SKLTAL VIDNC OI TRPANNINC ON A

5
th
CNTURY SKULL IROM LUDBRC, CROATIA
KCT/Nl ICK/Z C TREP/N/Cl}l N/
LIB/N}l lZ \. STCL}E/ lZ LIIBREG/
Mario Novak
l
, Miroslav Nad
2
, Tajana Plese
3
, Mislav Cavka
4
Sixx~nv
This paper presents a case of skull trepanation from the town of Ludbreg in north-western
Croatia. This is the second case of trepanation reported in human skeletal remains from
archaeological sites in Croatia. The procedure was performed on an adult male buried in
a tomb under tegulae at the Somoi Garden site. The archaeological context and radio-
carbon analysis date the bone sample to the 5
th
century AD, i.e. to the Migration Period. The
trepanned aperture is located on the left side of the frontal bone and the left parietal bone.
The lesion is oval in shape with all three layers of the calvarium breached, leaving dura ma-
ter exposed. This neurosurgical intervention was most probably performed by scraping for
therapeutic reasons (head injury). The morphology of the lesion strongly indicates that the
individual survived the operation and lived for a longer period of time, several years at least.
Key uorJs: skull trepanation; anthropological analysis; scraping technique; 5
th
century,
Ludbreg, Croatia
l
Croatian /cademy ol Sciences and /rts, Zagrel, Croatia.
2
/rchaeological Museum Zagrel, Croatia.
3
Croatian Conservation lnstitute, Zagrel, Croatia.
4
Iulrava Iniversity Hospital, Zagrel, Croatia.
Corresponding author: Ir Mario Novak. /nthropological Centre, Croatian /cademy ol
Sciences and /rts. Ilica /nte Kovaia , l0 000 Zagrel, Croatia.
E-mail address: mnovak(hazu.hr
Izvorni znanstveni ~lanak Acta med-hist Adriat 2013; 11(2);197-212
Original scientic paper UDK: 930.26:572.7:616-089.87(497.5)
197
l1nobic1io
Trepanation or surgical removal ol a portion ol the cranium is prolally
the most remarkalle trauma olserved in human skeletal remains lrom ar-
chaeological sites. The term is derived lrom the Greek (trepanon),
meaning auger or lorer, i.e. instrument used lor drilling and opening the
skull. /ccording to /ulderheide and Rodrguez-Martn |i|, the procedure in-
volves creating a delect in the skull vault to open a communication letween
the cranial cavity and the environment, whose success depends on avoiding
in]ury to the meninges, lrain, and llood vessels.
The earliest skeletal evidence ol trepanation prolally dates to the
Mesolithic |.-| and certainly to the early Neolithic Period |i,,-|. Prioreschi
|$| estimated that letween 6) and ic) ol excavated Neolithic skulls lrom
Europe have leen trepanned. Fewer examples are present lrom the European
post-Neolithic sites, possilly due to the popularity ol cremation during the
late Bronze /ge and the La Tene Period ||. Iuring the late /ntiguity and
the early Middle /ges, trepanation was more lreguent, especially in central
Europe |ic-..|. The practice declined in Europe alter the expansion ol lslam
and disappeared during the High Middle /ges |.,|. Trepanation was prac-
ticed all over the world and has leen documented in skeletal remains lrom
almost every continent, with the highest lreguency in South /merica and
Europe |.|.
The earliest written records ol trepanation come lrom the Hippocratic
texts entitled Places in man and Cn head wounds, which descrile par-
ticular types ol skull lractures that reguired surgical intervention, trepan-
ning in particular |.,,.6|. Galen, prolally the most lamous Roman physi-
cian, agreed that some skull lractures reguired therapeutic trepanation in
order to relieve pressure |.|. \hile head in]ury was lreguently cited as an
indication lor trepanation ly a numler ol Graeco-Roman authors, other in-
dications included epilepsy, headache, and paralysis |.,,.6|.
/s the oldest trepanation dates lack to at least the early Neolithic, i.e.
lelore the widespread use ol metals, the instruments used had to le made
ol stone, most prolally nint or olsidian. The Hippocratic writings descrile
some ol the instruments used in trepanation: the earliest texts mention a
crown saw, which is lasically a metal cylinder with teeth on one end, while
later texts descrile a much more advanced small saw, clearly a type ol Heys
saw |.$|. Galen and Celsus also mention two types ol instruments employed
to remove lone and relieve pressure: a crown trephine lor lone excision and
19o
reliel ol pressure in small wounds and a drill trepanon, which possessed a
toothed lit and was used lor larger wounds |.|. /lthough the Graeco-
Roman texts provide a relatively comprehensive description ol trepanation
instruments and their use, archaeological examples are surprisingly rare.
Prolally the lest known is the trepanation kit lound in a toml ol a Roman
surgeon in Bingen in Germany lrom the .
nd
century /I |.,,c|, that, among
other medical instruments, contained metal crown saws. Parts ol trepana-
tion instruments similar to those lrom Bingen were also lound in the sur-
geons house in Rimini |,i|. / somewhat more sophisticated, lut poorly pre-
served trepanation instrument was lound in the /var grave in Mezland,
Hungary |,.|.
Given the numerous examples ol trepanation lrom the territories sur-
rounding present-day Croatia, as well as the comprehensive descriptions ol
the procedure and the instruments used, it is dimcult to explain the lack ol
interest ol Croatian researchers lor this topic. So lar, the only pullished case
ol trepanation in Croatia relers to a small trepanned aperture on the lrontal
lone ol a cranium ,]a (adult male) lrom the Bronze /ge necropolis in the
Bezdan]aa cave |,,|.
This paper presents a case ol skull trepanation lrom Ludlreg in
north-western Croatia dated to the Migration Period. \e discuss possille
reasons lor this procedure, the technigue and instruments used, possille use
ol anaesthetics, and the possilility ol surviving such complicated operations.
M~1ini~i ~b xi1nobs
Ludlreg is a town in north-western Croatia, located approximately $c km
north ol Zagrel, near the Irava River (Fig. i). lt is the location ol a Roman
settlement ol Iovia-Botivo, lounded in the i
st
century /I. lt was situated on an
important route that ran along the Irava, connecting Pannonias ma]or pro-
vincial centres Poetovio (Ptu]) and Mursa (Csi]ek). /lter several centuries ol
prosperity, Iovia was most likely destroyed during the invasion ol the Goths
in the late
th
century /I. The tradition ol urlan lile was not alandoned,
instead, this Pannonian settlement has existed in continuity until today.
/rchaeological excavations (.cc$-.cii, conducted ly Ir Ta]ana Plee
lrom the Croatian Conservation lnstitute) in the very heart ol the pres-
ent-day town ol Ludlreg (Somoi Garden) are a continuation ol systemat-
ic test digs (i6$-i) conducted ly the /rchaeological Museum in Zagrel.
The results ol this pioneering work have made it possille to glean the general
199
urlan layout ol Roman Iovia. /ll ol the discovered architectural structures
may le dated lrom the .
nd
to the
th
century /I |,|.
Iuring the lour seasons ol excavations, a large portion ol Roman archi-
tecture was discovered in the Somoi Garden. ln the south-east part ol
the site, a small balnea was discovered. The lovian laths lelong to a group
ol smaller city laths, widespread throughout the Empire. Built as compact,
un-partitioned luildings (Blocktyp), they lulnlled the rules ol economical
and structural emciency. Cn the northern side ol the laths, a large part ol a
sizealle luilding with portico was discovered. The luilding was denned on
its western part with a colonnaded portico, through which one could enter
a wide space divided into nve rectangular rooms. Cn the eastern side the
luilding was organised around a sguare courtyard, denned ly corridors and
Figure i. The geographical location ol Ludlreg.
Slika 1. Zemljopisni poloaj Ludbrega
2OO
ad]acent wings. Both luildings were remodelled during several construction
phases, clearly indicating a long period ol usage |,,|. ln the easternmost, nlth
room ol the southern corridor an inhumation lurial (G cci].cii) in a toml
under tegulae (rool tiles) was discovered (Fig. .). The toml contained skeletal
remains ol one individual. / small, silver lelt luckle was the only artelact
lound in the toml - according to its stylistic leatures it may le dated to the
,
th
century /I, i.e. to the Migration period. / comprehensive analysis ol the
toml and the silver lelt luckle will le a sul]ect ol a separate paper which is
in preparation.
Radiocarlon analysis ol a human lone sample, conducted at the Beta
/nalytic laloratories in Miami, IS/, dates the skeleton letween ,c
and ,c /I (. Sigma, ,) prolalility), and ic and ,c /I (i Sigma, 6$)
prolalility).
/ comprehensive anthropological analysis ol skeletal and dental remains
lelonging to the individual luried in the descriled grave was conducted at
the osteological laloratory ol the /nthropological Centre ol the Croatian
/cademy ol Sciences and /rts in Zagrel. The sex and the age at death ol the
analysed individual were determined using methods descriled ly Buikstra
and Ilelaker |,6|. /ll olserved pathologies were recorded according to cri-
teria descriled ly Crtner |,|.
Continuous CT axial slices were oltained at the Iepartment ol Iiagnostic
and lnterventional Radiology, Iniversity Hospital Iulrava in Zagrel, using
an MICT scanner (Sensation i6, Siemens /G Medical Solutions, Erlangen,
Germany) with i6 x c., collimation and c. mm-reconstruction increment.
Scanning parameters were ,cc m/ and i.c k\. Solt (,c) and sharp (c)
kernel reconstruction algorithms were used. Three-dimensional reconstruc-
tion with CsiriX lmaging Soltware (Pixmeo, Geneva, Switzerland) included
multiplanar relormatting (MPR), maximum intensity pro]ection (MlP) re-
construction, and volume rendering technigue (\RT).
Risii1s
The skeleton was well preserved and lelonged to an adult male, aged le-
tween ,i and ,, years at the time ol death. The cranium and the mandille
were complete, while some postcranial elements were missing (Fig. ,). The
cranium had a roughly oval-shaped delect located on the lelt side ol the cor-
onal suture, approximately two thirds ol the lesion was located on the lelt
parietal lone and one third on the lrontal lone (Fig. on cover page). The
2O1
external diameter (ectocranial side) ol the delect is ,x,i mm, while the in-
ternal diameter (endocranial side) is .xi mm. /ll three layers ol the cal-
varium were lreached, and dura mater was most certainly exposed during
the operation (Fig. ). The edges in all sections ol the delect sloped gently
towards the opening (Fig. ,). Clvious signs ol healing were present, the edg-
es around the opening were smooth, remodelled, and ol unilorm thickness,
while the diplo was not visille (Fig. 6). No signs ol inlection were present on
either the endocranial or ectocranial side.
Figure ..
Grave i alter excavation.
Slika 2.
Grob 1. nakon iskopavanja
Figure ,. lnventory ol the preserved
skeletal elements.
Slika 3. Inventar sauvanih kotanih
elemenata
2O2
Figure . CT scan ol the cranium. \iew ol the trepanned aperture lrom the
ectocranial and endocranial side.
Slika 4. CT snimak lubanje. Pogled na trepanacijski otvor s ektokranijalne i
endokranijalne strane.
Figure ,. CT scan ol the cranium - antero-lateral view. The edges have a
lroad shallow level, which is typical ol the scraping technigue.
Slika 5. CT snimak lubanje - anterolateralni pogled. Rubovi su iroki s malim
nagibom, to je tipino za tehniku struganja.
2O3
Beside the trepanation, the analysed skeleton showed a slight degenera-
tive osteoarthritis on the shoulders, ellows, hips, knees, and several verte-
lrae, a Schmorls node on T$, and dental enamel hypoplasia on the maxil-
lary central incisors.
Iiscissio
The nrst guestion that arises lrom the trepanation in Ludlreg is what
might have led to this complicated operation. Lisowski || proposed three
groups ol reasons lor trepanning in past populations:
i therapeutic reasons - intended lor relieving cerelral pressure and
treating head in]uries, including lractures and scalp wounds,
. a comlination ol therapeutic and magic reasons - treating ol head-
aches, neuralgia or epilepsy which may have leen regarded as a conse-
guence ol possession ly evil spirits, and
, magic]ritual reasons.
The last reason would have leen likely il there had leen clear signs
that the procedure had leen carried out post mortem (alsence ol healing,
no visille pathological signs that would ]ustily trepanation). /ccording to
Figure 6. Close-up ol the trepanned aperture. The edges are smooth and
remodelled, while the diplo is not visille.
Slika 6. Uveana slika trepanacijskog otvora. Rubovi su glatki i remodelirani, a
sredinji porozni dio kosti (diplo) nije vidljiv.
2O1
some authors |,i,,|, ritual interventions were not uncommon, and were
usually done to oltain rondelles (round lone discs cut lrom the edge ol a
trepanation delect with a central hole lor a purpose ol suspension) or lone
powder lor healing potions or as magical amulets. Since the Ludlreg trepa-
nation shows clear signs ol healing, the procedure was dennitely conducted
ante mortem, which excludes magic]ritual reasons. /s in this particular case
there is no cultural or archaeological evidence to shed light on the motives
lehind the trepanation. \e lelieve that the procedure was purely therapeu-
tic, lased on the location ol the trepanned aperture. Since the ma]ority ol
trepanations identined in archaeological skeletal remains worldwide have
leen undertaken on the lelt side ol the cranium (lelt side ol the lrontal lone
and the lelt parietal lone), some authors |i,,$,,| suggest that this may le
due to interpersonal violence. ln a scenario where a right-handed adversary
laces the victim most in]uries caused ly the attacker will le located on the
lelt side ol the victims lody. The analysed skeleton does not show any signs
ol antemortem cranial trauma that would reguire trepanation, lut in most
ol the cases healed lesions do not reveal signs ol the original trauma, as the
damaged lony units are cut out in the course ol trepanation |.i|.
/mong other characteristics, trepanations may vary in terms ol the
methods used. So lar, at least lour distinguishalle methods have leen re-
corded |i,,c|: i) scraping - a sharp-edged tool is repeatedly scraped over a
designated portion ol the lone until the vault wears away and oval or round-
shaped perloration is complete with the edges that have a lroad shallow lev-
el, .) chiselling - a round]oval groove, usually with serrated, steeply levelled
edges is made with a pointed instrument. Numerous evidence suggests that
other devices such as drills or crown saws were also used, especially during
the Roman and medieval times |i|, ,) linear grooving - a sharp-edged tool
is applied at right angle to the vault surlace and moved lack and lorth until
a linear groove penetrates the skull. Three more grooves are necessary to
produce a rectangular shape, ) ]oining ol ad]acent lurr holes - a circle ol
small holes are drilled through the skull vault, the lridges lroken, and the
enclosed lone removed. This technigue was mostly limited to Peru |i|.
The morphology ol the trepanned aperture lrom Ludlreg strongly indi-
cates that the scraping technigue was used in this particular case. Scraping is
the oldest trepanning technigue |.|, it provides the greatest control over the
process and involves the lowest risk ol damaging the lrain |,|. For this pro-
cedure, especially lelore the widespread use ol metals, a sharp-edged oval
stone was applied, lut more advanced instruments such as metal scrapers
2O5
(raspatories) were also used |i|. Considering the archaeological context,
it is possille that a raspatory was used lor the trepanation ol the analysed
individual.
Since neither lone nor lrain possess pain receptors |,|, trepanation
should not have leen particularly traumatic or painlul alter the scalp and
solt tissue had leen pierced ||. However, it has leen suggested that sleep
could have leen induced in people who were leing prepared lor trepanation
ly making them ingest large amounts ol alcoholic drinks |,,6|. Besides, ex-
tracts lrom plants could also have leen used lor anaesthesia, coca was most
prolally used in South /merica |6,|, while in Europe, especially during
the medieval period, the analgesic properties ol poppy and nightshades were
known, and may have leen used in these procedures |$,|. ln certain cas-
es, an alternative to anaesthesia was to restrain the patient. ln the presented
case it is not possille to distinguish which type, il any, ol anaesthesia was
used, lut the most logical explanation involves the use ol a strong alcoholic
drink or plant with analgesic properties.
The lact that the edges ol the studied lesion are smooth and exhilit ex-
tensive remodelling and that the diplo is not visille is a strong indication
that the individual survived the operation. Nerlich et al. |,c| conducted a
study on dry lone samples oltained lrom individuals who had sunered in-
travital trepanation lor medical reasons in recent times and survived lrom a
lew minutes up to , years alter the procedure was conducted. The degree ol
healing ol the Ludlreg trepanation closely corresponds to those specimens
who lived letween lour and , years alter the operation, so it may assumed
that the Ludlreg male lived lor a long time, at least a couple ol years alter the
operation was perlormed.
Regarding the prolalility ol survival, one wonders what the survival
rates ol such complicated neurosurgical interventions were in past popu-
lations. lt seems that in the Roman and medieval times mortality was very
high, prolally due to inlections |i6| caused ly the trepans that were made ol
metal and washed letween interventions, turning them into potential carri-
ers ol lacteria ||. ln prehistoric periods the survival rates in procedures us-
ing stone instead ol metal were prolally much higher lecause lesions were
smaller |,i|, procedures shorter |.|, and lreshly knapped stone tools were
as good as sterile |6|. Stewart |,.| examined .ccc trepanned skulls, hall ol
them indicated long-term and additional i6) short-term survival - lased on
complete and partial healing ol lone, while Bennike |,,| reported an $c)
2O6
survival. However, only until recently, cranial surgery, including trepana-
tion, was principally extradural. ll the dura mater was penetrated, lethal
complications such as meningitis, lrain alscess, and critical intracerelral
lleeding could develop. Most likely, ancient surgeons were carelul to avoid
lreaching the dura lecause without respecting these anatomical landmarks
survival rates as high would not have leen possille |.|.
Beside skeletal remains, prolally the most comprehensive data on trep-
anation procedures, especially those conducted in primitive cultures, are
provided ly ethnographic texts. /ccording to the ethnographic sources lrom
the Balkan region |,,,,| the tradition ol trepanation in Serlia, /llania, and
Montenegro continued well into the .c
th
century, it was perlormed mostly
due to therapeutic reasons, lut it was also a lorm ol punishment. Iuring
trepanation, cylinder crown saws were used to remove the lone, sometimes
without anaesthesia, lut otherwise using spirits (rakija) as anaesthetic |,|.
There are literally hundreds ol .c
th
century accounts ol trepanation, par-
ticularly in Cceanic and /lrican cultures |,6|. Especially detailed and recent
ones concern the Kissii trile in Kenya and include photographs ol the surgi-
cal instruments, practitioners and patients, X-rays ol the skulls ol surviving
patients, detailed interviews, and even a documentary nlm |,6,,|.
Trepanation was clearly a phenomenon ol glolal proportions, practiced
ly past populations as well as primitive cultures ol the .c
th
century. The
alsence ol similar studies in Croatia is surprising, considering a wealth ol
archaeological and ethnographic sources that testily on the practice ol trep-
anation, particularly those originating lrom the immediate vicinity ol the
present-day Croatia. Therelore, we hope that this study will encourage lur-
ther and multidisciplinary research, not only in Croatia lut also in the wider
region.
Cociisio
Trepanation presented in this paper seems to le typical ol early medie-
val Central Europe. Cur comprehensive anthropological analysis points to a
complex neurosurgical procedure on an adult male, most prolally lor thera-
peutic reasons, using a scraping technigue. The trepanned patient survived
the operation and prolally lived lor a longer period ol time, apparently with-
out ma]or complications. /t the moment, we cannot estallish whether the
trepanation was perlormed in Ludlreg, where the individual was luried, or
somewhere else, and whether it was carried out ly a trained physician or a
2O7
priest or shaman. Hopelully, lurther multidisciplinary research ol this skel-
eton and its archaeological context that is planned in the near luture will
provide more dennite answers.
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Slike ] Images by:
Mario Novak (i, ,), Ta]ana Plee (.), Mislav avka (-,),
\lasta \yroulal (cover page, 6)
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/cioviiboxi1s
The authors wish to thank Ir }acgueline Balen, director ol the
/rchaeological Museum Zagrel, lor providing lunds lor the radiocarlon
analysis, and \lasta \yroulal lrom the /nthropological Centre, Croatian
/cademy ol Sciences and /rts lor the photos ol the trepanation. The au-
thors also wish to thank the anonymous reviewers lor their constructive sug-
gestions and comments.
S~zi1~i
U radu je predstavljen sluaj trepanacije lubanje koja potjee iz Ludbrega, grada na sjevero-
zapadu Hrvatske. To je tek drugi sluaj trepanacije zabiljeen na ljudskim kotanim ostaci-
ma iz arheolokog konteksta s podruja Hrvatske. Trepanacija je bila obavljena na odraslom
mukarcu koji je bio pokopan u grobu pod tegulama na nalazitu Vrt Somoi. Arheoloki
kontekst i radiokarbonska analiza uzorka ljudske kosti datiraju ukop u V. stoljee, tj. u raz-
doblje seobe naroda. Trepanacijski otvor nalazi se na lijevoj strani lubanje, tj. na lijevoj strani
eone kosti i lijevoj tjemenoj kosti. Otvor je ovalna oblika i probio je sva tri sloja kosti, dok je
tvrda modana ovojnica bila potpuno izloena. Neurokirurki zahvat najvjerojatnije je bio
izveden zbog terapeutskih razloga (ozljeda glave) uz upotrebu tehnike struganja. Morfologija
trepanacijskog otvora snano sugerira da je osoba preivjela operaciju i nakon nje poivjela
due vrijeme, najmanje nekoliko godina.
K|jucne rjec: trepanacija lubanje, antropoloka analiza, tehnika struganja, V. stoljee,
Ludbreg, Hrvatska
212