Sarah Taylor

Dr. Buzon
ANTH 534
7 December 2015
Trephination Across Cultures and Time
Trephination is a surgical procedure that has been performed cranially in many different
locations and cultures for many thousands of years. Trephination occurs when a hole is created
most typically in the human skull, through different methods, to treat health issues. This paper
will focus on cranial trephination in Peruvian, Roman, Chinese, and eastern African cultures,
which tools and techniques were used, and if any post-cranial trephination was performed. It will
also discuss how trephination is used both the cranium and post-cranially today and how
advancements have affected the skeleton.
Cranial trephination is first recognized in Peru. The reason for why trephination was used
are numerous, and it was thought to be performed for trauma, fractures, diseases of the cranium,
scalp, and cranial infections, epilepsy, headaches, mental disease, and some traumaturgic rituals
(Marino and Gonzalez-Portillo, 2000). The Paracus, Nazca, Huari, and Ia cultures show the
greatest number of trephination techniques used in their archeological populations. The Paracus
culture typically used circular cutting techniques (Marino and Gonzalez-Portillo, 2000). The
Nazca culture, which postdate the Paracus, had the first evidence of crosscut technique (Marino
and Gonzalez-Portillo, 2000). They developed into the Huari culture, which used crosscut and
drilling techniques (Marino and Gonzalez-Portillo, 2000). The Ia followed the Huari and used

circular and scraping techniques (Marino and Gonzalez-Portillo, 2000). According to Marino and
Gonzalez-Portillo (2000), examination showed that the wounds rarely resulted in infections and
some people even survived. It also is thought that antiseptics might be used in trephination,
which would be the same ones used for embalming.
Several different instruments were also used for trephination in ancient Peru. Chisels of
copper, silver, gold, and champi (Inca bronze) were used to perform linear incisions (Marino and
Gonzalez-Portillo, 2000). Tumi, which is a metal instrument with a T-shaped handle and
crescent-shaped blade, was used to open the scalp. Anesthesia was probably based on herbal
preparations or alcoholic beverages, which were given to patients in large amounts (Marino and
Gonzalez-Portillo, 2000). There were two types of tribal doctors. The churihapicamayoc treated
the nobility, and the sirkak or sangrador treated the common people and performed craniectomies
during war and peace.
Trephination in the Roman empire from a modern perspective may be considered
impressive in terms of surgical skill level and instrumentation available (Tullo 2010). The reason
for trephination in the empire is unknown as it is for most places, but trauma is thought to be the
main cause of these surgeries. Examples of trepanned skulls from the time period are rare
because of their custom of cremation (Tullo 2010). There were four different types of techniques
used for trephination in the Roman empire. They are scraping, chiseling of a circular groove,
joining of adjacent burr holes, and linear grooves.
Tools used for Roman trephination vary widely. A raspatory was used for scraping scalp
of the individuals. Chisels, gouges, hammers were used to break the skull. Meningophylax was a
metal piece that was used to protect the dura mater (Tullo 2010). Drill and crown saw (modiolus)

was a shallow cylinder of metal with a sharp edge rotated against the skull surface (Tullo 2010).
The choice of instrument was probably dependent on the case. The material composition of the
instruments were wood, metal, and woven material. Metals were used for surgical instruments,
which included gold, silver, copper, tin, lead, iron, zinc, and several different alloys (Tullo 2010).
Trephination of skulls in China date back to as far as 5000 BC. Trephination was used to
alleviate pathological conditions or injuries caused by trauma, such as blows to the head and
arrowheads (Kangxin and Xingcan, 2007). The study of five Chinese trepanned skulls from
different sites, Shandong, Qinghai, Henan and Heilongjiang provinces, and time periods,
Neolithic, Bronze, and Iron Ages, conducted by Kangxin and Xingcan (2007) concluded the
following results. The main technique for trephination is scraping. From the Neolithic to Iron
Ages, the scraping technique became more precise.
The skulls that were examined resulted in different forms of healing with relatively
smooth borders, which indicated that they were successful (Kangxin and Xingcan, 2007). This
shows that, though primitive, the trephination surgery was rather therapeutic. In Neolithic China,
it is likely that a stone flake was used. In the Bronze Age, a sharper tool, such as a metal blade,
was probably used. Finally, in the Iron Age, an even more advanced iron tool was possibly used
(Kangxin and Xingcan, 2007).
Trephination in Africa occurred mostly in the northern and eastern portions. In Eastern
Africa, it was adopted from the Persians and is still used today. Trephination is used to relieve
headaches, remove skull fracture lines secondary to cranial trauma, and occasionally for
ceremonies (Kinasha and Kucia and Vargas and Kavolus and Margarik and Ellegala and
Nicholas, 2012). Techniques used involved using drill and saw. A designated surgeon, omobari,

trained as an apprentice, by a member of the previous generation, performs the procedure and is
part of the upper class (Kinasha and Kucia and Vargas and Kavolus and Margarik and Ellegala
and Nicholas, 2012). The apprentice must complete between twenty-five and thirty surgeries
before being able to practice alone. The operation can last anywhere from one to twelve hours
and does not involve the use of anesthesia.
In conclusion, across cultures the same four types of techniques for trephination are used.
They are scraping, circular chiseling, crosscutting, and drilling. Typically, some type of metal or
stone tool was used for the procedure and depended on the type of technique was being used for
that particular trephination. Advancements have been made over time and trephination is still
used today for many different types of operations in areas that today are postcranial.
The first use of trephination today is to treat epidural hematoma. They are not very
commonly performed, but do increase the survival rates for patients that are deteriorating quickly
and do not have time for transfer (Smith and Clark and Nelson and Heegaard and Lufkin and
Ruiz, 2009). A craniotomy is preferred but often takes a much longer time to get a patient into
the operating room. A CT scan is necessary and a Galt trephinator is used to perform the surgery.
Trephination in this case is typically done in the temporal bone of the cranium and can be
dangerous performed in other areas.
The second use of trephination today is frontal sinus trephination. It is very useful when
reaching far lateral and superior disease in surgery when endoscopic access alone is not
sufficient (Patel and Cain and Lal, 2015). The combination of using frontal sinus trephination
along with endoscopic procedures for better results. Front sinus trephination be used to help treat
non-inflammatory diseases, such as fibrous dysplasia/osteoma, inverted papilloma, cerebrospinal

fluid leaks, posterior table fracture, meningioma, and pneumocephalus (Patel and Cain and Lal,
2015). It can also be used to help treat inflammatory diseases, such as narrow frontal recess,
severe edema, severe polyps, obstructing frontal cells, acute or chronic frontal sinusitis,
mucoceles, and frontal bone osteomyelitis (Patel and Cain and Lal, 2015). There is also minimal
post-operative scarring so the incision site is barely visible, which is very different from the
massive holes in the skull seen in ancient forms of trephination.
A third use of trephination today is for canalicular obstruction. Canalicular obstruction is
a common cause of troublesome epiphora and is often the result of drug toxicity, chronic
inflammation, or iatrogenic damage during dacryocystorhinostomy (DCR) surgery (Nathoo and
Rath and Wan and Buffam, 2013). Canalicular trephination is a minimally invasive alternative
and is typically used after failed DCR or after unrelated canalicular pathology. Trephination
tends to have better results than the traditional method of dealing with canalicular obstruction.
The final use of trephination is nail trephination for subungual hematoma. A subungual
hematoma is an accumulation of blood that collects in the space between the nail plate and the
nail bed and is often the result of a crush injury to a finger or toe (Salter and Ciocon and
Gowrishankar and Kimball, 2006). Typical methods of decompression of the hematoma often
cause discomfort. These methods include using a heated paper clip, electrocautery, or a
presterilized needle to bore a hole in the nail plate, as well as nail plate removal. They may cause
heat-induced coagulation and consequent incomplete evacuation of the hematoma. Nail
trephination is the quickest and convenient method.
Overall, trephination is a very useful technique both in the past and now. Techniques used
were very similar across ancient cultures. Tools were also similar, but made of different products

based on the resources in their environments. Today, most of the uses of trephination mostly
involve the cranium. However, the burr holes created, both in the cranium and post-cranially, are
much smaller and less obvious then those of the past. Trephination and its uses will continue on
in medicine and may even improve more surgical procedures.

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INDO-PACIFIC PREHISTORY ASSOCIATION BULLETIN 27: 22-27.

Kinasha A. Kucia E. Vargas J. Kavolus J. Magarik J. Ellegala D. Nicholas J. 2012. Neurosurgery

in Tanzania: A Discussion of Culture, Socioeconomics, and Humanitarians. World
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Marino R. Gonzalez-Portillo M. 2000. Preconquest Peruvian Neurosurgeons: A Study of Inca
and Pre-Columbian Trephination and the Art of Medicine in Ancient Peru. Neurosurgery
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Salter S. Ciocon D. Gowrishankar T. Kimball A. 2006. Controlled nail trephination for
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Smith S. Clark M. Nelson J. Heegaard W. Lufkin K. Ruiz E. 2010. EMERGENCY
DEPARTMENT SKULL TREPHINATION FOR EPIDURAL HEMATOMA IN
PATIENTS WHO ARE AWAKE BUT DETERIORATE RAPIDLY. The Journal of
Emergency Medicine 39(3): 377-383.
Tullo E. 2010. Trephination and Roman Medicine: A Comparison of Osteological Remains,
Material Culture, and Written Texts. J R Coll Physicians Edinb 40: 165-171.