Trepanations from Oman: A case of diffusion?

IntroductionIn 1971 during the Danish excavation of two stonecairns at Jebel Hafit, two fragmentary skulls markedwith numerous cranial lesions indicative of trepa-nation were recovered. Trepanations have beenfound in the UAE dating to the Neolithic period(3). The two Bronze Age skulls described here add tothis growing corpus of trepanations from the south-ern Gulf. However, we argue that the Jebel Hafitcrania vary in significant ways from the Neolithictrepanations and bear a striking similarity to latertrepanations from north India, suggesting that thelinkages between the southern Gulf and north Indiawere not just of trade goods but also of ideas. Thefinds also imply a striking discontinuity in thattransfer to the Dilmun region of the Gulf, although itis of course always dangerous to argue from thepoint of negative evidence.

This paper, therefore, is an analysis of the twocrania and a comparison with other trepannedcrania from the Middle East and north Indiaaddressing the issues of the cause of trepanationand its role as a cultural attribute.

Background and date of the materialThe two stone cairns, OA 1309 and 1315, weresituated on mountain ridges between Al Ain andJebel Hafit in the Buraimi oasis in Abu Dhabi andwere excavated together with a number of othercairns in 1971 during an archaeological campaignled by K. Frifelt of the Moesgard Museum. Thegraves are of Hafit style: a rounded stone moundwith the gap between inner and outer walls filledwith stone. The centre of the mound consists of asmall chamber and entrance way. They resemblesimilar cairns, nos 1–25, excavated in the previous1961–62 and 1962–63 campaigns in the same area (4).

The most complete skull (1309.1) comes from cairnno. 9, which was excavated by Niels Axel Boas,Steen Andersen, Michael Beck, Bo Madsen andKaren Frifelt. Within the grave were the fragmentaryremains of five individuals along with some beadsand two Jemdt Nasr pots. In the excavation diary itwas noted that some of the cranial fragments haveheavy lesions.

The second skull (1315-C) comes from cairn no. 15,which was excavated by Bo Madsen and Karen

Trepanations have been described from various locations around the worldleading to a suggestion that this is a cultural practice that has widely diffusedfrom one or two centres (1). In the UAE the earliest trepanations date to theNeolithic, significantly earlier than trepanations in surrounding areas. Thediscovery of at least two crania in Oman, dating apparently to the early thirdmillennium and resembling in technique and placement trepanations fromnorth India may be evidence of the diffusion of a therapeutic practice fromthe Gulf to the subcontinent. However, the lack of any trepanation among thenumerous contemporary skeletons from Bahrain suggests that any diffusionhas distinct limits and that, as anthropological work from the South Pacific(2) indicates, practices like trepanation are often heavily embedded inbroader, culturally located explanatory models.

Keywords: trepanation, ancient surgery, Bronze Age Oman

Judith Littleton1 and KarenFrifelt2

1University of Auckland,New Zealand2Moesgard Museum,DK–8270 Højbjerg, Denmark

J. Littleton

Dept of Anthropology, University of

Auckland, Private Mail Bag 92019,

Auckland, New Zealand. e-mail:

j.littleton@auckland.ac.nz

Arab. arch. epig. 2006: 17: 139–151 (2006)

Printed in Singapore. All rights reserved

139

Frifelt. Again the tomb contained the remains ofmultiple individuals (an estimated three) alongsidesome beads.

The initial dating of these tombs was to the JemdtNasr period on account of the pottery finds. They arecontemporary with many of the Hafit graves and arenow more commonly referred to as belonging to theHafit period 3200–2600/2500 BC (5).

The similarity of the trepanations (discussedbelow) as well as their proximity indicates theprobable contemporaneity of the skeletons. While itis most likely that they do date to the Hafit period,some of the Hafit graves have been used forsecondary burials in the later third and mid-secondmillennium BC and a Hafit period date is thereforetentative (6).

MethodsThe lesions were examined macroscopically andmicroscopically in order to confirm the extent ofmechanical marks and the presence or absence ofany signs of associated infection or healing. Inaddition, the second cranium (1315-C) was exam-ined by CT scanning. A Siemens Somatom CTscanner was used to explore internal and externalsurfaces and densities in a non-destructive and non-invasive manner. Although the scanner’s 1 mmresolution was not good enough to observe detailedanatomical features, accurate cross-sections of areasof interest were produced. The use of a micro-CTscanner and SEM was discussed. However, becausethis would have included destructive procedures,this was not completed.

Cranium 1 — 1309.1Cranium 1 is the reconstructed calotte still in twopieces (Fig. 1). This skull is particularly thin and hasa weathered surface, especially on its left side. Thecranium was reconstructed at the SmithsonianInstitution out of fragments 2–5 cm in size. Thebasicranium is missing along with most of the facealthough there is an associated right superior orbit.The right temporal is also partly preserved. Thecalotte itself is near complete.

The partial preservation of the skull means thatthe sole indicator of age is cranial suture closure.While highly variable, the lack of any closure of theexternal cranial sutures (coronal, sagittal and lamb-

doidal) and minimal closure of the endocranialcoronal suture only is more consistent with an ageattribution of a possible young adult (7).

This extremely thin skull is markedly gracile witha small supraorbital torus, sharp orbital border and asmall nucchal torus, indicating a female. However,the zygomatic root extends onto the mastoid that ismoderate in size, indicative of a possible male.Earlier Neolithic and later Umm an-Nar remainsfrom the Emirates are robust (8) and suggest that, onbalance, this skull should be identified as a possiblefemale.

Given its incompleteness, it was not possible totake any measurements of the skull. Along thelambdoid suture there is a large irregular inca boneas well as some probable wormian bones (nowmissing). There is no clear sign of pathologyalthough the occipital on the endocranial surface ismarkedly asymmetrical.

Fig. 1.

Calotte of Cranium 1309.

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The cranium has a series of nine erosions which allpenetrate the inner table (Fig. 2). Each lesion hasbeen numbered and the following paragraphs des-cribe each one in turn while the dimensions arepresented in Table 1.

Lesion 1 is located on the left frontal adjacent tothe coronal suture. The left side of the perforation ismissing post-mortem. The lesion is aligned antero-medial to postero-lateral. Its distal end crosses thecoronal suture but the suture is only superficiallyaffected. The lesion is oval shaped with straightsides. On the anterior part of the lesion the sides aresharp while the slope on the posterior half is muchgentler. The inner table is only perforated towardsthe anterior end. There are external scratch marksparallel to the long axis of the lesion, particularlyvisible on the anterior border. Under a microscope

there is no visible sign of remodelling, the scratchmarks are clear and unremodelled. The perforationedges, where not broken, are slightly rounded butwith no thickening and there is a sharp medialborder; this is all indicative of a lack of healing.

Lesion 2 is located on the anterior left mid-parietal. The bone surrounding the lesion is weath-ered and the surface eroded, while a post-mortemfracture runs through the hole. The lesion is roughlyoval shaped on the antero-medial to posterior-lateralaxis and is bevelled externally, exposing the diploicbone. The lack of any external bone surface makes itdifficult to determine whether the lesion shows signsof remodelling. The groove is very shallow butappears to have perforated the inner table. On theendocranial surface the perforation impinges on athird-order anterior branch of the middle meningealartery. The current perforation is larger due to post-mortem breakage. There are no clear scratch marksand the irregularity of the hole plus the lack of thesharp edges suggests possible remodelling (con-firmed by microscopy) and slight infilling of diploeon the lateral side. Under a microscope it is clear thatthe surface of the groove is planed and thereforerepresents deliberate and not accidental damage tothe skull.

Unlike lesions 1 and 2, lesion 3 is a rectangularlesion located on the mid-left parietal. The long axisof the lesion is parallel to the sagittal plane. Theanterior border is straight sided and angled slightlytowards the medial edge. The posterior border isrounded and blurred in outline. The medial andlateral sides are fairly straight and approximatelyparallel. The edges curve inwards with a gradualslope antero-posterior but with much steeper medialand lateral sides. It is probable that the inner tablewas perforated but this is now broken post-mortem,leaving a small irregular hole. Longitudinal stria-tions are visible on the surface of the lesion andextend up onto the bone surface. Internally thelesion crosses a third-order branch of the anteriorbranch of the middle meningeal artery. No signs ofhealing are visible.

Lesion 4 is located on the left parietal adjacent tothe posterior third of the sagittal suture. The medialside of the lesion is missing. There is an oval-shapeddepression with a straight lateral edge extendingbeyond the rounded anterior border. The anteriorand posterior ends slope gently but the lateral side

Table 1. Lesion dimensions in mm on Cranium 1309.1. Numbers

in parentheses are estimates of original dimensions.

Lesion

External Internal

A-P M-L A-P M-L

1 26.0 12.0–14.0 7.0 7.3

2 23.1 15.0 9.4 (5.3) 5.9 (3.9)

3 27.4 15.2 (8.8) 5.1

4 31.6 (14.5) (<9.0) (<8.6)

5 23.3 10.7 (3.4) 5.4

6 32.9 12.0 (<8.8) (<5.0)

7 26.8 15.1 – –

8 (30.5) (16.0) – –

9 (<21.0) (<13.0) – –

Fig. 2.

Diagram of locations of trepanation lesions on Cranium 1309.

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has a much steeper bevel. There is a series of smallparallel striations visible on the outer table adjacentto the anterior end. These are also visible at theposterior border. The diploe is still clearly visible,with no clear infilling except possibly at the poster-ior border (not confirmed by microscopy). Thelateral margin still appears very sharp. There areno signs of either ectocranial or endocranial bonereaction. Internally it appears that the surgery didnot cause any damage although it may have crosseda fourth- to fifth-order branch of the middle men-ingeal artery. The lesion is very close to the sagittalsinus but perforation of the inner table was unlikelyto impinge on it. There is no indication of remod-elling under the microscope.

Lesion 5 is an oval-shaped lesion located on theright anterior mid-parietal adjacent to the coronalsuture. The long axis is oriented antero-posterior. Alledges of the lesion are blunt and slightly rounded.There is an apparent small perforation of the innertable but the bone edges of the perforation havefractured so that exact dimensions are difficult todetermine. To the naked eye there are no clearscratch marks on the external surface but some arevisible under the microscope. There is possibleinfilling of diploe at the posterior end, and the lowerborder of the internal perforation also appearsrounded. Internally the lesion probably impingedon a third-order branch of the anterior middlemeningeal artery.

Lesion 6 is located on the inferior half of the mid-parietal. This is an oval-shaped depression orientedin an antero-lateral to postero-medial direction. Theanterior and posterior borders have a shallow angle,while the medial border is near vertical with only aslight curvature towards the base of the perforation.The diploe is exposed. The centre of the lesion andthe lateral border are missing and broken. It appearsthat a small part of the posterior margin of theinternal perforation is still present. Parallel linearscratches are visible across the surface of the lesionaligned to the long axis. Deeper grooving is visible atthe slight medial-anterior angle to the medial border.The edges are smooth and the borders are still sharp.The posterior border of the internal perforation has aslightly rounded edge. There is no other macroscopicor microscopic evidence of remodelling. The lesioninternally impinged on a third- or fourth-orderbranch of the anterior middle meningeal artery.

Lesion 7 is an oval lesion located in the superiorsection of the right mid-parietal. The anterior andmedial half of the lesion is missing, broken post-mortem. There are no visible striations on the outertable. The lesion is a shallow regular groove andthere is no real indication that the inner table wasactually perforated, although the bone at the base ofthe lesion is very thin (<1 mm). The diploe shows noindication of infilling although the margins areslightly rounded. There is no ecto- or endocranialindication of bone reaction.

Lesion 8 is a poorly preserved oval depressionlocated on the posterior half of the inferior leftparietal. The surface is weathered and broken andthe lateral and anterior edges are partly missing. Theedges of the lesion are very blurred but the shallowgroove has a planed surface. The oval depression isaligned in an antero-lateral to postero-medial direc-tion. There is no apparent impinging on the arteries.Microscopically the bone is too eroded to determineif any signs of remodelling were present or not.

Lastly, lesion 9 is only preserved in its posteriorsection. It is located on the anterior left parietaladjacent to the sagittal suture. The lesion is oval.Scratches are visible on the external surface medialto the lesion and extend 18.5 mm beyond thesubsequent depression. The diploe is slightlyexposed. The lesion did not affect the sagittal sutureand was apparently very shallow. It was possiblynot finished since the maximum possible completedimensions are less than 21 mm long and less than13 mm wide.

SummaryEach perforation is marked by linear striationsparallel to the long axis of the perforation, which isindicative of deliberate trepanation (Fig. 3). Eachperforation is an angled groove between 21–32 mmlong and 12–15 mm wide. At the base of each groovea small segment of the inner table has been removedwith only 5–9 mm by 3–7 mm of the soft tissueexposed.

There are differences in the shape and depth of thetrepanations: one (possibly two) is quadrilateral inshape while the remainder are shallow oval grooves(Figs 4–5).

None of the trepanations is associated with signsof bone inflammation and for the most part there is

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no evidence of healing. Lesions 5, 2, and possibly 8,however, do appear to have started to heal. It shouldbe noted that these signs of possible healing are veryslight and difficult to evaluate, given the fragment-ary nature of the skull. The variation in the nature ofthe lesions suggests at least two episodes of surgery;however, this does not correspond to the pattern ofpossible remodelling, lesions 5 and 8 being in theoval style and lesion 2 in the square form. It may bethat this variation is more a response to the relativethickness of the skull, with the thinner parts of theskull (closer to the temporal suture) being accom-modated by delimiting the lesion first with a bladeor chisel.

On the other hand lesion 9 appears to be unfin-ished, presumably either because the operation wasaborted (given its proximity to the sagittal andcoronal sutures it may have been thought too risky)or because the patient died during the process.

Cranium 2 — 1315-CThis is a fragmentary, reconstructed skull (Fig. 6).The outer table of the bone is chipped at the anteriorfrontal and weathered on the left-hand side andaround the basicranium. The skull is fragmentarybut the average fragment size is 8–10 cm in diam-

Fig. 4.

Quadrangular lesion on Cranium 1309.

Fig. 6.

CT reconstruction of Cranium 1315 with the lesion numbers

marked.

Fig. 5.

Oval grooved lesion from Cranium 1309.

Fig. 3.

Lesion showing the linear striations produced by scraping with a

stone implement.

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eter. No facial bones remain and a large proportionof the right side of the skull is missing, along with athird of the frontal. The left temporal is also missing.

Again the only indicator of age is the degree ofcranial suture closure. All of the visible sutures arebeginning to fuse on the endocranial surface. Ecto-cranially the sagittal suture is still open as is thelambdoidal suture, and the coronal suture is partlyfused as is the squamous suture. This suggests ayoung to middle-aged adult. The skull has a mod-erate to large mastoid, the zygomatic root continuesonto the mastoid process, and there is a visiblenucchal torus. These indicate a possible male butthis attribution is tentative given the incompletenessof the skull. There is a probable wormian bone (nowmissing) in the right lambdoidal suture. There are noindications of pathology other than the four depres-sions on the skull. These are numbered as indicatedon Figure 6 and dimensions are given in Table 2.

Lesion 1 is an oval perforation of the skull on theright frontal, just crossing the coronal suture. Thelong axis of the lesion is antero-posterior. The lesionis deeply grooved with near-vertical lateral andmedial margins. The anterior and posterior edgesare shallower and with rounded rather than sharpmargins. Longitudinal striations are visible to thenaked eye along the lengths of the perforation. Thediploe is visible in most of the lesion but the innertable is perforated in the centre of the depression,leaving an irregularly shaped hole. There is possibleinfilling of the diploe on the medial-posterior end.While the depression crosses the coronal suture, theperforation itself probably did not affect the sutureline. Despite being cleaned after excavation, thereare still broken pieces of bone visible under themicroscope within the diploe. This is possibly debrisfrom the scraping process.

Lesion 2 is an oval lesion with straight sidessituated on the anterior half of the right mid-parietal.

The lesion has a sharp, near-vertical medial border,rounded and shallowly curved anterior and poster-ior borders, and a near-vertical but slightly chippedlateral border. There is an irregular perforationthrough the inner table at the base of the lesionwith the diploe exposed. There are some horizontalstriations along the surface of the groove, whichruns in an antero-posterior direction. There is noevidence of reactive bone on either the endo- orectocranial surfaces. The internal perforation impin-ges on the anterior middle meningeal artery, third-or fourth-order branch. Under the microscope theborders have sharp edges and again there are smallfragments of bone caught in the diploic spaces nearthe base of the groove.

Lesion 3 is an oval lesion on the mid-parietalalongside the sagittal suture. The long axis runsparallel to the suture. This is a shallow groove withan irregular central perforation. There is post-mor-tem damage to the hole’s margins. The groove hassteep sides exposing the diploe. There is no clearevidence of infilling and the horizontal striationsremain clearly visible at the base of the hole. Thelong sides of the lesion are sharp with little evidenceof rounding, and there are no endo- or ectocranialindications of bone reaction. Under microscopy fineparallel scratches are visible on the posterior edge ofthe groove.

Lesion 4 is a deep oval lesion on the posterior leftparietal. There is no post-mortem breakage exceptfor some erosion of the external surface. The lesion isaligned in a medial-lateral direction. The anteriorborder has had a vertical angular chip removed. Atthe base of the lesion is a small circular holepenetrating the inner table. Horizontal striationsare visible at the base running along the long axis.Under the microscope there are clear scratch markson the medial side of the groove that still hasrelatively sharp edges. On the lateral side of thelesion the depression is slightly convex, there issome loss of diploic spaces and no visible scratching,all of which are suggestive of a limited degree ofremodelling prior to death.

SummaryThe grooves are slightly longer and wider onaverage than on Cranium 1 although the groovingstopped at the same point of perforation so that only

Table 2. Lesion dimensions in mm on Cranium 1315-C.

Lesion

External Internal

A-P M-L A-P M-L

1 33.1 16.1 (7.8) 5.1

2 34.2 16.4 (9.0) 3.4

3 – – – –

4 14.1(23) 31.7 4.5 6.0

J. LITTLETON AND K. FRIFELT

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a very small area of the soft tissue was exposed(Fig. 7).

Lesions 1 and 4 are deeper and both appear tohave minor signs of healing (Fig. 8). In lesion 1 thediploe appears to be infilled on the medial posteriorend. A CT section of this lesion indicates a roundedmargin, an area of denser bone on one side of thelesion and increased density near the inner table onthe opposing side (Fig. 9). In lesion 4 on the lateraledge the bone is rounded and the diploe infilled,with loss of diploic spaces and no visible scratches.This suggests a minimum of two episodes of surgeryand given the different orientation of the lesions andtheir placement, which would have required movingthe head and reorienting, it seems likely that lesions1 and 4 were in any case not done at the same time.

The trepanations comparedIn both crania the basic method of trepanation wassimilar. The scalp was cut back exposing the skulland a groove was produced by repeated scraping.An indication of the size of original exposure isgiven by the extent of scratching around lesion 9 onCranium 1. Judging by the parallel grooving, as wellas evidence of particles of bone caught in the diploeacross the lesions, a stone implement may have beenused. This is a relatively common technique acrossthe world and has the advantage of slow and carefulremoval (9).

In the case of the squarer trepanations on Cranium1, however, the lesion was started with the use of a(presumably) metal chisel or blade, which allowedfor the initial cuts to be made. There is evidence ofthis in the form of small chips lost from the linearedges (see Fig. 4). It may be that this is an accom-modation to the thin cranial bones of this individual,thus limiting the extent of the lesion. The lesion itselfwas subsequently completed in the normal fashionby scraping down, as evidenced by the parallelgrooves along the base of the lesion.

The size of the lesions, particularly of the innerperforations, is very controlled and relatively small.There is very little variation in the size of the lesions,particularly in the case of the second cranium, buteven in the first cranium the width of the lesionsvaries little. The difference in length is potentiallydue to a difference in the thickness of the skull.Cranium 2 was much thicker and in order to remove

Fig. 8.

Lesion with possible signs of healing including infilling of

diploe.

Fig. 7.

Grooved lesion from Cranium 1315.

Fig. 9.

Cross section of lesion 1 with indications of rounding of internal

margins plus thickening of lesion border.

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sufficient bone to expose the dura mater, thescraping would necessarily have continued forlonger and across a wider plane of the skull. Thisdifference in the thickness of the skull and theamount of work required to remove the bone wasnoted by Broca, who proved experimentally thatwhile a thin child’s skull could be perforated in fourminutes, perforating a thick adult cranium couldtake as long as 40–50 minutes before the dura materwas exposed (10).

In both instances the trepanations are restricted tothe parietals with an exception in Cranium 2 whereone is on the frontal. This is a common distributionacross the world and reflects both ease of access interms of treatment but also, particularly in the caseof the left parietal, the most frequent locations fortrauma (11). There is a curious coincidence, how-ever, in that the position of lesions 5 and 8 onCranium 1 are mirrored in Cranium 2, even down tothe angle of lesion 8 (lesions 1 and 4). At the veryleast it indicates that the heads of these two patientswere held in a similar fashion to allow access to thecrania (Fig. 10). It does raise the possibility of therebeing a defined sequence of lesions since 5 and 8,judging by the signs of healing, were the firsttrepanations to be conducted on the first individual,lesions 1 and 4 in the second individual. However,in the absence of a wider series, this is simplyspeculation. It is clear, however, that the operationson Cranium 1 probably involved five to six differenthead positions where the patient was angled in adifferent position in relation to the practitioner andon Cranium 2, probably three separate head posi-tions.

Unfortunately the incomplete and fragmentarynature of the crania makes it difficult to be abso-lutely certain that there is no pre-existing pathologythat provided the rationale for these operations. Thefracture lines on Cranium 1 do cross the trepana-tions, but they appear to be post-mortem and areprobably the result of the trepanations weakeningthe skull rather than being pre-mortem fracturesprompting the surgery. The only indication ofanything unusual about either of these skulls is theasymmetry of the lambdoid of Cranium 1, whichmay have been the result of asymmetrical prematureclosure of the left occipital suture. The relationshipof this to any precise neurological or behaviouralabnormality is however impossible to hypothesise.

Not all trepanations are related to physical traumaor physical signs, and therefore these skulls are notunusual in that sense. In a summary of potentialcauses Lisowski (12) summarises the motives fortrepanation as: therapeutic (including fractures,scalp wounds, concussion); magico-therapeutic(including headaches, neuralgia, delirium, epilepsy,meningitis, sinusitis etc; and magico-ritual (e.g. inthe case of feuds, for amulets). All of these classi-fications blur into each other since other medicalsystems incorporate therapy in ritual systems. Fur-thermore, in these cases the technique itself wouldhave produced bone dust and debris that may itselfhave had a particular purpose. Ruffer (13) points outthat even up to the Middle Ages it was supposedthat powdered cranial bones possessed curativepowers, although this is associated with post-mor-tem trepanations.

1309

1315

Burzahom

Fig. 10.

Comparison of lesion position between Crania 1309, 1315, and

Burzahom.

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In both individuals the slight signs of healing plusthe difference in the style of trepanations onCranium 1 suggest multiple episodes of trepanation,although the time between the episodes is probablyshort. Healing of trepanation occurs with osteoclas-tic resorption, which smoothes the sharp edges ofthe defect. Gradually the diploe is filled in, causing aloss of visible diploic structures so that ultimatelythe remodelled defect edges become just one com-pact bone layer (14). Accounts vary as to how longthat healing takes. A recent study of survivors oftrepanations by Nerlich et al. suggests that there areno signs of healing among those who survivedtrepanning for a few hours to a few days. Bycontrast, an individual who survived a year hadvisible focal remodelling with smoothed defectmargins. Zias and Pomeranz (15), on the other hand,suggest that healing may commence relatively soonafter the surgery. In these cases the signs of healinghere are minor and are perhaps indicative of daysand weeks rather than months between the first andlast episodes (16).

The care with which the scraping was done andthe deliberately limited exposure of the dura materalso suggest pre-mortem trepanation. The removalof skull bone for amulets or to remove the brain afterdeath frequently involves much more invasiveoperations and larger lesions than those observedhere (17).

Trepanations in the UAEKiesewetter (18) has recorded three trepanationsfrom Jebel Buhais dating to the Neolithic period. Allwere pre-mortem with evidence of healing. Two ofthe trepanations are clearly related to depressedfractures of the cranial vault, while the third ispossibly related to a cranial tumour. As with theHafit remains, it was suggested that the trepanationswere created using the same scraping technique,although these are significantly larger external andinternal lesions and they do not have the evidence ofany use of chisels as well as stone implements. Thesize of these trepanations seems to be much moreclearly related to the underlying cause, e.g. the sizeof the fracture, rather than the very regular androutinised lesions observed on the Hafit skulls,where each operation probably involved the pro-duction of more than one perforation and where

there was a series of operations undertaken with noapparent underlying physical cause. The compar-ison with Jebel Buhais tends to suggest the continu-ity of a therapeutic practice and also, potentially,changes in what were considered precipitatingcauses and in the nature of the operation that makesmultiple episodes likely.

The one other recorded trepanation from the Gulfat Bawshar is either later or possibly even penecon-temporary with these remains (19). However, itdiffers markedly in form, being a small circular holeproduced by drilling. Given the sharpness of thehole and the lack of any signs of healing it seemsvery possible that this is a post-mortem operation,although that is very hard to determine simply fromphotographs. Similar lesions elsewhere have beeninterpreted as operations for retrieving roundels ofbone or for hanging the skull (20). This would seemto be a very different set of circumstances from thoseinvolving the two crania from Jebel Hafit. With theexception of South America, the discovery of trep-anations is a rare occurrence as Table 3 indicates; itseems highly likely that more will appear from theEmirates and that they are part of a long-standingtradition.

From the rest of the Gulf there is only one reportwhere trepanation was suspected. This is the Hel-lenistic burial from Failaka Island where the skullhas two puncture wounds on the left parietal (21).However, these are clearly peri-mortem rather thanobviously pre-mortem lesions and are possibly, asargued by Maat, the result of a fatal injury with atwo-pronged tool.

Trepanations in south and west AsiaAs seen in Table 3 there is a relatively small numberof trepanations from south and west Asia. Overalltrepanations in the Middle East and south Asia arenot common, particularly when compared to thelarge number found in South America, and there isalso a notable lack of reported trepanations frommodern Iraq and Iran, although at least in Iran thismay reflect the rarity of skeletal remains. Thetrepanations are variable in style and range fromlarge square cuts (e.g. Lachish) (22) to small circulardrilled holes (e.g. Jericho) (23).

Apart from the other Emirati skulls, both thetime frame and geographical relationship places

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the Jebel Hafit skulls closest to the examplesfound at Harappan sites (or sites associated withHarappa) in north India, particularly given thediscontinuous geographical distribution in theMiddle East.

In particular, the pattern of multiple trepanationscarried out at separate intervals and the type oftrepanation is very similar to the Burzahom skullfrom north India (24). While Burzahom is a Neolithicsite dating to the mid-second millennium BC withnumerous cultural parallels to other cultures northof the Himalayas, the biological data (morphometricand dental) point to the closest affinities being withskeletons from cemetery R37 at Harappa (25). AsKennedy points out, this is not to imply that thesetwo ancient populations were lineages of a singlepopulation but that populations throughout nor-thern India ‘shared a higher frequency of geneticcharacters within this geographical sector of thesubcontinent than they did with populations ofpeninsular India’ (26).

The initial interpretation of the Burzahom skullwas that the trepanations were post-mortem andconducted for ritual purposes such as retrievingroundels of cranial tissue possibly as amulets (27). Amore recent analysis, however, has queried thisinterpretation. Like the two Oman cases the Burza-hom skull has multiple trepanations: six completedperforations and five shallow depressions. These areall with one exception on the left parietal. Theauthors argue, on the basis of the size and shape ofthe depressions, for multiple sitings for the trepa-nation. The technique varies from the Omaninstances since drilling was most likely used; how-ever here, as in Oman, there seem to have beenvariations in technique. In both cases the size of thetrepanations is small in comparison with the muchlarger lesions found in Iran and some of thePalestinian sites, or even the earlier lesions fromJebel Buhais. The other similarities are the siting ofthe trepanations (Fig. 10), the lack of clear physicalcausation and the probability of not only multiple

Table 3. Trepanations identified in south and west Asia (35).

Region/Site Date Comments

Arabian Gulf

Jebel Buhais 5100–4300 BC 3 adults with trepanations (36)

Bawshar (Oman) Iron Age 1 fragment – drilled? (37)

Bilad Al-Maiitin (Oman) Islamic? Crown trepan made of bronze (38)

South Asia

Burzahom (Kashmir) c.2300–2000 BC 1 adult — 11 attempts at trepanation,

partial healing? — produced by scraping (39)

Harappa c.2300 BC 2 adults (40)

Lothal Bronze Age child 9–10 yrs — drilled (41)

Kalibangan (W India) Bronze Age 1 adult — possible trepanation (42)

Timargarha (Pakistan) c.1500 BC 1 adult female (43)

Maski (S India) Megalithic Iron Age 1 adult — 2 circular trepanations (44)

Iran

Parchinah (Luristan) Chalcolithic 3 trepaned skulls, drilled? (45)

Dinkha Tepe 1100–800 BC 1 adult — healed — produced by scraping (46)

Mesopotamia

Isin (Isan Bahriyat) c.200 BC 1 adult male: fragment with 4 holes unhealed (47)

Levant

Tell al Mazar Iron Age 3 skulls — drilled? (48)

Dimona (Palestine) c.2200 BC 1 child 8–9 yrs (49)

Jericho 2000 BC 1 adult with 4 trepanations — scraping and drilling (50)

Jericho (tell es-Sultan) 83500–6000 BC 1 adult (51)

Lachish Bronze Age 4 skulls — ‘noughts and crosses’ (52)

Arad Early Bronze Age 1 skull (53)

Wadi Makuqh 3500 BC 8 individuals (54)

Tell es-Sultan (Jericho) Roman 3 adults with grooving and scraping technique (55)

Tell Bi’a (Syria) c.1700 BC 2 adults (56)

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operations but more than one lesion being created atone time.

It is striking that at the time of the Harappanskulls, both Oman and north India are part of awider zone of cultural and economic influence fromHarappa. There are three possibilities: that the ideaand practice of trepanation is part of a sharedcultural repertoire and has diffused from one placeto the other (from the Oman peninsula to northIndia, given the dates); that the skulls are muchmore closely contemporary and that they mayrepresent actual foreign practices in one or otherof the countries; or that this is simply coincidenceand we are looking at two independent inventions.The second scenario is the most unlikely: first, itseems most likely that the Hafit burials significantlypredate the Harappan examples; second, the bur-ials at Hafit are consonant with other burials onthe peninsula both in terms of style and gravegoods (28).

The remaining distinction is between diffusionand local invention. The parsimonious explanationis diffusion, given the earlier dates and long-termcontinuity in the Emirates, the stylistic similarity, thewide dispersal in north India at the time (alreadyindicative of diffusion), and the nature of multiplepre-mortem trepanation. Independent evolution,however, cannot be ruled out entirely.

In a recent paper, Brothwell (29) argued fortrepanation as a practice that originated in onlyone or two loci and then diffused across widegeographical areas. The evidence from the Gulf andelsewhere, however, makes this rather questionable.While the evidence here is suggestive of a limitedform of diffusion between two areas that we knowwere at least in contact for some periods, Bahrainhas been interpreted by some as part of the samecultural zone as Harappa and the southern Gulf; yet,despite large numbers of skulls from varying timeperiods on Bahrain, no evidence of trepanation hasbeen found (so far), suggesting that despite culturalsimilarities, some practices did not get imported orshared. Similarly, despite even larger skeletal seriesfrom Egypt, the practice of trepanation that is foundin Palestine is much rarer in Egypt, again suggestinga lack of diffusion despite close cultural connections(30).

The Pacific provides the clearest ethnographicparallel to this. Trepanation is widely practised in

some Pacific localities for varying reasons includingtreatment for head injuries and prophylaxis. How-ever, these foci of trepanation are separated fromeach other by both thousands of miles and by otherislands where the practice is simply not reported(31). Even where neighbouring groups share thepractice the circumstances under which it is under-taken may vary greatly (32).

Part of the reason for discontinuities in its distri-bution is possibly to do with chance: the transport ofuncommon practices relies upon the connection (inthe absence of detailed written records) between twopotential practitioners and presumably a suitablepatient or victim. In the case of open-skull fractureswith visible bone fragments (as at Jebel Buhais) onecan easily understand how removing the fragmentsof bone from the field of injury may be an obviousresponse. Trepanation, however, particularly in theabsence of clear open fractures, is a rather differentcase. Firstly, it is not immediately obvious where thesite of the therapeutic action should be and sec-ondly, it is a highly developed technique with a highrisk of death attached, which involves not onlycutting the scalp but also removing a part of thebody (33). Medical practices are frequently situatedwithin a set of precepts involving the role of ritual,notions of how the body works, and of the causation,identification and treatment of illness or deviationfrom the norm (34). As such the adoption of a newmedical or ritual practice (and often this is anarbitrary distinction) is not a straightforward pro-cess. Adoption depends upon the assimilation notjust of the practice but also of the associatedjustification and understanding of the world. It isnot that these need to be entirely congruent, but ifthe new practice is to be taken up then it is morelikely to be adopted if it does not do violence to pre-existing rules and explanatory models. As a basicinterpretation the practice emphasises the well-known cultural linkages and similarities betweenthe two polities of Magan and Harappa and thedistance between these and Dilmun. It does, how-ever, also point to the subtlety of those linkageswhereby practices unrelated to economic life and infact very uncommon are either shared or diffused.Unlike pottery, this is one of those instances wherethe initial diffusion, if it occurred, most likely didinvolve the exchange of knowledge between indi-viduals who physically met.

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ConclusionIn the current case, the similarity between the northIndia technique and execution (as seen at Burzahom)is striking, particularly in light of known culturalconnections between this area and the Oman pen-insula. However, the similarity and temporal linkagedo not clearly indicate whether this is a case ofdiffusion or of local inventions. There are furtherquestions still to be answered and which can reallyonly be answered with further finds, when it ishoped that it will be possible to see when, why andunder what circumstances trepanations were con-

ducted and the frequency of the practice, partic-ularly given that in these two instances healing, if itoccurred at all, is extremely slight.

AcknowledgementsOur thanks to Seline McNamee, University of Auckland, for the

original production of a poster on this research; to Dr Frøhlich

for undertaking the reconstruction, photography and CT scan-

ning as well as commenting on the manuscript; and to Drs

Kennedy, Kiesewetter, Lukacs and Smith who all assisted with

information on other trepanations from the region.

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