507 HISTORY IR.SEVIER The History of Trephination in Africa with a Discussion of Its Current Status and Continuing Practice Charles E. Rawlings, III, M.D., and Eugene Rossitch Jr., M.D. Forsyth Neurosurgical Associates, Winston-Salem, North Carolina, and Division of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts Rawlings C III, Rossitch E Jr. The history of trephination in Africa and in some areas, especially North and East Africa, it with a discussion of its current status and continuing practice. continues even today [2,8,10,11,40,41]. Surg Neurol 1994;41:507-13. African trephinations were performed by sawing, scraping, or cutting using a fairly standard set of instru- Trephination of the skull is one of the most fascinating and, certainly, one of the oldest therapeutic procedures ments in the hands of a specially trained medicine man. known to man. After Pruni~res' discovery of the tre- Although none of the tribes paid particular attention to phined skull at Aigui~res in 1868, a plethora of informa- cerebral localization, the North African groups assidu- tion has been gathered about the procedure. There, ously avoided suture lines that were thought to be the however, exits little documentation of African trephina- "fingerprints of Allah." All groups avoided the dura tion or its history. Using both primary and secondary because they were well aware of the complications asso- sources, we have discovered that African trephination ciated with its violation. The indications for trephina- was known in the time of Herodotus, has a rich history, tions were many and varied, but they were performed and is currently practiced widely throughout Africa for primarily for headaches following a head injury or, specific reasons. We discuss these findings as they relate rarely, for the release of evil spirits. to preconceived notions of trephinations in other coun- Trephination in Africa has a long tradition originat- tries and to the history of neurosurgery. ing in prehistory. The procedure, as practiced in North KEY WORDS: Africa; Headache; Medical history; Trepanation; Africa, originated from ancient Arabs and its practi- Trephination tioners included the extinct Guanches of the Canary Islands and the Tuareg Berbers and Chaou'ias of Mor- occo, Libya, Chad, and Algeria [1,2,5,8,13,15,21- 23,29,30,32,36,37,46,49]. The East African group Trepanation, or trephination, is one of the most fasci- included the Kisii and Tende in Kenya and Tanzania. nating and ancient practices in the history of medicine. Tribes in both these geographical regions continue to The word trepanation is from the Greek trypanon perform the procedure today. The practice of trephina- meaning "a borer" whereas trephination is a French tion on the continent was not confined to these two variant. Trepanation describes scraping, whereas tre- regions and examples can be found in Uganda, South phination connotes drilling of the skull. For all intents Africa, Nigeria, and Somalia. Surprisingly, the early and purposes they are interchangeable and imply a Egyptians did not routinely trephine patients [8,14, depression or perforation in the calvarium [8]. 16,20,25,33,34,41,45]. Since Pruni~res discovered a trephined Neolithic Many anthropologists consider Africa to be the center skull in 1868 at Aigui~res and Broca asserted that the of human evolution with Egypt being a most prominent patient survived the procedure, a plethora of reports region of early civilization. This is certainly true with have appeared concerning this practice. Most articles regard to early medical practice and knowledge as re- deal with prehistoric trepanations, particularly in Neo- flected by the Edwin Smith Surgical Papyrus and early lithic Europe and pre-Columbian South America, but it mummification. Treatments for head injuries and brain has become evident that the procedure has been per- removal through the transphenoidal route are docu- formed extensively in almost all regions of the world mented in this publication. It is surprising, therefore, that trephination of the skull was rarely practiced in Egypt as many more varied and complicated procedures Address reprint requests to: Charles Rawlings, III, M.D., Forsyth were performed. A few examples of trephination in Neurosurgical Associates, 3080 Trenwest Drive, Winston-Salem, N,C. 27103. Egypt are available. One is a trepanned skull from the Received May 13, 1993; accepted June 21, 1993. Twelfth Dynasty (2000-1788 B.C.) found in the deep (D i994 bv ElsevierScience lnc C)()9(I- S() I ~)I~) I '$q.{)() 508 Surg Neurol Rawlings and Rossitch 1994;41:507-13 pits at Lisht [3,7,35,39,41]. The question arises, there- • h i fore, from whence did early trephination originate and where was it found if not in Egypt. Our attention is next drawn to the unlikely region of the Canary Islands. The Canary Islands Hans Meyer, in 1896, was one of the first to document trephination in the Guanches, a group of now extinct aboriginal people who were most likely a Berber group closely related to various North African Arab tribes. In Meyer's book, Von Luschan described three examples of trephined skulls found among a series of 52 skulls on the island of Tenerife [8,28]. After these discoveries several other authors including Lambert, Hooton, and Beattie described crania that showed signs of trephina- tion [4,8,24,48]. Most defects had not completely filled Figure 1. A collection of surgical instruments obtained from Algeria showing various trepanning saws and elevators. Source: Hilton-Simpson in, but new bone formation was clearly evident around MW. Arab medicine and surgery: a study of the healing art in Algeria. the edges with several showing complete healing. Many London: Oxford University Press, 1922:3-38. Used with the permission of of the trephinations were similar to the sincipital "T" Oxford University Press. form found in many Neolithic trephined skulls. This suggests not only a European influence but also the the 400s B.C. it has only recently been discovered by direct importation of this practice into the Islands "modern medicine" [2,8,11,40--42]. [4,8,12,17,24,27,28,48]. Bertherand, in 1855, indicated that he believed the Kabyle Berbers in Morocco and Algeria practiced tre- phination [5]. Other French literature later in the cen- North Africa tury confirmed its existence and summarized its practice Along with the the Guanches of the Canary Islands, [5,8,10,17,18,27,30,32,37]. Hilton-Simpson, in a clas- many Arab tribes in North Africa practiced trephination sical expedition to the mountains of Algeria and Mor- and continue to do so today. As early as Herodotus, it occo, discovered and observed trephinations amongst the was noted that Libyans practiced trepanation, and pre- Berbers in the 1920s. A number of skulls, instruments, historic skulls showing signs of trepanation were found and bone plugs removed from skulls were collected by by General Faidherbe in Algeria and subsequently ex- their expedition and placed in various museums. amined by Broca [8,10,18]. Since the late 1800s several At no time were the dura or sutures (the fingerprints expeditions have been mounted to North Africa to of Allah) violated, and the variety and workmanship of document the practice of trephination amongst the the instruments used were quite excellent (Figure 1). Tuareg Berbers, Tibu, Chaou~'a, and Kabyle Berbers. It Holes were made in the skull with a hand-twirled drill is quite apparent that the practice is based upon a firm and connected by means of a serrated saw. However, historic foundation, is extensively employed, and is circular trephines were also used. After the holes were currently extant in this part of Africa [1,2,5,13,15,21- drilled, any blood or pus under the bone was drained 23,29,30,32,37,46,49]. and any "bad" bone removed. A dressing was then The origins of this trephining tradition can be easily applied that consisted of sheep's butter, pine, resin, understood once it is realized that Arab medicine men honey, and wheat flour. No sutures were ever used, and were well-versed in this technique and have been prac- the dressing was removed in 14 days. An interesting ticing this procedure for thousands of years [8,42]. Add variant of this procedure was a staged technique wherein to this the fact that the Canary Islands acted as a bridge all the incisions and bone work were done in one step; allowing the Neolithic techniques of trephination to act the bone was then removed 3 to 15 days after its upon the already competent Arabic traditions in North devitalization. This waiting period allowed the bone to Africa, and it becomes apparent that the origins of be plucked from the skull. The medicine men in this trephination in North Africa were a synthesis of Neo- area were noted to have completed hundreds of these lithic and Arabic practices. Although the trephination procedures, claimed excellent pain relief, and the resto- of skulls has been practiced in North Africa for thou- ration of consciousness following injury [8,13,15,18, sands of years and was noted by Herodotus as early as 21-23,27,29,32,40,41]. A History of Trephination in Africa Surg Neurol 509 1994;41:507-13 The two major countries in which this practice is found are Kenya and Tanzania, and the tribes involved include the Kisii and Tende. Although the practice of trephina- tion was known during the early days of British and German colonization and was documented in early colo- nial government files, it has only been recently that this practice has been viewed in a modern context. Whereas the amalgamation of Neolithic and Arabic practices produced a clear line of evolution for the history of North African trephination, no such obvious historical basis exists for trephination in East Africa.