are called “tissue depth markers” to the surface of the skull (Taylor 2001 p 422-429). Tissue depth markers provide a projected map of the thickness of the layers of soft tissue that cover the surfaces of the skull in life (Taylor

2001). This phase also included placing prosthetic eyes appropriately into the orbits, and applying the first sections of clay in correspondence with the tissue depth markers

(Taylor 2001). This phase is essentially the preliminary set-up and building stage of the face (Taylor 2001). These preliminary steps can be viewed in Figures 1, 2, and 3.

Subject is male, the Subject Inca from is

ial Reconstruction ial dimensional facial reconstruction dimensional facial - c

Skull Cast Skull for Craniofa

Figure 1:Figure skullusedofcastviews Three3 in and remnants a and deformation, ofsurgery. Empire,healed trephination exhibits artificial cranial

Figure 2: Tissue Depth Markers Image of skull cast with tissue depth markers in place; primed for clay application.

Figure 3: Preliminary Layers of Clay Image of skull cast with tissue depth markers, placed prosthetic eyes, and fundamental layers of clay.

The “artistic phase” of facial reconstruction includes sculpting the individual facial features like the contours of the cheeks and forehead, the mouth and lips, the nose, the eyelids, and the ears (Taylor 2001 p 422). In addition, this phase also included adding signs of age, wear, and texture to the skin surface, sculpting this individual’s prominent head wound, adding a wig, and adding culturally relevant clothing, including gold earrings, and a tunic that was also hand-sewn for the sculpture. This phase is where the true “individualization” is most prominent (Taylor 2001 p 419; Krogman 1962). These steps can be viewed in Figures 4, 5, 6, 7, 8, and 9.

Figure 4: Preliminary Sculpted Face Image of reconstruction with initial sculpted clay face; addition of even skin, eyelids, nose, and mouth.

Figure 5: Construction of the Bust Image of reconstruction with beginnings of constructed and sculpted neck, shoulders, and chest.

Figure 6: Musculature of the Bust Image of reconstruction with preliminary clay musculature of the neck and chest.

Figure 7: Completed Sculpture Image of completed reconstruction sculpture; addition of covered musculature, ears, and eyebrow coloration.

ReconstructionCompleted

8:Figure additioncompletedblackgold of reconstruction wig viewsThreelong of earrings. sculpture; and

Figure 9: Completed Reconstruction Outfitted in Tunic Finished facial reconstruction including hand-sewn tunic.

Overall, it is apparent from this reconstruction process that culturally and medically relevant cranial modifications are present on the skull cast of this individual.

The remnants of these modifications, the elongation of the head and the large head wound, are not only overt in the skull, but they would have also helped to create the overall appearance of this individual in life. These modifications are not just part of the skull, they are an essential part of this individual’s identity. The sentiment of recreating these faces, and uncovering individual stories for the sake of honor and reverence, that is shown through this process, is what is essential to understanding the potential of bioarchaeological research (Taylor 2001; Lee et al. 2014; Duan et al. 2014; Landau and

Steele 1996; Knudson and Stojanowski 2008; Ortner 2011).

INTRODUCTION

All remnants from past human populations provide significant but different insights into the lives of their people (Landau and Steele 1996; Knudson and Stojanowski

2008). Material culture such as structures, features, art, weapons, or cooking implements all provide specific details of the nature of everyday life (Landau and Steele 1996;

Marino and Gonzales-Portillo 2000). Human remains work to provide similarly significant and more unique details that may otherwise be less cogent (Landau and Steele

1996; Knudson and Stojanowski 2008; Mednikova 2003; Ortner 2011; Mendoza 2003).

Many studies of human remains over the course of the last century have provided significant clues for both reconstructing lifeways and a deeper understanding of the human condition and human health (Landau and Steele 1996; Knudson and Stojanowski

2008; Mednikova 2003; Ortner 2011). Many bioarchaeological studies have focused on the skull as a means of testing hypotheses about both cultural and biological specificities of ancient people (Landau and Steele 1996; Marino and Gonzales-Portillo 2000). One such categorical example of this preoccupation with the human skull is the breadth of research conducted on body modification practices, such as artificial cranial deformation, and early surgical applications, namely trephination (Landau and Steele 1996; Andrushko and Verano 2008; Pain 2000; Blom 2005; Lozada 2011). Both of these practices were quite frequent among ancient peoples of South America (Landau and Steele 1996; Blom

2005; Andrushko and Verano 2008; Lozada 2011).

Modifications to the body, although performed during life, can leave indelible evidence on bones (Landau and Steele 1996). This evidence, when viewed and interpreted contextually provides direct, palpable substantiation of culturally and medically significant processes that other sources, like artifacts and written or verbal accounts, cannot always provide on their own (Landau and Steele 1996; Knudson and

Stojanowski 2008; Blom 2005; Mendoza 2003). Bone has no social, political, cultural, or religious biases; disease and mechanical processes affect it in ways that adhere to physiological constraints (Landau and Steele 1996; White et al. 2012; Boston 2012). The information it can often provide can be deciphered with careful observation, the correct application of anatomy and physiology principles, and knowledge of development

(Landau and Steele 1996; Boston 2012; White et al. 2012). This is not the case for other mediums of material culture and historical accounts, which are ultimately dependent on the personal perspective from which they were created (Landau and Steele 1996;

Mendoza 2003; Knudson and Stojanowski 2008; Blom 2005).

Here, with examples from the literature, artificial cranial deformation, and trephination will be explored and discussed. Their presence in societies in South

American history will be highlighted, based on the inspiration provided by the previously discussed 3-dimensional craniofacial reconstruction. The purpose of this analysis is to explore the ritualistic or cultural, and medical significance these practices may have held in these societies, in an attempt to support bioarchaeological analysis of human remains.

This kind of analysis can provide answers to a variety of research questions and, ultimately, this research can be a viable and worthwhile outlet for bringing to light the

stories of past populations (Landau and Steele 1996; Knudson and Stojanowski 2008;

Ortner 2011). These stories are precious, and should be valued and appreciated in the scheme of human history for generations to come. This kind of research provides an essential outlet for rediscovering the faces or identity of people of the past in a meaningful, impactful, inimitable, and respectful way.

SKULL DEVELOPMENT

The human skull is made of two main portions, the cranial vault and base, and the facial bones; also known as the “neurocranium” and the “splanchnocranium” (White et al. 2012 p 51; Boston 2012 p 53). These portions of the skull differ in when and how they form and develop, but work together to encase and protect the brain and form the face

(Boston 2012; White et al. 2012). These various elements of the skull are formed by either endochondral or intramembranous ossification (Boston 2012; White et al. 2012).

The development of the fully formed skull is controlled by the complex interactions of all the different tissues that make up the entire human head, including the brain (Antón

1989; White et al. 2012; Boston 2012).

Endochondral ossification is characterized by two phases (White et al. 2012;

White and Folkens 2005; Boston 2012). The blueprint of the future bone structure is formed in cartilage first, and then is steadily ossified into bone throughout development

(White et al. 2012; White and Folkens 2005). Intramembranous ossification differs in that there is no cartilage preparation stage; ossification simply proceeds progressively as the first and only step by way of “apposition on tissue within an embryonic connective tissue membrane” (White et al. 2012 p 584; White and Folkens 2005; Boston 2012). The skull is not completely grown when an infant is born and therefore the growth cycle continues by way of both “cortical displacement” or “translation” and “cortical drift” or

“remodeling” (Boston 2012 p 53-54).

The flat bones that make up the superior portion of the skull, or the vault, are formed by intramembranous ossification (White et al. 2012). This ossification begins in fetal growth, rapidly progresses during the first two years of life, and is nearly complete in early childhood, around seven or eight years of age (Boston 2012). This means that at birth these bones are incompletely ossified, separated by areas of cartilage that will ultimately ossify and close when growth is complete (White et al. 2012; White and

Folkens 2005; Boston 2012). This makes the skull more malleable at birth, and therefore especially vulnerable to interior growth pressures, and in turn exterior forces, during infancy and into early childhood (Boston 2012; White et al. 2012). The bones of the face, including part of the mandible, also form by way of intramembranous ossification starting in fetal development (Boston 2012). The growth of these bones then progresses gradually from birth until around age seven, and then quickly proceeds until the early adult years (Boston 2012). Therefore, these bones, like those of the cranial vault are partially dependent on the growth of hard and soft tissues throughout their development

(Boston 2012; White et al. 2012).

The bones of the cranial base are those that, in contrast, form by endochondral ossification, which also starts in fetal development (Boston 2012; White et al. 2012). The majority of this area is complete by age seven, which then finishes forming by the early adult years like the other portions of the skull (Boston 2012). However, due to the different mode of ossification, and the overall growth constraints present on the cranial base, it grows markedly more slowly than the other parts of the skull (Boston 2012).

Therefore this portion of the skull, like the vault, is especially susceptible to changes

based on the developing tissues it houses and any exterior forces (Boston 2012; White et al. 2012). The susceptibility of this area to growth and change in early stages of life is manifested in the actual appearance of the face in comparison to the rest of the skull; the splanchnocranium is proportionally much smaller than base and vault, indicating the significance of brain development early on (White et al. 2012).

Recognizing these differences in ossification pattern and relative developmental periods are integral to understanding how the overall skull can be deeply affected by any outside force that acts on it during life, and especially during the first phases of life

(Boston 2012). The portions of the skull, like the rest of the body, grow and develop as one interconnected whole (Antón 1989). Changes in one area affect, whether overtly or minimally, all other areas of the skull (Antón 1989; Boston 2012). This key concept of how the skull forms throughout life is essential to the following discussion of how modifications to the skull, whether they be medically relevant, like trephination, or cultural, like intentional cranial deformation, can affect growth and/or body functions.

ARTIFICIAL CRANIAL DEFORMATION

Artificial Cranial Deformation

Body piercings, tattoos, scarification, and many other forms of body modification are found in most every culture throughout the world, both in ancient and modern times

(Gerszten and Gerszten 1995; Mednikova 2003). One such example of body modification that leaves an indelible imprint on the human skeleton, and that has been found among the remains of both ancient and more modern cultures, is artificial cranial deformation

(Khudaverdyan 2011).

Artificial, or intentional, cranial deformation is characterized as the process of physically influencing how the skull grows in order to create a different, unnatural shape to the head (Antón and Weinstein 1999; Gerszten and Gerszten 1995). The shape of interest is created by utilizing various kinds of apparatuses like tightly wrapped fabric or twines, or even placement of rigid elements, around the skull in an attempt to either flatten or reshape specific bones of the head (Antón 1989; Antón and Weinstein 1999;

Ayer et al. 2010; Blom, 2005). The employment of these apparatuses commences shortly after an infant is born, and they are left on for variable amounts of time depending on cultural preference; usually for two to five years (Antón and Weinstein 1999; Blom

2005). This process has also been conducted by manual manipulation of the skull, however this form produces less dramatic results (Antón and Weinstein 1999). Infancy is the best time for application because the skull is then at its most vulnerable and

impressionable state (Blom 2005; Boston 2012). This ultimately incites the growth of the bones in the desired direction, rather than their natural pattern (Ayer et al. 2010). This process creates an altered shape to the head that is permanent (Ayer et al. 2010). In

Mesoamerica, this practice was eventually prohibited by the Church who deemed it a heathen tradition (Goodrich and Ponce de Leon 2010). Many other ethnographic accounts also show that this practice seemed highly peculiar to Western outsiders (Blom 2005).

Previous research has detailed varied reasons for this procedure (Boston 2012;

Ayer et al. 2010; Blom 2005; Lozada 2011). Some of the major reasons cited include the need to distinguish some members of society from others whether based on status, ethnicity, or gender; to indicate a notion of physical attractiveness; as a health precaution; as a way to alter the intellect or cognitive function of an individual; and to alleviate the risk of harm from demonic forces (Boston 2012). This practice can aid in the creation of group delineations whether for social or ethnic motivations (Ayer et al. 2010; Blom

2005). The popular term “‘heads of state’” could have been created in response to the use of this tradition among high status, powerful individuals (Nichter et al. 1986 p 325; Ayer et al. 2010 p 1). Some historical accounts of South American culture state that the deformation style chosen by certain groups was based on the likeness of their heads to topographical elements from their area of origin, like a particular mountain or a volcano

(Blom 2005).

Many studies investigated the prevalence and significance of this practice in ancient South America (Boston 2012; Blom 2005; Blom et al. 1998; Lozada 2011).

However, this process is found throughout the world including areas in Europe, the

Middle East, North America, Asia, Oceania, Mesoamerica, the Caribbean, and Africa

(Gerszten and Gerszten 1995; Antón 1989; Boston 2012; Goodrich and Ponce de Leon

2010; FitzSimmons et al. 1998; Ayer et al. 2010). This process may have begun before the evolution of modern Homo sapiens (Ayer et al. 2010; Boston 2012). It has been suggested that some skeletal evidence from Homo neanderthalensis, from Iraq shows evidence of artificial cranial deformation (Ayer et al. 2010, Boston 2012). This field of evidence is around 300,000 to 30,000 years old (Ayer et al. 2010).

There is also unintentional cranial deformation, commonly referred to as

“plagiocephaly,” and it arises most commonly in babies who are allowed to sleep in predominantly one position (Ayer et al. 2010 p 4). This condition influences around 10% of infants (Ayer et al. 2010). The condition of plagiocephaly has also been suggested to be due to other causes including “genetics, health, hormones, nutrition, accidents,” and the way a baby is positioned inside the uterus (Boston 2012 p 20; Antón 1989). These factors surely occurred in ancient times and may contribute to the diversity seen in artificial cranial deformation specimens (Boston 2012; Ayer et al. 2010).

Types of Artificial Cranial Deformation

Researchers have classified many types of artificial cranial deformation ranging from highly simplistic to highly complex (Antón 1989; Boston 2012). The simplest classification has two main categories, the “annular,” and “anteroposterior” deformation styles (Antón 1989 p 253; Antón and Weinstein 1999 p 196).

The “annular” type of deformation results in varying degrees of a pointed shaped skull (Antón 1989 p 253; Antón and Weinstein 1999 p 196). In this type, the head is wrapped tightly with soft objects like fabric, cords, or other similarly lax materials that wrap around the circumference of the skull (Antón 1989; Antón and Weinstein 1999;

Ayer et al. 2010). This creates a shape that is narrowed, lengthened, and often tapered

(Antón 1989; Antón and Weinstein 1999; Ayer et al. 2010).

The other main style of deformation, “anteroposterior,” is achieved by more rigid constraints (Antón 1989 p 253; Antón and Weinstein 1999p 196). In this type, hard materials like “boards, stones, or pads” are placed at the frontal bone and the occipital bone (Antón 1989 p 254; Antón and Weinstein 1999; Ayer et al. 2010). This category also includes instances in which just the occipital bone is affected (Antón 1989). These firm objects are affixed in place to create suitable pressure (Antón 1989; Antón and

Weinstein 1999). This category also includes the use of a “cradleboard” (Ayer et al. 2010 p 2; Goodrich and Ponce de Leon 2010) This apparatus works to create a skull that has distinct horizontal planes (Antón 1989; Antón and Weinstein 1999). In the more extreme forms of this category, in which both the frontal and occipital bones are flattened, the skull has two compressed planes and then a more bulbous shape along the parietal bones

(Antón 1989; Antón and Weinstein 1999; Ayer et al. 2010). The rest of the skull becomes more widened or globular at the sides (Antón 1989; Antón and Weinstein 1999; Ayer et al. 2010).

Health Implications of Artificial Cranial Deformation

The safety of this practice and if it could have affected overall health among populations in antiquity has been discussed by several authors (Antón 1989; Antón and

Weinstein 1999; Cheverud and Midkiff 1992; Boston 2012; Gerszten and Gerszten 1995;

Goodrich and Ponce de Leon 2010; Ayer et al. 2010; Holliday 1993; Kurin 2013).

Artificial cranial modification may affect the cranial base angle, growth of the cranial vault, and growth dimensions of the facial bones (Antón 1989; Antón and

Weinstein 1999). In general, the bony elements are induced to taper in the “annular” deformation type, while these skeletal regions in the “anteroposterior” type are encouraged to widen (Antón 1989 p 253; Antón and Weinstein 1999 p 196).

Other more subtle changes to skull structures have also been correlated to deformation when compared to unmodified individuals (Antón and Weinstein 1999).

These include higher numbers of wormian or “extrasutural” bones, indentations or agglomerations of bone at Bregma, abnormal impressions in the occipital bone, and more broad and variable changes in the landscape of the endocranial surface, such as grooves for the sinuses and the vasculature (Antón and Weinstein 1999 p 197; Boston 2012). This condition of inappropriately placed structures and vasculature may cause “discomfort and pain,” sometimes severe, in the afflicted (Boston 2012 p 115).

Artificial cranial deformation may also have effects on brain growth (Boston

2012; Gerszten and Gerszten 1995; Goodrich and Ponce de Leon 2010). Goodrich and

Ponce de Leon 2010, mention the work of Dr. William Feindel who stated that artificial cranial deformation could have led to altered structure of the “skull base and middle

fossa,” which in turn stunt the growth of the hippocampus and could lead to neurological disorders like “epilepsy and seizure disorders” (Goodrich and Ponce de Leon 2010 p 93-

95). Sutures in individuals with deformation can close differently in terms of order and time (Gerszten and Gerszten 1995). Gerszten and Gerszten 1995, explain that some cases show sutures that closed abnormally early, around age ten, whereas some cases show no suture closure well into adulthood (Gerszten and Gerszten 1995). Several studies have been conducted into how the incorrect closing of cranial sutures can change brain growth

(Boston 2012). Conditions correlated with abnormal suture closure include “increased cranial pressure, distorted brain growth, mental retardation, seizures, blindness, developmental delays, epilepsy, nerve abnormalities, and other conditions” (Boston 2012 p 115). Others argue that while the brain shape is altered by the constraints of the bones around it, the volume of the skull and brain do not appear to change (Gerszten and

Gerszten 1995). Due to this, there should not be any major changes in cognitive function associated with this practice (Gerszten and Gerszten 1995).

In addition to these important growth concerns, other potentially detrimental health effects have been observed including infection, death of bone tissue, and other more subtle lesions and abnormalities (Ayer et al. 2010; Gerszten and Gerszten 1995;

Boston 2012).

Death of bone tissue, or “necrosis,” has been associated with certain apparatuses that can inhibit the correct flow of blood to corresponding tissues (Ayer et al. 2010;

Gerszten and Gerszten 1995; Holliday 1993 p 284). This has been commonly seen in the occipital bone (Ayer et al. 2010; Gerszten and Gerszten 1995).

Higher instances of “cribria orbitalia” and “dental enamel hypoplasia” have been correlated with cranial modification (Boston 2012 p 146). The latter disorder correlates with episodes of stress, and it has been suggested that cranial deformation could have been a contributing, stressful factor (Boston 2012). Guillen et al. 2009 and Mendoca de

Souza et al. 2008 also report the existence of “porotic lesions and periostitis on the cranial bones” in association with artificial cranial deformation (Boston 2012 p 111).

In additional, individuals in South America who underwent cranial modification appear to have faced a higher rate of violence and sustained more wounds than those who did not received cranial deformation (Kurin 2013). They “were victims of sub-lethal and lethal trauma at significantly higher rates than their unmodified counterparts” (Kurin

2013 p 485). Therefore, some of this past research indicates there was a positive relationship, minor or overt depending on the case, between modification and increased risk of death (Boston 2012).

Artificial Cranial Deformation in Peru

The Andean region has yielded many of the best studied examples of artificial cranial deformation (Ayer et al. 2010; Boston 2012; Blom 2005; Blom et al. 1998;

Lozada 2011). Evidence is from both the well-known Inca culture, and many other pre-

Inca cultures (Blom 2005; Blom et al. 1998; Lozada 2011; Boston 2012; Ayer et al.

2010). The earliest examples of this practice are found in Peru and date back to around

7,000-8,000BC (Ayer et al. 2010, Boston 2012). The many examples from this area exhibit both of the main types of deformation detailed in Antón 1989 (Blom 2005; Blom

et al. 1998; Lozada 2011; Boston 2012). In some past excavations up to 90% of discovered skulls are deformed (Ayer et al. 2010).

Ultimately the two main reasons cited for intentional cranial deformation in this area are tied to ethnic or social identification (Ayer et al. 2010; Blom 2005; Blom et al.

1998). Many past researchers and historians have believed specific “ethnic groups or

‘tribes’” were differentially deformed (Blom 2005 p 16). Others have taken this association of group distinctions and expanded it to include delineations based on mode of livelihood or geographical location (Blom 2005; Blom et al. 1998; Lozada 2011). The

“annular” deformation style has been connected with areas of higher elevation and the

“anteroposterior” type has been related to lower areas (Blom 2005; Antón 1989 p 253;

Boston 2012). The use of artificial cranial deformation could correlate with physical affiliation in a “warrior class” or less specifically could work to further empower a hierarchal system (Tommaseo and Drusini 1984; Ayer et al. 2010 p 2). The most powerful group could have dictated that higher status members were allowed to mimic their respective head shape artificially in their offspring (Ayer et al. 2010).

Historical documents and archaeological evidence indicate groups in the Andes, in both pre-Inca and Inca times, strove to differentiate themselves into specific groups based on the garments they wore (Blom 2005). Artificial cranial deformation could have gone hand in hand with garment choices like hat or headdress styles chosen by particular groups (Blom 2005). All of these practices could convey “group affiliation” in terms of

“regional, ethnic, and/or kin group differences” (Blom 2005 p 3).

The Andean Tiwanaku culture probably used artificial cranial deformation to signal hierarchical differences (Blom 2005; Blom et al. 1998). Tiwanaku was most prominent from 500AD to 1,150AD, predating the Inca Empire (Blom 2005). This society included specific social and political sectors and an established, stratified hierarchy (Blom 2005). Blom found that the majority of the population had deformed crania; both the “annular” and “fronto-occipital” types (Blom 2005 p 10; Antón 1989 p

253). Neither the incidence nor the type of deformation was sex-related (Blom 2005).

The “fronto-occipital” style was found in the lowland areas exclusively, and both styles were found in the highland areas, and the core Tiwanaku area (Blom 2005 p 10; Blom et al. 1998). Blom suggests this modification of the physical body served to mediate a connection with the surrounding cultural touchstones of organization (Blom 2005). In

Tiwanaku, modification styles could have served as a means of delineating ethnic groups; the core area of Tiwanaku was then a diverse zone that would have brought both groups together for social and economic purposes (Blom 2005; Blom et al. 1998).

Another study by Lozada discusses the Chiribaya culture, another pre-Inca society in existence between 700AD and 1,359AD (Lozada 2011). It suggests that different deformation types were tied to the livelihood of small groups and that these groups were in turn associated with a particular, larger ethnicity divide (Lozada 2011; Blom 2005).

The main groups observed were the “labradores” or those involved in farming and the

“pescadores” or those involved in fishing activities (Lozada 2011 p 229; Blom 2005 p 5).

This distinction shows a cultural connection among ethnicity, economic status, mode of livelihood, and geographical location (Lozada 2011; Blom 2005).

For the Inca Empire, ethnographic accounts attributed the practice of artificial cranial deformation to higher status members of society; elites may have used their altered head shapes to signal their exclusive status (Blom 2005).

Instances of Artificial Cranial Deformation Globally

Other examples of artificial cranial deformation have been found in Europe, the

Middle East, North America, Asia, Oceania, the Pacific Islands, Mesoamerica, the

Caribbean, and Africa (Gerszten and Gerszten 1995; Antón 1989; Boston 2012; Goodrich and Ponce de Leon 2010; FitzSimmons et al. 1998).

In Mesoamerica, this practice is found in the Olmec, and most notably among the

Maya (Goodrich and Ponce de Leon 2010). Those that were subjected to cranial deformation in these areas were those of higher social status, and had prominent regional affiliations (Goodrich and Ponce de Leon 2010). Altered cranial shape was seen as physically attractive, as well (Goodrich and Ponce de Leon 2010).

Artificial cranial deformation was sometimes employed by fearful 20th century

European families during the Nazi regime (Boston 2012). It was used to fix abnormalities to make sure children adhered to the “‘master race’” requirements (Boston 2012 p 22).

This practice has also been found among other European populations in France,

Switzerland, Germany, Hungary, Austria, and Russia (Gerszten and Gerszten 1995).

In addition, this tradition is found among those of Asia, Australia, the Pacific

Islands, and many of the populations of northern Africa (Gerszten and Gerszten 1995).

Other reasons for this practice among these additional groups include enhancing physical

attractiveness; acquiring prosperity; achieving physical prowess and good health; and functional uses like what is seen in some African groups, in that a different head shape helped with transporting objects on their heads (Boston 2012).

Many cultures in several countries have continued this tradition in more modern times (FitzSimmons et al. 1998). These include several countries of Central America,

Jamaica, China, and Croatia (FitzSimmons et al. 1998).

Artificial cranial deformation is widespread throughout time and space (Blom

2005; Boston 2012; Ayer et al. 2010; Gerszten and Gerszten 1995). This speaks to the impact it has not only on individuals, but also on the deep interaction this tradition has with cultural construction and maintenance (Blom 2005; Boston 2012; Ayer et al. 2010;

Gerszten and Gerszten 1995).

TREPHINATION

Trephination (Trepanation) Surgery

The term trephination was originally characterized as meaning, “drilling of the skull,” while the term trepanation, was identified with “scraping” (Rawlings and Rossitch

1994 p 507). These terms are often used synonymously (Rawlings and Rossitch 1994), and the term trephination will be used for the remainder of this work and should be assumed to encompass both definitions.

Trephination has been readily accepted as the most ancient form of surgery and it has been found in many different cultures, independently, throughout the world, throughout prehistory (Sanan and Haines 1997; Dobanovački et al. 2012; Rifkinson-

Mann 1988; Stone and Miles 1990). Some of these practicing cultures include those of ancient South America, most notably, and those of the Middle East, the Near East,

Melanesia, Europe, Asia, and parts of Africa (Sanan and Haines 1997; Adamson 1991;

Andrushko and Verano 2008; Ng and Dan 1997; Aufderheide and Rodríguez-Martín

1998; Khudaverdyan 2011).

Four main types of trephination are observed in ancient skeletal samples, especially when South American specimens were analyzed (Andrushko and Verano

2008; Aufderheide and Rodríguez-Martín 1998; Khudaverdyan 2011). These methods include cutting in a linear fashion, so that the bone piece removed is quadrangular; drilling where small holes are used to perforate and weaken the skull in a specified

shape which is then removed; scraping, where a specific tool is used to carefully and gradually grind against the skull until a hole forms; and cutting or grooving the skull so that a rounded or oval piece is removed (Andrushko and Verano 2008; Aufderheide and

Rodríguez-Martín 1998; Khudaverdyan 2011). Regardless of the method used, the size and overall shape of trephination wounds often differ from individual to individual

(Andrushko and Verano 2008).

Reasons for conducting trephination surgeries in ancient times surely varied

(Dobanovački et al. 2012). They included, “therapeutic,” “magico-therapeutic,” and

“magico-ritual” reasons (Aufderheide and Rodríguez-Martín 1998 p 32). Instances when this surgery was likely conducted for purely medical or healing purposes, such as what is mostly found in South America, would be classified as “therapeutic” (Aufderheide and

Rodríguez-Martín 1998 p 32). The “magico-therapeutic” approach combines alleviation of symptoms in both medical and cultural contexts (Aufderheide and Rodríguez-Martín

1998 p 32). This grouping has been correlated with situations in which individuals were most likely experiencing physical discomforts that were culturally associated with forces or “spirits” that required escape from the head (Aufderheide and Rodríguez-Martín 1998 p 32). The third reason, “magico-ritual” has been attributed to more unique, less concrete instances (Aufderheide and Rodríguez-Martín 1998 p 32). In the early 1990s, Prioreschi suggested, in accordance with this type, that trephination could have been seen as a way of bringing people back from a comatose state or even death (Aufderheide and

Rodríguez-Martín 1998). The evidence for this was suggested by specimens in which

holes did not heal or examples that show unfinished trephinations (Aufderheide and

Rodríguez-Martín 1998).

Sir Francis Galton, a known racist, asserted that there was no way that people of such a simple means of living, and so far deep in time, could have conceived of something as complex as cranial surgery (Andrushko and Verano 2008). However, more recent studies have close to dismissed this prejudiced way of thinking about past societies

(Andrushko and Verano 2008; Mendoza 2003 Pain 2000). As more and more samples are viewed and contextualized, it is becoming more and more apparent that at least in the

Andean region, practitioners were highly skilled in performing effective surgeries of this complexity (Andrushko and Verano 2008; Mendoza 2003).

Health Implications of Trephination Surgery

Several cultures utilized this practice in cases of dire health needs (Dimopoulos et al. 2008; Pitsios and Zafiri 2012; Khudaverydan 2011; Andrushko and Verano 2008;

Dalrymple-Champneys 1958; Finger and Fernando 2001; Kurin 2013; Marino and

Gonzales-Portillo 2000). Hippocrates explained certain situations in which trephination could be implemented: if a patient experienced skull damage consistent with a “crush- injury,” any break in the bones of the skull, and in cases of depressed skull fractures

(Dimopoulos et al. 2008 p 134; Pitsios and Zafiri 2012). Each of these conditions requires release of pressure (Khudaverdyan 2011). Situations like this could result in internal bleeding, seizures, epilepsy, coma, severe headaches, and related neurological

disturbances (Andrushko and Verano 2008; Dalrymple-Champneys 1958; Finger and

Fernando 2001; Kurin 2013; Marino and Gonzales-Portillo 2000).

Trephination in any time period puts an individual at risk for other health problems (Ng and Dan 1997; Pain 2000; Andrushko and Verano 2008). These include infection, neurological problems including the “syndrome of the trephined,” and ultimately death from these, and other, complications (Ng and Dan 1997 p 346; Pain

2000; Andrushko and Verano 2008).

Infection, as in modern surgeries, would have been an obstacle to overcome in ancient surgeries as well (Pain 2000). Andrushko and Verano 2008 found very few instances of infection in the samples observed, lower than 5% (Andrushko and Verano

2008). This may be because practitioners took care to not damage or destroy the meninges or associated vessels (Andrushko and Verano 2008; Pain 2000). Harming these tissues would have led to higher risk of infection and extreme bleeding that could have more quickly led to death (Andrushko and Verano 2008; Pain 2000). This low rate of infection was possibly also due to the fact that in ancient times lithic instruments were used instead of metal tools, which are more difficult to sanitize (Pain 2000). Also the lack of formal hospitals could have contributed to less infection, especially when compared to early hospitals in Europe, which were not very hygienic (Pain 2000).

Neurological problems have also been associated with trephination surgery, including the “syndrome of the trephined” (Ng and Dan 1997 p 346). Ng and Dan 1997, explain that this syndrome is believed to come from the presence of a hole in the skull and is thought to cause symptoms like loss of memory, impairment in language skills,

dyspraxia, tiredness, dizziness, painful headaches, epilepsy, and paresis of the limbs (Ng and Dan 1997).

In addition to these general risks associated with trephination, ancient populations also illustrate that the chosen methodology of the procedure had significant impacts on mortality (Andrushko and Verano 2008; Mendoza 2003; Kurin 2013). These include the actual method of cutting involved and where on the skull the bone was removed; specifically whether or not important structures were disturbed such as muscles, the underlying meninges, and associated sinuses and vasculature (Andrushko and Verano

2008; Mendoza 2003; Kurin 2013). It has been found, especially in South American samples, that trephination wounds on the frontal, parietal, or occipital bone correlated with higher survival, due to the fact that musculature is less in danger (Andrushko and

Verano 2008). In addition to this, the methods that allowed for more gentle removal of the bone piece, like scraping techniques and careful circular grooving or cutting, were consistent with lessened mortality (Andrushko and Verano 2008; Mendoza 2003). Less controllable techniques like drilling, which could lead to extensive, and possibly fatal damage to the fragile tissues underneath the cranial bones had lower survival rates (Kurin

2013; Andrushko and Verano 2008).

Trephination Surgery in Peru

The Andes have yielded the most trephined individuals of any area in the world, and these specimens span a timeline of thousands of years (Verano and Andrushko 2008;

Andrushko and Verano 2008). The earliest Peruvian examples are from about 3,000BC

(Stone and Miles 1990). The majority of specimens are from “the Paracas, Nazca, Huari, and [Inca] cultures” (Marino and Gonzales-Portillo 2000 p 944). Based on this it appears that trephination was going on in the Andes before the establishment of the Inca Empire and, presumably, minimally or not at all after Spanish contact in the 1500s (Andrushko and Verano 2008; Kurin 2013; Marino and Gonzales-Portillo 2000). The Inca are ultimately regarded as the most skilled at trephination (Pain 2000).

Trephination in the Andes was done by specific surgeons called “sirkaks” who were distinct from other members of the medical community in that they performed cranial surgeries and treated non-nobility for other medical matters (Dalrymple-

Champneys 1958 p 390; Marino and Gonzales-Portillo 2000). It was accomplished in this region using a variety of specialized tools (Andrushko and Verano 2008; Dalrymple-

Champneys 1958). Some of these tools still survive today and have been excavated from various locations including Paracas (Andrushko and Verano 2008; Dalrymple-

Champneys 1958). The most important tools used in this procedure were tumi knives, which are metal, handled knives whose blades are shaped like a half-circle (Andrushko and Verano 2008; Dalrymple-Champneys 1958; Marino and Gonzales-Portillo 2000).

These knives are believed to have been used, primarily, to get through the soft tissue of the scalp as opposed to cutting the actual bone (Dalrymple-Champneys 1958; Marino and

Gonzales-Portillo 2000). In addition to tumis, blades of varying sizes and shapes made of obsidian were also used (Andrushko and Verano 2008; Dalrymple-Champneys 1958;

Marino and Gonzales-Portillo 2000). Other accompanying tools used include bone

elevators, retractors, scalpels, chisels, needles, forceps, and bandages in addition to the use of drill bits in some areas (Kurin 2013).

All four of the main methods of trephination mentioned earlier were employed in the Andes (Andrushko and Verano 2008; Marino and Gonzales-Portillo 2000).

Andrushko and Verano 2008, assert that the “circular-cutting and scraping” methodologies were used the majority of the time in Cuzco (Andrushko and Verano 2008 p 4). Marino and Gonzales-Portillo 2000, also note that circular-cutting was found in

Paracas; quandrangular cutting was used among the Nazca and the Huari; drilling was also observed in the Huari; and the Inca most commonly used circular grooving and grinding techniques (Marino and Gonzales-Portillo 2000).

Some forms of anesthetics were likely used during ancient trephinations in Peru

(Dalrymple-Champneys 1958; Kurin 2013). Specific plant substances including special variations of chicha and the coca plant had anesthetic properties (Dalrymple-Champneys

1958; Marino and Gonzales-Portillo 2000; Pitsios and Zafiri 2012). Phytotherapy is important in this area today and was in the past, however definitive evidence of anesthetic use has not been found (Dobanovački et al. 2012; Rifkinson-Mann 1988).

Limited evidence for the possible use of cataplasms, or concoctions spread over a wound for healing purposes, and the practice of cutting hair from around wound areas has also been cited with similar levels of debate and speculation over their authenticity (Kurin

2013; Verano and Andrushko 2008).

Areas chosen for surgery sites usually correlate to an injury site, however others clearly do not, meaning that this process appears to have included a formal diagnostic

evaluation by the surgeon (Finger and Fernando 2001). There is also clear evidence of bone healing in much of the specimens found (Andrushko and Verano 2008; Finger and

Fernando 2001). In fact, Finger and Fernando 2001, found in their study that 70% of Inca specimens indicate bone healing, meaning these individuals lived after surgery (Finger and Fernando 2001). These surgeons also showed skills that rivaled later surgeons in the

Western world (Andrushko and Verano 2008; Mendoza 2003; Pain 2000). For many centuries, performing trephinations close to sutures was cautioned against by other cultures, including by Hippocrates (Bakay 1982; Dimopoulos et al. 2008). It was commonly believed that sutures were especially sensitive areas that if disrupted would result in increased risk of hemorrhaging, damage to the underlying tissue, and damage to such structures as the venous sinuses (Bakay 1982). The exaggerations of this belief were eventually corrected in the Western world with more modern medical advancements; however, those in the Andes did not always avoid sutures in all of their trephination patients and had success in most cases regardless (Andrushko and Verano 2008; Bakay

1982). It has also been proposed that these populations improved these procedures over time (Andrushko and Verano 2008; Kurin 2013). Some have suggested that practitioners became better at performing these surgeries by practicing on dead individuals (Kurin

2013). It has been asserted that these surgeons were so adept at their procedures, that they were even able to conduct several trephinations, at different times, on a single individual

(Andrushko and Verano 2008; Oakley et al. 1959). Some of these examples have shown as many as seven holes, and many show bone reaction and healing for more than one of the surgeries (Andrushko and Verano 2008; Oakley et al. 1959). In general, survival rates

are most significant in showing the medical skill of these Andeans, because over 80% survived, which is much higher than the rates observed in Europe in the late 19th century; statistics of survival from some hospitals in England during this period were less than

30% (Andrushko and Verano 2008; Mendoza 2003; Pain 2000).

The main impetus of the beginning of these surgeries was most likely related to the ever-present warfare and violence in this region and high incidence of injuries, especially head injuries; this yielded an ideal arena for medical exploration (Andrushko and Verano 2008; Mendoza 2003; Dalrymple-Champneys 1958; Finger and Fernando

2001; Kurin 2013). Based on this, trephination became commonplace as a medically based practice, used to achieve improved health of victims of wartime head injuries, like

“depressed cranial fractures” derived from this cultural and temporal affinity for violence

(Andrushko and Verano 2008; Dalrymple-Champneys 1958; Finger and Fernando 2001 p

381; Kurin 2013). Therefore battle wounds would have caused people in this region to seek out trephination surgery for both direct traumatic injuries, and subsequent symptoms like internal bleeding, seizures, epilepsy, coma, severe headaches, and related neurological disturbances (Andrushko and Verano 2008; Dalrymple-Champneys 1958;

Finger and Fernando 2001; Kurin 2013; Marino and Gonzales-Portillo 2000; Mendoza

2003; Pain 2000). Several studies recount work by J. C. Nott in which it was indicated that injuries, especially those that broke through the tissue of the head, would result in negative neurological problems (Andrushko and Verano 2008; Finger and Fernando

2001). He tested and proved that taking out a piece of the skull helps alleviate pressure from internal bleeding (Andrushko and Verano 2008; Finger and Fernando 2001).

Research done by MacCurdy in the 1920s supports this proposition of trephination being born out of the prevalence of warfare in this region (Andrushko and

Verano 2008; Rifkinson-Mann 1988). He stated that the majority of trephinations being located on the left side, and the abundance of cases with associated signs of injury, were due to individuals being injured by right-handed enemies in combat (Andrushko and

Verano 2008; Rifkinson-Mann 1988; Finger and Fernando 2001). MacCurdy also decided that “stellate-pointed clubs” were the most to blame for the injuries in need of trephination (Andrushko and Verano 2008 p 5). Verano suggests that another significantly hazardous weapon was the slingshot (Pain 2000). The large number of trephined skulls found was also related with the most intense periods of violence; this could have been when those conducting the trephinations were able to hone their skills

(Andrushko and Verano 2008).

The significant relationship between this practice and warfare is also found when demographics are analyzed (Andrushko and Verano 2008; Finger and Fernando 2001).

Men make up the largest proportion of those receiving the surgery, followed by women, and children are the smallest, most rarely found group (Andrushko and Verano 2008;

Finger and Fernando 2001). Verano has suggested that the presence of some women and children with head injuries and surgical intervention also supports the idea of warfare being the impetus in that this is indicative of “raids on their villages” (Pain 2000 p 34). In terms of age, most individuals seem to have received the surgery in their young adult years (Andrushko and Verano 2008; Kurin 2013). Kurin 2013 found that in Andahuaylas examples, individuals over age 20 were the only ones found with trephination wounds

(Kurin 2013). Several authors mention extensive work by John Verano that states that over 50% of the male populations in the central highland areas of Peru would have sustained skull injuries (Finger and Fernando 2001; Pain 2000). This again supports the idea that in this region, battle wounds were the main motivation for trephination, affecting mainly fighting age men (Finger and Fernando 2001; Andrushko and Verano

2008).

Trephination is not found in areas that were related to nobility, like Machu Picchu due to the fact that this would not have been a prime location for military activities, and this was where foreign servants served the royalty, who also would not have been prime participants in battle (Andrushko and Verano 2008).

Due to the benefits trephination served for those with battle wounds, it could have also been employed for other health related problems (Andrushko and Verano 2008;

Kurin 2013; Marino and Gonzales-Portillo 2000; Pain 2000). Some studies have potentially correlated trephination to other physical problems like the condition of

“mastoiditis” (Andrushko and Verano 2008 p 11). This condition results in extreme pain induced by inflammation of the mastoid portion of the temporal bone that is a result of more severe ear infections (Andrushko and Verano 2008). Various studies including those by Oakley in 1959, Mann in 1991, and Andrushko and Verano 2008, mention the presence of people who possessed both this condition and evidence of trephination wounds on their cranial bones (Andrushko and Verano 2008). Trephinations in the area of Andhuaylas were found correlated to instances of “inflammatory, porotic bone” (Kurin

2013 p 488). Some individuals may have also been trephined to alleviate problems from

“longer-term infections of the scalp, epicranial aponeurosis, or the ectocranial surface itself” (Kurin 2013 p 492; Marino and Gonzales-Portillo 2000). In addition, Verano suggested that cases with more than one trephination wound could be indicative of surgeons trying to fix chronic symptoms of different discomforts (Pain 2000).

Also, others have suggested that trephination could have been utilized in cases of mental illness (Andrushko and Verano 2008; Khudaverdyan 2011). Verano suggested that these cultures may have had advanced knowledge of the brain (Pain 2000). He suggests that they may have evaluated how behavior and motor function could have changed before and after a head injury, and before and after a trephination (Pain 2000).

Overall, it is apparent that trephination was an important practice in ancient Peru that had both cultural and medical significance (Andrushko and Verano 2008; Verano and Andrushko 2008; Pain 2000; Kurin 2013; Marino and Gonzales-Portillo 2000).

Specimens exhibiting this procedure are palpable evidence of the innovative and advanced medical minds that existed in this region long ago; a viewpoint that is disregarded in most literature due to the ethnocentric perspectives of Europeans who made first contact with this area in antiquity (Andrushko and Verano 2008; Dalrymple-

Champneys 1958; Finger and Fernando 2001; Mendoza 2003; Pain 2000). It is evident that this procedure and in turn medical exploration in general, were hallmarks of this area and therefore are integrally significant aspects of culture, that prior to bioarchaeological analyses as those presented above, would not be definitively proven (Andrushko and

Verano 2008; Verano and Andrushko 2008; Pain 2000; Marino and Gonzales-Portillo

2000; Kurin 2013).

Instances of Trephination Surgery Globally

Although South America, most namely Peru, Bolivia, and Ecuador, provide us with some of the best body of evidence for trephination, many other locations globally were also performing this procedure (Sanan and Haines 1997; Verano and Andrushko

2008; Valesco-Suarez et al. 1992; Adamson 1991; Balanzar 2010; Dimopoulos et al.

2008; Dobanovački et al. 2012).

For example, the skull of an Iron Age juvenile was found in Iran that showed evidence of being trephined (Adamson 1991). This specific example showed indications that the child lived through the surgery (Adamson 1991). Other examples in the Middle and Near East have been found in Iraq, Armenia, and Israel (Crubézy et al. 2001;

Khudaverdyan 2011).

Other limited examples of trephination were found in Mesoamerica, such as in

Monte Albán, Mexico (Balanzar 2010; Goodrich and Ponce de Leon 2010; Valesco-

Suarez et al. 1992). These examples are tied to head trauma, similar to that exhibited in the Andes (Balanzar 2010). However, Balanzar 2010 does suggest that health improvement from trephination in Mexico would have been attributed to “magic powers”

(Balanzar 2010 p 98). Still other limited examples have been found in North America, namely in Canada and some portions of the United States (Mendoza 2003; Stone and

Miles 1990).

Further examples of trephination have been found on skulls found in the

Mediterranean region of Europe (Crubézy et al. 2001). The specimens in this area belong to the Late Neolithic era and the Early Bronze Age period, while some examples are even

older (Crubézy et al. 2001). The definitive reason for the surgery in these examples is still not identified, however it is most often suggested that it had “magical and religious significance” (Crubézy et al. 2001 p 418). Trephination was also practiced in Greece

(Dimopoulos et al. 2008; Pitsios and Zafiri 2012). Similarly evidence of trephination and innovations in this procedure also took place in Rome (Pitsios and Zafiri 2012). Other

European examples of this practice have also been found in Ukraine, France, the Czech

Republic, Scandinavia, the Balkans, like Albania, former Yugoslavia, and areas of

Siberia, like Russia (Crubézy et al. 2001; Pitsios and Zafiri 2012; Dobanovački et al.

2012; Pain 2000).

North Africa, and most specifically Morocco, has also yielded some other examples of this practice, including an example with healing evidence (Crubézy et al.

2001; Rawlings and Rossitch 1994). Some evidence has also been found in the Canary

Islands (Dobanovački et al. 2012; Rawlings and Rossitch 1994). It has been suggested, by researchers like Margetts, that some populations in modern day Africa still utilize trephination for getting “cranial rondelles,” which could then be used for personal adornment (Khudaverdyan 2011 p 39). However, others suggest that this surgery in

Africa is most commonly used for pain caused by trauma, and secondarily for limited spiritual purposes (Rawlings and Rossitch 1994).

In addition to other ancient societies, variations on trephination surgery are performed in modern biomedicine (Dimopoulos et al. 2008; Ng and Dan 1997; Sanan and

Haines 1997). Modern procedures closely related to these ancient processes are classified as craniotomies and craniectomies (Dimopoulos et al. 2008; Ng and Dan 1997). The tools

utilized today are different, being made mostly of metal rather than lithic material, however, the reasons for administering the surgery and some of the main safety precautions are similar (Dimopoulos et al. 2008; Ng and Dan 1997; Sanan and Haines

1997; Shah et al. 2014; Bonfield et al. 2014). Careful attention is still given to dodging vulnerable areas of the skull like the meninges and vasculature, in addition to evaluating key anatomical features and bone thickness (Dimopoulos et al. 2008).

Cranioplasty

Cranioplasty has occurred since prehistoric times in tandem with trephination

(Aciduman and Belen 2007; Bonfield et al. 2014). It is a medical procedure in which the skull is repaired after part has been damaged or removed, by using organic or inorganic material and sometimes even the reinstatement of the original piece of bone (Sanan and

Haines 1997; Aciduman and Belen 2007; Bonfield et al. 2014; Shah et al. 2014).

Cranioplasty restores the overall shape and appearance of the normal skull and safeguards the sensitive meninges, and in turn the brain (Ng and Dan 1997; Verano and Andrushko

2008).

Evidence for cranioplasty has been observed in archaeological remains, and in documents and descriptions found in the Ottoman Empire, Persia, ancient Greece and

Rome, and other locations (Aciduman and Belen 2007; Bonfield et al. 2014; Ng and Dan

1997; Shah et al. 2014). Instances of this practice are not only found deep in time, some examples are as early as 7,000BC, but they are also found throughout the world,

including in Europe, South America, Polynesia, Melanesia, Asia, and Africa (Shah et al.

2014; Ng and Dan 1997).

Some of the earliest materials used for cranioplasties included metals, such as silver and gold, and various organic materials like coconut shells, different kinds of gourds, elements of the coca plant, and the maté plant, and in some rare cases human or animal bone (Aciduman and Belen 2007; Bonfield et al. 2014; Sanan and Haines 1997).

In Peru, it is believed that those who received metal plates over their cranial defects were proposed to be of higher status socially, whereas the use of organic materials like gourds were for those of lower status in society (Sanan and Haines 1997; Shah et al. 2014).

Several Peruvian trephined skulls have been found with metal plates of silver or gold, pieces of gourds, and shells closely associated (Sanan and Haines 1997).

Many prime examples of the procedure, found with trephined skulls come from time periods and locations heavily associated with warfare (Bonfield et al. 2014). Based on the different materials used and the distribution of examples, it appears that at least in

South America, this practice was both medically and culturally significant (Sanan and

Haines 1997; Shah et al. 2014; Bonfield et al. 2014; Kurin 2013).

As discussed previously, trephination can leave patients highly vulnerable with higher susceptibility to infection or injury of the brain, and the potential for neurological abnormalities, such as the “syndrome of the trephined” and epilepsy (Ng and Dan 1997 p

346). Ng and Dan 1997 found in their study that a patient showed symptoms of the

“syndrome of the trephined” when various plugs were removed from the skull, but had

“significant neurological improvement” when implants were in place (Ng and Dan 1997

p 346-347). Modern cranioplasty has been tied to bettering “electroencephalographic abnormalities, cerebral blood flow abnormalities, and other neurological abnormalities”

(Shah et al. 2014 p 1). It is likely that ancient populations, who were capable of performing effective cranial surgeries like trephination, would have covered the manufactured hole in the skull in order to maximize survival and livelihood of patients

(Sanan and Haines 1997).

Some researchers have argued that these evidentiary accounts of cranioplasty in

South America should be regarded with skepticism (Verano and Andrushko 2008). These authors argue that few clear examples of cranioplasty in this region have survived to today and may never have existed to begin with (Verano and Andrushko 2008). They do note one mummy found close to Cuzco that does show evidence of cranioplasty with the original piece of bone removed being replaced after trephination (Verano and Andrushko

2008). Some past ethnographic accounts, especially research conducted by Adolf

Bandelier in the late 1800s, reveal that inhabitants of this region maintain that trephination did occur and that sometimes it was concluded with cranioplasty (Verano and Andrushko 2008). Bandelier was able to find a few individuals who claimed to have either undergone the surgery or known others who had; all of whom claimed that elements of gourds had been used to fill the cranial holes (Verano and Andrushko 2008).

Ultimately, however, the minimal examples of cranioplasty could be caused by many extenuating circumstances (Bonfield et al. 2014; Sanan and Haines 1997; Verano and Andrushko 2008). It is plausible that implants made of more valuable materials like metal or shell could have been removed after death; the fragile plant materials that have

been suggested could have not preserved well; or any of these objects could have been lost (Bonfield et al. 2014; Sanan and Haines 1997; Verano and Andrushko 2008). In terms of this last possibility, it has been established that much of the skeletal evidence from this region that show evidence of trephination was recovered in the late 1800s and early 1900s in “communal tombs or burial caves where skeletal remains were commingled and disturbed by artifact collectors and other taphonomic agents” (Verano and Andrushko 2008 p 270).

CONCLUSION

Anthropological, and especially archaeological, research draws upon a breadth of knowledge in many different disciplines. Human remains can be important for answering many research questions about ancient peoples, and provide unique information that other evidence cannot contribute (Landau and Steele 1996; Knudson and Stojanowski 2008;

Mednikova 2003; Ortner 2011; Mendoza 2003; Blom 2005). The physical body can provide clues to many individual aspects of a person’s former life (Landau and Steele

1996; Knudson and Stojanowski 2008; Mednikova 2003).

The body is the vessel within which many stresses of life are felt, withstood, and recorded (Landau and Steele 1996). It is intimately affected every day by what it experiences, especially over long periods of time (Landau and Steele 1996). Although different cultures view the connection between the mind and the body differently, both the mind and the physical body contribute in some way to the overall construction of sense of self (Halliburton 2002; Scheper-Hughes and Lock 1987). These relationships both affect and are affected by cultural traditions and beliefs in a dynamic, fluid interdependence (Scheper-Hughes and Lock 1987). Therefore, alterations to the body, whether they be reliant on specific cultural traditions, like artificial cranial deformation, or whether they are necessitated by injuries or disease from the environment, like trephination, are essential to understanding the human condition cross-culturally

(Mednikova 2003; Knudson and Stojanowski 2008; Landau and Steele 1996).

Understanding the deep and profound connections between health, sense of self, and cultural specificities epitomizes why analyses of human remains are potentially significant for anthropological study (Landau and Steele 1996; Mednikova 2003). The instances of body modification and details of healing practices in this discussion provide information about individuals and their environment that can be seen as much more reflective of the human condition than some other archaeological remains indicate

(Landau and Steele 1996; Mednikova 2003). As has been established through this exploration of cranial deformation, and trephination, the skull is a vulnerable part of the body, and modifications to it have specific consequences (Andrushko and Verano 2008;

Pain 2000; Boston 2012; Holliday 1993; Kurin 2013; Gerszten and Gerszten 1995; Antón

1989). Executing any of these practices would have had the potential for detrimental health effects; however, it is obvious that the idea of personal identity and attempting to heal the wounded outweighed the risks (Boston 2012; Kurin 2013; Andrushko and

Verano 2008; Pain 2000; Holliday 1993; Gerszten and Gerszten 1995). These practices that can be viewed physically in osteological analysis, show how devoted people have been to these concepts and the high importance they held for everyday maintenance of culture and identity (Landau and Steele 1996; Mednikova 2003; Knudson and

Stojanowski 2008; Blom 2005; Lozada 2011; Andrushko and Verano 2008; Pain 2000).

Further analysis into both of these specific past traditions and others like them will continue to support the use of skeletal material in research. The goal is not to exploit, manipulate, or desecrate remnants of past individuals (Landau and Steele 1996). The goal is to utilize what they have left behind in an attempt to give honor and dignity to those

who have come before (Landau and Steele 1996; Knudson and Stojanowski 2008; Blom

2005). This is ultimately another way to recreate the inimitable faces of the past. In addition, research in this realm can help decipher to what extent culture affects everyday life, and the body most specifically (Landau and Steele 1996; Knudson and Stojanowski

2008; Blom 2005). It is also essential in the continued quest to learn why human beings as a species are so adaptable, resilient, innovative, and extraordinary (Landau and Steele

1996; Knudson and Stojanowski 2008; Blom 2005).

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