Clinical Anatomy 19:372377 (2006)

REVIEW

Articial Deformation of the Human Skull: A Review

R. SHANE TUBBS,1* E. GEORGE SALTER,1
1

AND

W. JERRY OAKES2

Department of Cell Biology, University of Alabama at Birmingham, Birmingham, Alabama 2 Pediatric Neurosurgery, Childrens Hospital, Birmingham, Alabama

Early examples of intentional human cranial deformation predate written history. Intentional cranial deformation as an extreme has seemingly not persisted into this century. However, mild forms of this manipulation are still practiced by various groups worldwide. Accidental cranial deformation or mild forms of intentional cranial deformation may be encountered by the clinician or anatomist. We review the literature regarding intentional C manipulation of the human cranium. Clin. Anat. 19:372377, 2006. V 2005 Wiley-Liss, Inc. Key words: molding; cranium; calvaria; shape; cranioplasty; plagiocephaly

The propensity to deform, or alter from the natural form, some part of the body, is one which is common to human nature in every aspect in which we are acquainted with it, the most primitive and barbarous, and the most civilized and rened. Paul Broca (18241880)

Examples of self-mutilation include tattooing, circumcision, foot-binding, body piercing, various cosmetic surgeries, and intentional cranial deformation. The earliest written record of this latter phenomenon is from approximately 400 BC by Hippocrates who described the Macrocephales people, who derived their name from the custom of head deformation (McGibbon, 1912; Gerszten and Gerszten, 1995). There are also examples of intentionally and posturally produced head deformation (this unintentional deformation may result from accidental application of pressure to the bones such as a strong preference for a sleeping position as an infant), reaching as far back as the Neolithic and Bronze Ages (McGibbon, 1912; Moss, 1958; FitzSimmons et al., 1998). The practice of intentional alteration of the head shape in accordance with certain preconceived ideas of beauty has been found from almost every geographical area of the world and is only possible during infancy when the cranium or more specically the calvaria is malleable. Early examples of intentional cranial deformation predate written history, thus it is impossible to ascertain conclusively why prehistoric civilizations molded their childrens heads. That articial cranial deformation and molding can change skull shape and produce dysmorphic head shapes is without debate. Perhaps the earliest
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evidence of this practice dates back to approximately 45,000 BC, based upon Neanderthal skulls from Shanidar Cave in Iraq (Trinkaus, 1982). It is likely that aestheticism drove the Ancient Egyptians to cranial deformation. The Egyptians favored an elongated skull and pointed chin. A famous example is the shape of Queen Nefertitis head (Figs. 1 and 2). Conical heads have also been desired via intentional binding techniques in other parts of Africa such as Senegal (Brian, 1979). Similarly the Ancient Greeks applied a mold to the infants head shortly after birth to give it a shape symbolic of aristocracy. Nowhere in the world was the art of head molding as commonplace as in the Americas. It is thought that the early South Americans practiced intentional cranial deformation to maintain local cultural views of beauty and to facilitate tribal identity or distinction between families. Some also believed that their efforts were to impart a more ferocious and terrifying image of a warrior, a practice similar to that of the Huns of Mongolia (Fothi, 2000). The Incas believed that attened foreheads made their children more obedient. It is also important to note that certain cranial deformations may have been

*Correspondence to: R.S. Tubbs, PhD, Pediatric Neurosurgery, Childrens Hospital, 1600 7th Avenue South, ACC 400, Birmingham, AL 35233, USA. E-mail: rstubbs@uab.edu Received 7 December 2004; Revised 2 June 2005; Accepted 18 March 2005 Published online 9 August 2005 in Wiley InterScience (www. interscience.wiley.com). DOI 10.1002/ca.20177

2005 Wiley-Liss, Inc.

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Fig. 3. An example of a Chinook child being carried by its mother in a cradle board used for cranial deformation. Note the equally deformed head of the mother. (From Mason OT, 1889.)

granted as a privilege to noble Incas so that they could have reshapened their childrens heads in a fashion to resemble those of the royal family. Infants who were carried on the cradle boards, such as some Native Americans, grew into adults with attened occipital regions. This type of occipital attening has been termed posturally-produced, which was an intentional deformation or the result of an infant lying upon a hard surface as in a primitive crib with no soft head rest (McGibbon, 1912). North American populations such as the Chinook (of the neighborhood of the Columbia river, and the natives of Vancouver Island), also called the Flathead Indians of the Pacic Northwest, may have molded heads to avoid social stigma (Fig. 3). In fact, in 1805, Lewis and Clarks famous expedition led them to the mouth of the Columbia River, where they saw and commented on the deformed heads of the Chinook tribe (Gerszten and Gerszten, 1995). One letter from this expedition in reference to a baby Chinook undergoing head molding read its little black eyes, forced out by the tightness of the bandages, resembled those of a mouse choked in a trap (Brain, 1979; Goodrich and Tutino, 2001). The method by which cranial deformation was achieved amongst different civilizations was similar in as much that external forces were applied to the Fig. 2. Another sculptured interpretation of the appearance of infants head to achieve the desired shape. The early Queen Nefertiti of Egypt. South Americans fastened the infants head to cradle
Fig. 1. Queen Nefertiti of Egypt. Note the elongated nature of her covered head.

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Fig. 4. A South American skull from our anatomical bone collection with obvious intentional cranial deformation.

boards with straps. Others applied pressure with bandages, boards, stones, tight caps, and bindings (Mason, 1889). As a typical example, the early Mesoamericans laid their children face down 45 days after birth on a small cot with the childs head

between two pieces of wood, which were then tied together tightly. One board was applied to the occipital region and the other to the forehead, which permanently attened these areas of the head (Figs. 4 and 5). This was believed to make the appearance more formidable and make the individual healthier (McGibbon, 1912). Additionally, some people of the Andes deformed their heads in this manner in an attempt to make their warriors look taller so as to intimidate their foes (Gerszten and Gerszten, 1995). Head molding has also been found in Europe, Asia, Australia, and sub-Saharan Africa (Gerszten and Gerszten, 1995). For example, in parts of France, this custom has been practiced from Neolithic times until modern times. Conical head congurations were most treasured and sought after in this region primarily by the elite and were created via a tight headdress called a bandeau (Fig. 6). This bandage was seldom removed and harbored lice that contributed to skin infections and ulcers of its users. Interestingly, in France, the lower classes adopted the custom of head molding in an attempt to emulate the nobility of their day. Some have opined that the

Fig. 5. Same specimen as seen in Figure 4. Note the near vertical nature of the occipital bone.

Fig. 6. Portrait of a Princess of the House of Este (ca. 1436 1438) by Pisanello, Musee du Louvre, Paris. Notice the conical shape of the head of this young lady presumed to be Ginevra dEste.

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Fig. 7. Superior view of an infant from our clinic with positional molding of the right occiput. Note that this child is looking toward the left. The vertical arrow marks the nose and the horizontal arrow marks the right ear.

idiom heads of state as found in many Western languages may have found its origin in the practice of head molding of the nobility (Nichter et al., 1986). Many in Europe believed that a longer head provided more room for memory and increased intellectual abilities. However, it has been shown that deformed skulls have the same cranial capacities when compared to non deformed skulls (Nichter et al., 1986). Brain (1979) has stated that anxious parents in Hitlers Germany massaged their babies heads to transform the racially despised round head in the favored long, dolichocephalic (scaphocephalic) style of the master race. By the early to mid-20th century, procedures producing extreme deformations were believed to have been abandoned almost everywhere. FitzSimmons et al. (1998) found that mild forms of infant head molding are still prevalent among various Caribbean, Latino, European, African American, Asian, and Native American groups. A search of the recent medical literature reveals only three instances in which nonclinical intentional infant head shaping (cultural aesthetic enhancement) is mentioned as a modern phenomenon (Adebonojo, 1991; Dobson, 1994; FitzSimmons et al., 1998). FitzSimmons et al. (1998) found that many mothers currently use selective manual pressure on the cranium to mold the heads of their infants for the rst year of life. The

primary reasons given for this practice were for the enhancement of beauty, health, and intelligence of the child. In the book of Dobson (1994), Baby Beautiful: a Handbook of Baby Head Shaping, multiple techniques are given for the articial deformation of the infants cranium. For example, palpation techniques are presented for decompressing the occipital condyles, aligning the frontal bones, and shaping the parietal bones. Cases in which the dysmorphic calvaria suggest idiopathic craniosynostosis (i.e. no known synostotic suture or preferred sleeping position) should be investigated with the knowledge that the childs family may have practiced head molding. Ironically, as a consequence of new sleeping habits instilled by infants parents following a supine sleeping position in an attempt at avoiding sudden infant death syndrome (SIDS), there is a growing incidence of positional plagiocephaly, an asymmetrical attening of the skull (Hemingway and Oliver, 2000) (Figs. 7 and 8). Some have advocated the use of helmets or bands to remold these malshapened crania. However, our experience has demonstrated that all of these positional deformations resolve with time as they are not true forms of craniosynostosis. These external devices (e.g. bands and helmets) have also been used for the treatment (both primary and following cranioplasty) of other forms of true synostosis such as sagittal synostosis (Ham and Meyer, 1987; Strohecker,

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Fig. 8. Examples of four various head shapes encountered clinically. Each row depicts the head shape from two views of the involved area (rst and second columns) and a radiographic depiction of the skull (third column). The rst row shows the head of a child with scapholcephaly (dolichocephaly), usually due to sagittal synostosis. Row two illustrates an example of plagiocephaly, which

is either due to occipital attening from sleeping preferences or unilateral coronal synostosis. The third row demonstrates a brachycephalic head, which is often due to bilateral coronal synostosis. Finally, the fourth row shows a trigonocephalic head, usually due to metopic suture synostosis.

1991; Longaker et al., 1998; Seymour-Dempsey et al., 2002; Teichgraeber et al., 2004). The current understanding of the biomechanics of calvarial growth is that as the brain grows, the bones are displaced outwardly primarily by the expanding meninges. A principal area for growth response is the sutural junction of each bone of the calvaria. As bones of the calvaria are expanded, osteogenic membranes at the sutures produce bone equal to the amounts of their displacement, thereby increasing the size of each bone while maintaining its surrounding articulations (Cohen, 2000). Restriction via intentional cranial deformation techniques would thereby redirect these physiologic responses with compensatory bony outgrowth (Moloy, 1942). In noncraniosy-

nostotic skulls (e.g. those with intentional deformation) once the sutures of the calvaria are fused they will remain in their manipulated position and not return to their original shape. Intentional cranial deformation as an extreme has seemingly not persisted into this century. However, mild forms of this manipulation are still practiced by various groups worldwide. Accidental cranial deformation presents as a milder form of altered head conguration and may be encountered by the clinician or anatomist. The parents of these latter children may need counseling to assist them in resolving their feelings about the discrepancy in the appearance of the infant and what they had anticipated prenatally (Budreau, 1989).

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