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Early Iron Age Surgical Technologies: Ante-mortem Trepanation among the Early Nomads of Gorny Altai
ARCHAEOLOGY, ETHNOLOGY & ANTHROPOLOGY OF EURASIA Archaeology Ethnology & Anthropology of Eurasia 42/4 (2014) 146–154 E-mail: [email protected]
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ANTHROPOLOGY T.A. Chikisheva1, P.V. Volkov1, A.L. Krivoshapkin2, A.T. Titov3, V.P. Kurbatov2, A.V. Zubova1, and A.P. Borodovsky1 Institute of Archaeology and Ethnography, Siberian Branch, Russian Academy of Sciences, Pr. Akademika Lavrentieva 17, Novosibirsk, 630090, Russia E-mail: [email protected]; [email protected]; [email protected]; [email protected] 2 Meshalkin Research Institute of Circulation Pathology, Ministry of Health Care and Social Development of the Russian Federation, Rechkunovskaya 15, Novosibirsk, 630055, Russia E-mail: [email protected]; [email protected] 3 Institute of Geology and Mineralogy, Siberian Branch, Russian Academy of Sciences, Pr. Akademika Koptyuga 3, Novosibirsk, 630090, Russia E-mail: [email protected] 1
EARLY IRON AGE SURGICAL TECHNOLOGIES: ANTE-MORTEM TREPANATION AMONG THE EARLY NOMADS OF GORNY ALTAI*
Results of a science-based analysis of ante-mortem trepanation carried out by Scythian Age surgeons of Gorny Altai (4th–3rd centuries BC) are presented. Inductively coupled plasma-mass spectrometry, energy dispersive X-ray Àuorescent analysis using synchrotron radiation, and magnetic resonance tomography were supplemented by microwear experiments. All trepanations were performed by scraping and included two stages. The bone tissue around the holes reveals high concentrations of copper and tin but no traces of iron or arsenic, suggesting that surgical instruments were made of tin bronze. A knife, experimentally manufactured of copper, tin, and zinc alloy and shaped like knives used by Southern Siberian nomads, was successfully used to perform trepanation on a cadaver. Keywords: Trepanation, Pazyryk culture, Scythian Age, experimental micro-wear analysis, mass spectrometry, X-ray Àuorescence.
Introduction Successful high-risk operations performed by ancient surgeons long before the turn of the Christian Era and documented by skeletal remains are very impressive
and prompt researchers to examine this practice in detail. This particularly concerns ante-mortem trepanations, which resulted in the exposure of intracranial soft tissues such as vessels, dura mater, and sometimes the brain*.
*Supported by the Russian Foundation for Basic Research (Project No. 13-06-00153a).
*Ante-mortem trepanations include those which do not affect the inner cortical table. They are known as symbolic
Copyright © 2014, Siberian Branch of Russian Academy of Sciences, Institute of Archaeology and Ethnography of the Siberian Branch of the Russian Academy of Sciences. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.aeae.2015.06.015
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Prehistoric trepanations ¿rst came to light in 1865, when Ephraim George Squier, a United States diplomat in Peru and an amateur archaeologist and ethnologist, brought to the New York Academy of Medicine a cranium from an Inca burial in the Cuzco region of Peru. The specimen had an opening, 15 × 17 mm in size, on the right part of the frontal bone, limited by four rectilinear incisions made with a burin-like tool (Fernando, Finger, 2003). The views of the Academy members as to the success of the operation were divided. The cranium was sent to the famous French surgeon, anatomist, and anthropologist Paul Broca, who concluded that the operation had been performed ante mortem, and that the sharp edges around the hole and signs of inÀammation showed that death occurred one or two weeks later. In the mid-1800s, less than 10 % of patients normally survived trepanation even in the best European hospitals. This was due to a very high risk of infection and to the fact that only patients with grave cranial injuries were operated on (Gross, 1999). Even at the present time, progress in medicine notwithstanding, trepanation cannot be regarded as safe and requires considerable skill. The risk it entails is about the same as in brain contusion (Prakticheskaya neirokhirurgiya…, 2002). Apart from the dif¿culty of the surgery itself, ef¿cient anesthetics are needed, profuse bleeding from soft tissues and bone must be curtailed, and the development of infection in the wound must be prevented. In the 20th century, hundreds of trepanned crania were discovered and examined, spanning the period from the Epipaleolithic to the 18th century. As a result, ¿ve principal techniques of craniotomy were described (Lisowski, 1967; Saul F.P., Saul J.M., 1997). 1. Making a rectangular hole by straight cuts. This technique is exempli¿ed by the Peruvian skull. The tool was made of Àint or obsidian. 2. Scraping. Paul Broca reproduced this technique using a piece of glass. It took him 50 minutes to scrape a hole in the cranium of a cadaver (Finger, Clower, 2003). 3. Cutting a circular groove and lifting off the disc of bone. This method was widely used in Kenya until recently (Gross, 1999). trepanations (Bartucz, 1950) and have been practiced since the Upper Paleolithic (Mednikova et al., 2012) with apparently magic purposes (Mednikova, 2001, 2003, 2004). Symbolic trepanations are related to the tradition of scari¿cation and tattooing, which were part of the rites of passage (Mednikova, 2004: 142). Rather than touching upon symbolic trepanations, we address true craniotomies.
4. Using a trephine (crown-saw). This method, described by Hippocrates, was elaborated by Roman surgeons and is still used (Fabbri et al., 2012). 5. Drilling a circle of closely spaced holes and then cutting or chiseling the isthmuses of bone between them. This method was recommended by the Romans, adopted by the Arabs, and became common in the Middle Ages. Its variant is still used today despite the availability of high-speed electric and pneumatic drills which have generally replaced the manually pulled Gigli saws. It was found that the safest among the ancient techniques was scraping (Kirkur, 2003). The analysis of healing in a large collection of trepanned crania from Anatolia demonstrated that scraping yielded better results than sawing or drilling (Erdal Y.S., Erdal Ö.D., 2011). Each technique varies depending on the material of which the tool was made, on the idiosyncrasies of “medical schools”, and on the skills mastered by a specific surgeon. Even in modern medicine the surgeon’s training and his practice are highly individual because surgery has always been an art rather than a craft. Our in-depth study addresses the techniques of three ante-mortem trepanations on crania from early nomadic (Scythian Age) burials in Gorny Altai (4th– 3rd centuries BC). The results were partly published in our previous article (Chikisheva et al., 2014), where we assessed the cultural and historical context of the trepanations, their adequacy from the standpoint of modern neurosurgery and radiology; also, we used written sources such as medical treatises outlining neurosurgical theories adopted in major medical centers of the past*. Materials and methods The trepanation technique was studied in three crania: those of a male aged 50–60 from Bikeh III burial mound 3, excavated by V.D. Kubarev (2001); a female *Only theories were evaluated, since their ef¿ciency is by far not always reÀected by skeletal remains. A hypothesis explaining the disagreement between the detailed descriptions of recommended trepanations and their low frequency has been proposed by Nerlich et al. (2003), who examined trepanations in crania from Egyptian cemeteries spanning the period from 3000–500 BC. The authors hypothesized that Egyptian physicians, who realized the unordinary nature and complexity of trepanation as well as the risk it entailed, deemed it worth theoretical description rather than actual implementation.
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b
ɚ
Fig. 1. General view of trepanations in Pazyryk crania. a – Bikeh III burial mound 3; b – KyzylDzhar IV burial mound 2; c – KyzylDzhar V burial mound 3.
c
aged about 30 from Kyzyl-Dzhar IV burial mound 2, and a male of 40–45 years of age from Kyzyl-Dzhar V burial mound 3; both of the latter mounds were excavated by V.A. Mogilnikov (1983). All of these were low-status burials of nomads from various tribal groups of the Pazyryk society. Based on experimental studies of archaeological materials from North and Central Asia (Volkov, 2013), micro-wear analysis was conducted at the Institute of Archaeology and Ethnology SB RAS in order to evaluate the surgical practices and the tools used. Binocular microscopy and photography were employed (Fig. 1). Because no tools specially destined for trepanning have been discovered in Pazyryk graves, we used science-based methods of analyzing the bone tissue to assess the material of which the tools were made. During cutting or scraping, particles of the tool’s working parts are left in the bone. This is true even of modern surgical instruments, which are made of highstrength steel and nevertheless get worn in the process of cutting, sawing, and drilling the bone.
To detect the particles or molecules of respective substances we used two highly sensitive methods of elemental analysis*: (1) inductively coupled plasmamass spectrometry (ICP-MS) using the high-resolution ELEMENT spectrometer (Finnigan MAT) after acid decomposition in the microwave system MARS-5. Concentrations of elements were measured using external calibration and an internal standard. Multielement solutions produced by Merck were employed; (2) energy dispersive X-ray Àuorescent analysis using synchrotron radiation (SI EDS) employing the VEPP-3 system. Concentrations of elements were evaluated by the external standard method with a phosphorite BCR-32 sample recommended by the Commission of the European Communities Bureau of Reference. To detect particles of iron, magnetic resonance tomography (MRT) was applied using the GE Signa In¿nity 1.5T system. *We are grateful to Y.P. Kolmogorov and I.V. Nikolaeva, who analyzed the bone samples at the Institute of Nuclear Physics SB RAS Siberian Center of Synchrotron Radiation.
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ɚ
b
ɚ
Fig. 2. Cutmarks left at the ¿rst (a) and second (b) stages of trepanation in the male cranium from Kyzyl-Dzhar V burial mound 3.
Results and discussion All three trepanations were made by scraping. Traces left on the surface of trepanation openings disclose the succession of stages whereby the operation was performed. While the necessary initial stage was to remove the skin, no traces of this operation were detected. Given the good preservation of bone surface in all three specimens, scalping must have been performed quite skillfully. Trepanation itself included two stages. At the ¿ rst, most important stage, a super¿ cial layer of bone was removed with a sharp cutting tool without penetrating the cranial cavity. Traces of that stage are distinct on the surface of the male cranium from Kyzyl-Dzhar V, revealing the movements of the cutting tool. The cutting plane was tangent to the convex surface of the braincase (Fig. 2, a). At that stage, the angle between the tool and the cranial surface was small. At the second stage, a hole was made, whereby the angle was much larger (Fig. 2, b). While the same tool was evidently used at both stages, the cutting planes were different. During the removal of the super¿ cial layer, the travel of the tool was long, whereas the hole was made by short and frequent cuts. Cutmarks left at the ¿rst stage are petal-like, porous, and relatively wide (Fig. 3, ɚ). Their succession indicates masterful regular motion (Fig. 3, b). In contrast, the short movements at the second stage left stepped abrupt marks on the edge of the opening (Fig. 4). The position of locations operated on at both stages was somewhat different. The placement of the super¿cially affected area does not always coincide
b
Fig. 3. Cutmarks left at the ¿rst stage of trepanation (a) and the rugged surface of the outer edge of the operation area (b) in the cranium from Kyzyl-Dzhar V burial mound 3.
b
ɚ
Fig. 4. Areas of cutting at different angles at each stage of trepanation (Kyzyl-Dzhar V burial mound 3).
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with that of the opening, which was apparently planned in advance (Fig. 5). Possibly, the surgeons did not recognize the risk inherent in the first stage of the operation, and only the second stage was performed carefully. Judging by the marks, there were two ways of making a hole in the bone. One was to employ the same tool as at the ¿rst stage; the movements were the same too. This technique is documented by the male skull from Kyzyl-Dzhar V. The female cranium from Kyzyl-Dhar IV and the male specimen from Bikeh III document the second option, whereby the opening
was made by piercing rather than cutting. As a result, the edges of the opening became stepped (Fig. 6), indicating irregular piercing movements. Evidently, as soon as it became possible to remove the bone fragment, this was done by a usual cutting motion. Piercing movements, frequent but more super¿cial than in the Kyzyl-Dhar IV cranium (Fig. 6, b), indicate greater care with regard to placement and con¿guration of the opening, and thus greater skill. There are no signs of accidental breakage of bone. Instruments used by the Pazyryk surgeons could theoretically have been made of flint, iron, or bronze. The high-field MRT scanner did not detect ferromagnetic (i.e. iron) particles around the trepanation openings. SI EDS analysis revealed the following concentrations of copper relative to the external standard: 94.0 % in Bikeh III, 78.0 % in Kyzyl-Dzhar IV, and 23.8 % in Kyzyl-Dzhar V (error, 20.0 %). Concentrations of tin were 636.0, 2.7, and 6.0, respectively (error, 15.0 %). The ICP-MS analysis of the same samples revealed these concentrations of copper: 87.0, 97.0, and 21.0 mcg/g, respectively; those of tin were 480.0, 6.6, and 5.3 mcg/g, respectively. Relatively high concentrations of titanium, vanadium, chrome, nickel, and iron (see Table) were detected in the surrounding ground as well, so these substances were present in rockforming minerals. High concentrations of manganese and zinc are evidently due to the fact that these were isomorphic parts of hydroxyl-apatite, which replaces
Fig. 5. Relative inaccuracy in the placement of the operation area at the ¿rst stage of trepanation (Kyzyl-Dzhar V burial mound 3).
ɚ
Fig. 6. Stepped edge of the trepanation opening (Kyzyl-Dhar IV burial mound 2 (a) and Bikeh III burial mound 3 (b)).
b
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151
Concentrations of chemical elements in the bone tissue around the trepanation holes SI EDS, percent relative to external standard Element Ti
ICP-MS, mcg/g
Kyzyl-Dzhar IV
Kyzyl-Dzhar V
Bikeh III
Kyzyl-Dzhar IV
Kyzyl-Dzhar V
Bikeh III
781.00
68.00
163.00
188.00
43.00
46.00
V
46.70
29.70
28.00
9.30
13.00
7.40
Cr
47.10
0.00
14.20
11.00
5.40
7.70
Mn
546.00
2655.00
533.00
440.00
1800.00
450.00
Fe
6230.00
1293.00
1739.00
6000.00
1700.00
2900.00
Ni
12.60
9.30
10.80
13.00
7.90
11.00
Cu
78.00
23.80
94.00
97.00
21.00
87.00
Zn
276.00
377.00
367.00
150.00
240.00
230.00
Sr
474.00
605.00
484.00
–
–
–
Mo
1.49
1.15
2.19
0.78
1.10
2.70
Ag
0.28
0.40
0.32
0.13
0.11
1.30
Sn
2.70
6.00
636.00
6.60
5.30
480.00
As
0.00
0.00
2.30
–
–
–
calcium in human bones. Numerous facts suggest that apatite is a good sorbent for these elements, and eventually they can accumulate in large quantities. No traces of arsenic have been detected. Therefore, judging by the high concentrations of copper and tin, and by the absence of arsenic, the instruments for trepanations were manufactured of tin bronze. S.V. Khavrin’s analysis of Scythian Age bronze artifacts suggests that this alloy Fig. 7. Experimental knife made by A.P. Borodovsky. was widely used by the Tagar people of the Minusinsk Basin at the Saragash stage (4th–3rd centuries BC). We proposed that Pazyryk trepanations were made with instruments manufactured by the Saragash artisans (Chikisheva et al., 2014). Experiments aimed at testing the results of the elemental analysis lend indirect support to this hypothesis. We trepanned the cranium of a cadaver using a knife made by A.P. Borodovsky of a copper, tin, and zinc alloy, and reproducing one of the types common among the early nomads of southern Siberia (Fig. 7). The operation was performed by one Fig. 8. Cranium trepanned by the experimental knife. of the present authors, a practicing neurosurgeon. Cutting a hole 25 mm in diameter and exposing the dura mater took him 28 Using the point of the knife, the ancient surgeon made minutes (Fig. 8). The micro-wear analysis has made it a hole in the cortical layer, proceeding from the center possible to reconstruct the initial stage of trepanation. to the periphery.
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Certain tools housed in the N.M. Martyanov Museum of Regional Studies in Minusinsk could have been used as surgical instruments in the Scythian Age. The most typical of them are shown in Fig. 9. These tools are random finds collected in 1901 near the villages of Vostochnoe (Fig. 9, 1, 2), Berezovka (Fig. 9, 3), Bely Yar (Fig. 9, 4), and Martyanovo (Fig. 9, 5). Their general size and that of their blades is as follows: 1 – 179 × 12 × 3.3 mm, 113 mm; 2 – 153 × 22 × × 2.2 mm, 81 mm; 3 – 154 × 17 × 2.6 mm, 88 mm; 4 – 178 × 26 × 2.9 mm, 96 mm; and 5 – 186 × 39 × 4.5 mm, 120 mm. Cutting bone with such tools leaves cutmarks virtually identical to those observed in trepanned crania described above. Tools such as those from Beiskoe and Listvyagovo villages, now at the Minusinsk Museum (Fig. 9, 7), could have functioned as lancets. The
thickness of blades is standard (1.5 mm), and the width ranges from 7 to 9 mm, the total length being 104– 126 mm. An instrument such as specimen No. 3250 at the Minusinsk Museum (Fig. 9, 8) could have served as a probe, and specimen No. 8688 from the same collection (Fig. 9, 9), as tweezers; it is 125 mm long, and its cross-section diameter is 3 mm. All those artifacts have parallels among the contemporaneous surgical instruments of European surgeons, especially among Roman ones (Mednikova, 2001, 2004; Nagler, 2013). Roman medicine was greatly inÀuenced by Greek medicine, and Greek surgeons were the first to practice in Rome (Mirsky, 2000). Roman surgical instruments were basically replicas of Greek ones of the Hellenistic Age. This does not imply direct borrowing of medical skills from people
1 7 2 b
ɚ 3
4
8
5
ɚ
b
c
6 ɚ
9
b
c
Fig. 9. Instruments, probably surgical, used by the Tagar people at the Saragash stage (collection of the Minusinsk Museum of Regional Studies). 1–5 – knives (Nos. 2087, 2093, 2094, 2096, 208); 6 – saw (No. 701) and its working parts (a–c); 7 – lancet (No. 9330) and its working parts (a, b); 8 – probe (No. 9350) and its working part (a–c); 9 – tweezers (No. 8688).
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living thousands of kilometers away and belonging to a different civilization. More archaeological facts are needed to explore these parallels. Among the artifacts owned by the Minusinsk Museum, four could be described as bone saws, judging by the use-wear (Fig. 9, 6). They were found near the village of Panachevo, Kuragino District, Krasnoyarsk Territory. The micro-wear analysis of their working edges revealed signs of cutting hard organic substances such as bone and/or horn. Theoretically, those might have been surgical instruments as well. They have no parallels in European archaeological collections. Their dimensions are 213 × 30 mm (No. 699); 205 × 43 mm (No. 700), and 200 × 40 mm (No. 701). The thickness of their blades is the same, decreasing from 2.5 mm at the base to 1.5 mm at the tip. The teeth were made by sawing with an unde¿ned tool perpendicular to the blade. The spring had been initially absent and was formed later, during work. Conclusions Results of the micro-wear and science-based analyses of cranial trepanation practiced by the Pazyryk nomads of Gorny Altai in the 4th–3rd centuries BC demonstrate that the surgeons were skillful and their methods were ef¿cient. All the three trepanations were done by scraping in two stages. Each case reveals the surgeon’s individuality, especially at the second stage, when the operation area was prepared. We propose that trepanations were conducted by three different surgeons. The bone tissue around the trepanation openings contained no particles of iron or molecules of arsenic. Instead, it revealed high concentrations of copper and tin. The instruments, therefore, were made of tin bronze, which was widely used by the Tagar people of the Minusinsk Basin at the Saragash stage (4th– 3rd centuries BC). No tools that might be regarded as surgical instruments in terms of form and function were found in Pazyryk burials. Such tools, however, are present among the bronze artifacts manufactured by the Saragash artisans. Some of them, such as knives and saws, are original, whereas others such as lancets, probes, and tweezers, are paralleled by contemporaneous medical instruments from Europe. These facts demonstrate that medical skills might have been exchanged over much wider territories than were other elements of culture.
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References Bartucz L. 1950 Adatok a koponyalékelés (trepanáció) és bregmasebek kapcsolatának problémájához magyarországi népvándorláskori leletek alapján. Annales Biologicae Universitatis Szegediensis, No. 1: 389–435. Chikisheva T.A., Zubova A.I., Krivoshapkin A.L., Kurbatov V.P., Volkov P.V., Titov A.T. 2014 Trepanation among the early nomads of Gorny Altai: A multidisciplinary study. Archaeology, Ethnology and Anthropology of Eurasia, vol. 42, No. 1: 130–141. Erdal Y.S., Erdal Ö.D. 2011 A review of trepanations in Anatolia with new cases. International Journal of Osteoarchaeology, vol. 21: 505–534. Fabbri P.F., Lonoce N., Masieri M., Caramella D., Valentino M., Vassallo S. 2012 Partial cranial trephination by means of Hippocrates’ trypanon from 5th Century BC Himera (Sicily, Italy). International Journal of Osteoarchaeology, vol. 22: 194–200. Fernando H.R., Finger S. 2003 Ephraim George Squire’s Peruvian skull and the discovery of cranial trepanation. In Trepanation: History, Discovery, Theory, R. Arnott, S. Finger, C.U.M. Smith (eds.). Lisse: Swets & Zeitlinger, pp. 3–18. Finger S., Clower W.T. 2003 On the birth of trepanation: The thoughts of Paul Broca and Victor Horsley. In Trepanation: History, Discovery, Theory, R. Arnott, S. Finger, C.U.M. Smith (eds.). Lisse: Swets & Zeitlinger, pp. 19–42. Gross C.G. 1999 A hole in the head. The Neuroscientist, vol. 5, No. 4: 263– 269. Kirkur J. 2003 The evolution of cranial saws and related instruments. In Trepanation: History, Discovery, Theory, R. Arnott, S. Finger, C.U.M. Smith (eds.). Lisse: Swets & Zeitlinger, pp. 289–304. Kubarev V.D. 2001 Bike I, III: Pogrebalnye pamyatniki skifskoi epokhi srednei Katuni. Drevnosti Altaya: Izvestiya laboratorii arkheologii (Gorno-Altaisk), No. 7: 120–145. Lisowski F.P. 1967 Prehistoric and early historic trepanation. In Diseases in Antiquity, D.R. Brothwell, A.T. Sandison (eds.). Spring¿eld: C.C. Thomas, pp. 651–672. Mednikova M.B. 2001 Trepanatsii u drevnikh narodov Evrazii. Moscow: Nauchny mir. Mednikova M.B. 2003 Ritual initiation in prehistoric Eurasians based on cranial data: Symbolic trephination. Archaeology, Ethnology and Anthropology of Eurasia, No. 1: 147–156. Mednikova M.B. 2004 Trepanatsii v drevnem mire i kult golovy. Moscow: Aleteiya.
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Mednikova M.B., Dobrovolskaya M.V., Buzhilova A.P., Khartanovich V.I., Selezneva V.I., Moiseyev V.G., Potrakhov N.N. 2012 Esche raz k voprosu o rannikh trepanatsiyakh golovy v kamennom veke: Nakhodka na Telmanovskoi stoyanke i ee vozmozhnaya interpretatsiya. KSIA, iss. 227: 112–123. Mirsky M.B. 2000 Khirurgiya ot drevnosti do sovremennosti. Moscow: Nauka. Mogilnikov V.A. 1983 Kurgany Kyzyl-Dzhar II–V i nekotorye voprosy sostava naseleniya Altaya vo vtoroi polovine I tys. do n.e. In Voprosy arkheologii i etnografii Gornogo Altaya. Gorno-Altaisk: GANIIIYL, pp. 40–71. Nagler A. 2013 O nalichii meditsinskikh instrumentov u naseleniya Evrazii v epokhu rannego zheleza (k postanovke problemy). In Fundamentalnye problemy arkheologii, antropologii i etnogra¿i Evrazii: K 70-letiyu akademika A.P. Derevianko. Novosibirsk: IAE SO RAN, pp. 337–351.
Nerlich A.G., Zink A., Szeimies U., Hagedorn H.G., Rosing F.W. 2003 Perforating skull trauma in ancient Egypt. In Trepanation: History, Discovery, Theory, R. Arnott, S. Finger, C.U.M. Smith (eds.). Lisse: Swets & Zeitlinger, pp. 191–203. Prakticheskaya neirokhirurgiya: Rukovodstvo dlya vrachei. 2002 B.V. Gaidar (ed.). St. Petersburg: Gippokrat. Saul F.P., Saul J.M. 1997 Trepanation: Old World and New World. In A History of Neurosurgery, S.H. Greenblatt (eds.). Park Ringe: The American Association of Neurological Surgeons, pp. 29–36. Volkov P.V. 2013 Opyt eksperimenta v arkheologii. St. Petersburg: NestorIstoriya. Received September 1, 2014. Received in revised form September 10, 2014.
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ANTHROPOLOGY T.A. Chikisheva1, P.V. Volkov1, A.L. Krivoshapkin2, A.T. Titov3, V.P. Kurbatov2, A.V. Zubova1, and A.P. Borodovsky1 Institute of Archaeology and Ethnography, Siberian Branch, Russian Academy of Sciences, Pr. Akademika Lavrentieva 17, Novosibirsk, 630090, Russia E-mail: [email protected]; [email protected]; [email protected]; [email protected] 2 Meshalkin Research Institute of Circulation Pathology, Ministry of Health Care and Social Development of the Russian Federation, Rechkunovskaya 15, Novosibirsk, 630055, Russia E-mail: [email protected]; [email protected] 3 Institute of Geology and Mineralogy, Siberian Branch, Russian Academy of Sciences, Pr. Akademika Koptyuga 3, Novosibirsk, 630090, Russia E-mail: [email protected] 1
EARLY IRON AGE SURGICAL TECHNOLOGIES: ANTE-MORTEM TREPANATION AMONG THE EARLY NOMADS OF GORNY ALTAI*
Results of a science-based analysis of ante-mortem trepanation carried out by Scythian Age surgeons of Gorny Altai (4th–3rd centuries BC) are presented. Inductively coupled plasma-mass spectrometry, energy dispersive X-ray Àuorescent analysis using synchrotron radiation, and magnetic resonance tomography were supplemented by microwear experiments. All trepanations were performed by scraping and included two stages. The bone tissue around the holes reveals high concentrations of copper and tin but no traces of iron or arsenic, suggesting that surgical instruments were made of tin bronze. A knife, experimentally manufactured of copper, tin, and zinc alloy and shaped like knives used by Southern Siberian nomads, was successfully used to perform trepanation on a cadaver. Keywords: Trepanation, Pazyryk culture, Scythian Age, experimental micro-wear analysis, mass spectrometry, X-ray Àuorescence.
Introduction Successful high-risk operations performed by ancient surgeons long before the turn of the Christian Era and documented by skeletal remains are very impressive
and prompt researchers to examine this practice in detail. This particularly concerns ante-mortem trepanations, which resulted in the exposure of intracranial soft tissues such as vessels, dura mater, and sometimes the brain*.
*Supported by the Russian Foundation for Basic Research (Project No. 13-06-00153a).
*Ante-mortem trepanations include those which do not affect the inner cortical table. They are known as symbolic
Copyright © 2014, Siberian Branch of Russian Academy of Sciences, Institute of Archaeology and Ethnography of the Siberian Branch of the Russian Academy of Sciences. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.aeae.2015.06.015
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Prehistoric trepanations ¿rst came to light in 1865, when Ephraim George Squier, a United States diplomat in Peru and an amateur archaeologist and ethnologist, brought to the New York Academy of Medicine a cranium from an Inca burial in the Cuzco region of Peru. The specimen had an opening, 15 × 17 mm in size, on the right part of the frontal bone, limited by four rectilinear incisions made with a burin-like tool (Fernando, Finger, 2003). The views of the Academy members as to the success of the operation were divided. The cranium was sent to the famous French surgeon, anatomist, and anthropologist Paul Broca, who concluded that the operation had been performed ante mortem, and that the sharp edges around the hole and signs of inÀammation showed that death occurred one or two weeks later. In the mid-1800s, less than 10 % of patients normally survived trepanation even in the best European hospitals. This was due to a very high risk of infection and to the fact that only patients with grave cranial injuries were operated on (Gross, 1999). Even at the present time, progress in medicine notwithstanding, trepanation cannot be regarded as safe and requires considerable skill. The risk it entails is about the same as in brain contusion (Prakticheskaya neirokhirurgiya…, 2002). Apart from the dif¿culty of the surgery itself, ef¿cient anesthetics are needed, profuse bleeding from soft tissues and bone must be curtailed, and the development of infection in the wound must be prevented. In the 20th century, hundreds of trepanned crania were discovered and examined, spanning the period from the Epipaleolithic to the 18th century. As a result, ¿ve principal techniques of craniotomy were described (Lisowski, 1967; Saul F.P., Saul J.M., 1997). 1. Making a rectangular hole by straight cuts. This technique is exempli¿ed by the Peruvian skull. The tool was made of Àint or obsidian. 2. Scraping. Paul Broca reproduced this technique using a piece of glass. It took him 50 minutes to scrape a hole in the cranium of a cadaver (Finger, Clower, 2003). 3. Cutting a circular groove and lifting off the disc of bone. This method was widely used in Kenya until recently (Gross, 1999). trepanations (Bartucz, 1950) and have been practiced since the Upper Paleolithic (Mednikova et al., 2012) with apparently magic purposes (Mednikova, 2001, 2003, 2004). Symbolic trepanations are related to the tradition of scari¿cation and tattooing, which were part of the rites of passage (Mednikova, 2004: 142). Rather than touching upon symbolic trepanations, we address true craniotomies.
4. Using a trephine (crown-saw). This method, described by Hippocrates, was elaborated by Roman surgeons and is still used (Fabbri et al., 2012). 5. Drilling a circle of closely spaced holes and then cutting or chiseling the isthmuses of bone between them. This method was recommended by the Romans, adopted by the Arabs, and became common in the Middle Ages. Its variant is still used today despite the availability of high-speed electric and pneumatic drills which have generally replaced the manually pulled Gigli saws. It was found that the safest among the ancient techniques was scraping (Kirkur, 2003). The analysis of healing in a large collection of trepanned crania from Anatolia demonstrated that scraping yielded better results than sawing or drilling (Erdal Y.S., Erdal Ö.D., 2011). Each technique varies depending on the material of which the tool was made, on the idiosyncrasies of “medical schools”, and on the skills mastered by a specific surgeon. Even in modern medicine the surgeon’s training and his practice are highly individual because surgery has always been an art rather than a craft. Our in-depth study addresses the techniques of three ante-mortem trepanations on crania from early nomadic (Scythian Age) burials in Gorny Altai (4th– 3rd centuries BC). The results were partly published in our previous article (Chikisheva et al., 2014), where we assessed the cultural and historical context of the trepanations, their adequacy from the standpoint of modern neurosurgery and radiology; also, we used written sources such as medical treatises outlining neurosurgical theories adopted in major medical centers of the past*. Materials and methods The trepanation technique was studied in three crania: those of a male aged 50–60 from Bikeh III burial mound 3, excavated by V.D. Kubarev (2001); a female *Only theories were evaluated, since their ef¿ciency is by far not always reÀected by skeletal remains. A hypothesis explaining the disagreement between the detailed descriptions of recommended trepanations and their low frequency has been proposed by Nerlich et al. (2003), who examined trepanations in crania from Egyptian cemeteries spanning the period from 3000–500 BC. The authors hypothesized that Egyptian physicians, who realized the unordinary nature and complexity of trepanation as well as the risk it entailed, deemed it worth theoretical description rather than actual implementation.
147
148
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b
ɚ
Fig. 1. General view of trepanations in Pazyryk crania. a – Bikeh III burial mound 3; b – KyzylDzhar IV burial mound 2; c – KyzylDzhar V burial mound 3.
c
aged about 30 from Kyzyl-Dzhar IV burial mound 2, and a male of 40–45 years of age from Kyzyl-Dzhar V burial mound 3; both of the latter mounds were excavated by V.A. Mogilnikov (1983). All of these were low-status burials of nomads from various tribal groups of the Pazyryk society. Based on experimental studies of archaeological materials from North and Central Asia (Volkov, 2013), micro-wear analysis was conducted at the Institute of Archaeology and Ethnology SB RAS in order to evaluate the surgical practices and the tools used. Binocular microscopy and photography were employed (Fig. 1). Because no tools specially destined for trepanning have been discovered in Pazyryk graves, we used science-based methods of analyzing the bone tissue to assess the material of which the tools were made. During cutting or scraping, particles of the tool’s working parts are left in the bone. This is true even of modern surgical instruments, which are made of highstrength steel and nevertheless get worn in the process of cutting, sawing, and drilling the bone.
To detect the particles or molecules of respective substances we used two highly sensitive methods of elemental analysis*: (1) inductively coupled plasmamass spectrometry (ICP-MS) using the high-resolution ELEMENT spectrometer (Finnigan MAT) after acid decomposition in the microwave system MARS-5. Concentrations of elements were measured using external calibration and an internal standard. Multielement solutions produced by Merck were employed; (2) energy dispersive X-ray Àuorescent analysis using synchrotron radiation (SI EDS) employing the VEPP-3 system. Concentrations of elements were evaluated by the external standard method with a phosphorite BCR-32 sample recommended by the Commission of the European Communities Bureau of Reference. To detect particles of iron, magnetic resonance tomography (MRT) was applied using the GE Signa In¿nity 1.5T system. *We are grateful to Y.P. Kolmogorov and I.V. Nikolaeva, who analyzed the bone samples at the Institute of Nuclear Physics SB RAS Siberian Center of Synchrotron Radiation.
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149
ɚ
b
ɚ
Fig. 2. Cutmarks left at the ¿rst (a) and second (b) stages of trepanation in the male cranium from Kyzyl-Dzhar V burial mound 3.
Results and discussion All three trepanations were made by scraping. Traces left on the surface of trepanation openings disclose the succession of stages whereby the operation was performed. While the necessary initial stage was to remove the skin, no traces of this operation were detected. Given the good preservation of bone surface in all three specimens, scalping must have been performed quite skillfully. Trepanation itself included two stages. At the ¿ rst, most important stage, a super¿ cial layer of bone was removed with a sharp cutting tool without penetrating the cranial cavity. Traces of that stage are distinct on the surface of the male cranium from Kyzyl-Dzhar V, revealing the movements of the cutting tool. The cutting plane was tangent to the convex surface of the braincase (Fig. 2, a). At that stage, the angle between the tool and the cranial surface was small. At the second stage, a hole was made, whereby the angle was much larger (Fig. 2, b). While the same tool was evidently used at both stages, the cutting planes were different. During the removal of the super¿ cial layer, the travel of the tool was long, whereas the hole was made by short and frequent cuts. Cutmarks left at the ¿rst stage are petal-like, porous, and relatively wide (Fig. 3, ɚ). Their succession indicates masterful regular motion (Fig. 3, b). In contrast, the short movements at the second stage left stepped abrupt marks on the edge of the opening (Fig. 4). The position of locations operated on at both stages was somewhat different. The placement of the super¿cially affected area does not always coincide
b
Fig. 3. Cutmarks left at the ¿rst stage of trepanation (a) and the rugged surface of the outer edge of the operation area (b) in the cranium from Kyzyl-Dzhar V burial mound 3.
b
ɚ
Fig. 4. Areas of cutting at different angles at each stage of trepanation (Kyzyl-Dzhar V burial mound 3).
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with that of the opening, which was apparently planned in advance (Fig. 5). Possibly, the surgeons did not recognize the risk inherent in the first stage of the operation, and only the second stage was performed carefully. Judging by the marks, there were two ways of making a hole in the bone. One was to employ the same tool as at the ¿rst stage; the movements were the same too. This technique is documented by the male skull from Kyzyl-Dzhar V. The female cranium from Kyzyl-Dhar IV and the male specimen from Bikeh III document the second option, whereby the opening
was made by piercing rather than cutting. As a result, the edges of the opening became stepped (Fig. 6), indicating irregular piercing movements. Evidently, as soon as it became possible to remove the bone fragment, this was done by a usual cutting motion. Piercing movements, frequent but more super¿cial than in the Kyzyl-Dhar IV cranium (Fig. 6, b), indicate greater care with regard to placement and con¿guration of the opening, and thus greater skill. There are no signs of accidental breakage of bone. Instruments used by the Pazyryk surgeons could theoretically have been made of flint, iron, or bronze. The high-field MRT scanner did not detect ferromagnetic (i.e. iron) particles around the trepanation openings. SI EDS analysis revealed the following concentrations of copper relative to the external standard: 94.0 % in Bikeh III, 78.0 % in Kyzyl-Dzhar IV, and 23.8 % in Kyzyl-Dzhar V (error, 20.0 %). Concentrations of tin were 636.0, 2.7, and 6.0, respectively (error, 15.0 %). The ICP-MS analysis of the same samples revealed these concentrations of copper: 87.0, 97.0, and 21.0 mcg/g, respectively; those of tin were 480.0, 6.6, and 5.3 mcg/g, respectively. Relatively high concentrations of titanium, vanadium, chrome, nickel, and iron (see Table) were detected in the surrounding ground as well, so these substances were present in rockforming minerals. High concentrations of manganese and zinc are evidently due to the fact that these were isomorphic parts of hydroxyl-apatite, which replaces
Fig. 5. Relative inaccuracy in the placement of the operation area at the ¿rst stage of trepanation (Kyzyl-Dzhar V burial mound 3).
ɚ
Fig. 6. Stepped edge of the trepanation opening (Kyzyl-Dhar IV burial mound 2 (a) and Bikeh III burial mound 3 (b)).
b
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151
Concentrations of chemical elements in the bone tissue around the trepanation holes SI EDS, percent relative to external standard Element Ti
ICP-MS, mcg/g
Kyzyl-Dzhar IV
Kyzyl-Dzhar V
Bikeh III
Kyzyl-Dzhar IV
Kyzyl-Dzhar V
Bikeh III
781.00
68.00
163.00
188.00
43.00
46.00
V
46.70
29.70
28.00
9.30
13.00
7.40
Cr
47.10
0.00
14.20
11.00
5.40
7.70
Mn
546.00
2655.00
533.00
440.00
1800.00
450.00
Fe
6230.00
1293.00
1739.00
6000.00
1700.00
2900.00
Ni
12.60
9.30
10.80
13.00
7.90
11.00
Cu
78.00
23.80
94.00
97.00
21.00
87.00
Zn
276.00
377.00
367.00
150.00
240.00
230.00
Sr
474.00
605.00
484.00
–
–
–
Mo
1.49
1.15
2.19
0.78
1.10
2.70
Ag
0.28
0.40
0.32
0.13
0.11
1.30
Sn
2.70
6.00
636.00
6.60
5.30
480.00
As
0.00
0.00
2.30
–
–
–
calcium in human bones. Numerous facts suggest that apatite is a good sorbent for these elements, and eventually they can accumulate in large quantities. No traces of arsenic have been detected. Therefore, judging by the high concentrations of copper and tin, and by the absence of arsenic, the instruments for trepanations were manufactured of tin bronze. S.V. Khavrin’s analysis of Scythian Age bronze artifacts suggests that this alloy Fig. 7. Experimental knife made by A.P. Borodovsky. was widely used by the Tagar people of the Minusinsk Basin at the Saragash stage (4th–3rd centuries BC). We proposed that Pazyryk trepanations were made with instruments manufactured by the Saragash artisans (Chikisheva et al., 2014). Experiments aimed at testing the results of the elemental analysis lend indirect support to this hypothesis. We trepanned the cranium of a cadaver using a knife made by A.P. Borodovsky of a copper, tin, and zinc alloy, and reproducing one of the types common among the early nomads of southern Siberia (Fig. 7). The operation was performed by one Fig. 8. Cranium trepanned by the experimental knife. of the present authors, a practicing neurosurgeon. Cutting a hole 25 mm in diameter and exposing the dura mater took him 28 Using the point of the knife, the ancient surgeon made minutes (Fig. 8). The micro-wear analysis has made it a hole in the cortical layer, proceeding from the center possible to reconstruct the initial stage of trepanation. to the periphery.
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Certain tools housed in the N.M. Martyanov Museum of Regional Studies in Minusinsk could have been used as surgical instruments in the Scythian Age. The most typical of them are shown in Fig. 9. These tools are random finds collected in 1901 near the villages of Vostochnoe (Fig. 9, 1, 2), Berezovka (Fig. 9, 3), Bely Yar (Fig. 9, 4), and Martyanovo (Fig. 9, 5). Their general size and that of their blades is as follows: 1 – 179 × 12 × 3.3 mm, 113 mm; 2 – 153 × 22 × × 2.2 mm, 81 mm; 3 – 154 × 17 × 2.6 mm, 88 mm; 4 – 178 × 26 × 2.9 mm, 96 mm; and 5 – 186 × 39 × 4.5 mm, 120 mm. Cutting bone with such tools leaves cutmarks virtually identical to those observed in trepanned crania described above. Tools such as those from Beiskoe and Listvyagovo villages, now at the Minusinsk Museum (Fig. 9, 7), could have functioned as lancets. The
thickness of blades is standard (1.5 mm), and the width ranges from 7 to 9 mm, the total length being 104– 126 mm. An instrument such as specimen No. 3250 at the Minusinsk Museum (Fig. 9, 8) could have served as a probe, and specimen No. 8688 from the same collection (Fig. 9, 9), as tweezers; it is 125 mm long, and its cross-section diameter is 3 mm. All those artifacts have parallels among the contemporaneous surgical instruments of European surgeons, especially among Roman ones (Mednikova, 2001, 2004; Nagler, 2013). Roman medicine was greatly inÀuenced by Greek medicine, and Greek surgeons were the first to practice in Rome (Mirsky, 2000). Roman surgical instruments were basically replicas of Greek ones of the Hellenistic Age. This does not imply direct borrowing of medical skills from people
1 7 2 b
ɚ 3
4
8
5
ɚ
b
c
6 ɚ
9
b
c
Fig. 9. Instruments, probably surgical, used by the Tagar people at the Saragash stage (collection of the Minusinsk Museum of Regional Studies). 1–5 – knives (Nos. 2087, 2093, 2094, 2096, 208); 6 – saw (No. 701) and its working parts (a–c); 7 – lancet (No. 9330) and its working parts (a, b); 8 – probe (No. 9350) and its working part (a–c); 9 – tweezers (No. 8688).
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living thousands of kilometers away and belonging to a different civilization. More archaeological facts are needed to explore these parallels. Among the artifacts owned by the Minusinsk Museum, four could be described as bone saws, judging by the use-wear (Fig. 9, 6). They were found near the village of Panachevo, Kuragino District, Krasnoyarsk Territory. The micro-wear analysis of their working edges revealed signs of cutting hard organic substances such as bone and/or horn. Theoretically, those might have been surgical instruments as well. They have no parallels in European archaeological collections. Their dimensions are 213 × 30 mm (No. 699); 205 × 43 mm (No. 700), and 200 × 40 mm (No. 701). The thickness of their blades is the same, decreasing from 2.5 mm at the base to 1.5 mm at the tip. The teeth were made by sawing with an unde¿ned tool perpendicular to the blade. The spring had been initially absent and was formed later, during work. Conclusions Results of the micro-wear and science-based analyses of cranial trepanation practiced by the Pazyryk nomads of Gorny Altai in the 4th–3rd centuries BC demonstrate that the surgeons were skillful and their methods were ef¿cient. All the three trepanations were done by scraping in two stages. Each case reveals the surgeon’s individuality, especially at the second stage, when the operation area was prepared. We propose that trepanations were conducted by three different surgeons. The bone tissue around the trepanation openings contained no particles of iron or molecules of arsenic. Instead, it revealed high concentrations of copper and tin. The instruments, therefore, were made of tin bronze, which was widely used by the Tagar people of the Minusinsk Basin at the Saragash stage (4th– 3rd centuries BC). No tools that might be regarded as surgical instruments in terms of form and function were found in Pazyryk burials. Such tools, however, are present among the bronze artifacts manufactured by the Saragash artisans. Some of them, such as knives and saws, are original, whereas others such as lancets, probes, and tweezers, are paralleled by contemporaneous medical instruments from Europe. These facts demonstrate that medical skills might have been exchanged over much wider territories than were other elements of culture.
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