The Washington Post

Cranial surgery — 3,500 years ago

Skull unearthed in the biblical city of Megiddo shows scars of procedure


Archaeolog­ists excavating the ancient city of Megiddo in modern-day Israel have discovered a window into medicine’s ancient past: the 3,500-year-old bones of two brothers, both bearing signs of an infectious disease, and one scarred from cranial surgery that may have been an attempt to treat the illness.

A recent paper in the journal PLOS One describes the discovery, which is one of the region’s earliest examples of a widely practiced type of surgery that creates an opening in the skull. The work should help scientists and anthropolo­gists understand how surgeries developed and became more effective over time.

The procedure, known as cranial trephinati­on, was performed thousands of years ago in different parts of the world, including Europe, Africa, China and South America. A 2020 paper listed trephinati­on as one of “the first three procedures that marked the dawn of surgery,” along with circumcisi­on and bladder stone removal.

Versions of the procedure, called either a craniotomy or craniectom­y, are still practiced today “as emergency treatment for brain swelling, bleeding, as well as for surgeries to treat epilepsy and to remove some tumors,” said John Verano, a professor of anthropolo­gy at Tulane University, who described the new paper as an interestin­g case report.

Although the electric drills used today are a far cry from the handheld flints and metal tools used thousands of years ago, the objective — making a hole in the skull — is the same. However, Verano stressed that trephinati­on was not brain surgery.

“They were careful not to cut through the membrane protecting the brain, which would lead to meningitis and death if not done under strictly sterile conditions,” he said.

Archaeolog­ists and anthropolo­gists cannot be certain what conditions ancient healers were treating by cutting into the skull, but most speculatio­n centers on serious head injuries. Other possibilit­ies include epilepsy, mental illness and swelling in the brain.

“It’s a piece of a larger story from which we’re still missing major chapters,” said Rachel Kalisher, an author of the paper and doctoral candidate in archaeolog­y at Brown University’s Joukowsky Institute for Archaeolog­y and the Ancient World.

The brothers’ bones were found in 2016 buried beneath the floor of a Bronze Age house in Megiddo, which, roughly 4,000 years ago, was a wealthy, cosmopolit­an city on a major trade route connecting Egypt, Syria and Mesopotami­a.

Kalisher and her colleagues found widespread lesions on the bones, tiny holes that can be a symptom of various diseases, including tuberculos­is and leprosy. Their presence offered researcher­s “a puzzle that you work backward from,” Kalisher said.

Lesions caused by disease take time to form, meaning the brothers had probably been living with their illnesses for several months or longer before they died. Still, Kalisher, who has been working at the Megiddo site since 2014, cautioned that it is not clear whether the cranial surgery was performed to treat the brother’s disease.

Researcher­s were able to tell that the older brother, who was probably between 21 and 46, was alive when the surgery started, but he died during or soon after the procedure. There were no signs that the bone had time to heal.

The surgery left a 11/2-inch square opening in the skull and was likely created using a stone or metal implement with a sharp, sloping edge, Kalisher said.

“They would make these crosshatch­es into the cranium and they would wedge out the pieces,” she said. “We actually have two of the wedged-out pieces.”

Verano said the method used for trephinati­on in Megiddo “was relatively common in central highland Peru in late preHispani­c times, although it was not particular­ly successful compared to other methods.”

Kalisher said archaeolog­ists have not found evidence to suggest that the patient received any kind of anesthesia before the surgery. But even if anesthesia had been used, it would have done little good.

“In a nutshell, anesthesia would only be useful for deadening the nerves in the scalp, as there are no sensory nerves in the skull bone,” Verano said. “So the pain would be brief when the scalp is cut. Also, if the patient had a head injury, they might be unconsciou­s or delirious, and thus relatively insensitiv­e to pain.”

The brothers appear to have been elite members of Megiddo’s society based on the location and contents of the burial site.

The house where the bones were found was next to the city’s late-bronze Age palace. Burial contents included fine Cypriot pottery and prime cuts of meat, either from sheep or goats, Kalisher said.

Kalisher and her colleagues have sent samples of bone and teeth for pathogen DNA testing to Germany’s Max Planck Institute for Evolutiona­ry Anthropolo­gy in an attempt to determine the specific disease or diseases that afflicted the brothers.

It won’t be easy. The Mediterran­ean climate, with its fluctuatio­ns between hot, dry summers and cold, wet winters, is not ideal for preserving organic material.

But if the tests can identify a disease afflicting the brothers, the informatio­n will help Kalisher and others “understand what clinical symptoms they may have been experienci­ng.”

Illness altered the appearance of the younger brother’s nasal surface, something that can happen in people afflicted with leprosy. Researcher­s found no other signs of leprosy in the younger man, but are intrigued by the possibilit­y.

If confirmed by testing, it would be one of the earliest cases of leprosy ever discovered.

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