alexey l. krivoshapkin, tatiana a. chikisheva, alisa v. zubova , vladislav p. kurbatov, anatoli t....

Peer-Review Reports

Scythian Trepanations in the Gorny Altai in Hippocratic Times: Modern Expert Appraisal

of Ancient Surgical Technologies

Alexey L. Krivoshapkin1,3, Tatiana A. Chikisheva2, Alisa V. Zubova2, Vladislav P. Kurbatov1, Anatoli T. Titov4,Pavel V. Volkov2

-OBJECTIVE: To report the analysis of 3 cases of ancient trepanation discov-ered in the craniological collection (153 skulls) of the Pazyryk nomadic culture(500e300 BC) from the Gorny Altai, Russia, and to evaluate the technique,instrumentation, and materials used for cranial surgery as well as the motivationfor the trepanations in Scythian times.

-METHODS: A multidisciplinary approach was chosen to study the trepannedskulls. Visual inspection and examination undermagnification,multislice computedtomography, high-field magnetic resonance imaging, and coupled plasma massspectrometry and synchrotron radiationeinduced x-ray fluorescenceanalysis of thebone samples from the site of trephination were used.

-RESULTS: In the Pazyryk culture, trepanation was very likely used to performthe intracranial procedures that were not yet indicated by Hippocrates. No signsof bone infection were detected. Higher copper abundance found at the site oftrepanation showed that a bronze knife was the most likely tool used byScythian surgeons.

-CONCLUSIONS: Our data suggest that the Scythian population of the AltaiMountains had sufficient medical knowledge to perform sophisticated andsuccessful manipulations on the human skulls. Scraping technique with bronzetools was quite effective for prevention of wound infection and resulted in a highsurvival rate after surgery. In the era of methicillin-resistant Staphylococcusaureus, it may be useful to consider some ancient surgical technologies.

Key words- Archaeology- Gorny Altay- Head injury- MSCT- Multislice computed tomography- Scythian times- Trepanation

Abbreviations and AcronymsBCR-32: Community Bureau of Reference, BrusselsICP-MS: Inductively coupled plasma massspectrometryMSCT: Multislice computed tomographySR-XRF: Synchrotron radiationeinduced X-rayfluorescence analysis

From 1Meshalkin Novosibirsk State ResearchInstitute of Circulation Pathology, Novosibirsk;

2Institute of Archaeology and Ethnography, Russian Academyof Sciences Siberian Branch, Novosibirsk; 3Novosibirsk StateMedical University, Novosibirsk; and 4Institute of Geologyand Mineralogy, Russian Academy of Sciences SiberianBranch, Novosibirsk, Russia

To whom correspondence should be addressed:Professor Tatiana A. Chikisheva.[E-mail: [email protected]]

Citation: World Neurosurg. (2014) 82, 5:e649-e655.http://dx.doi.org/10.1016/j.wneu.2014.06.045

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INTRODUCTION

The Gorny Altai region is a unique areawhere many human occupation traces ofdifferent eras starting from the LowerPaleolithic (800 million years ago) (8) andfossils of a few subspecies or species of thegenus Homo have been found (31). Forthousands of years, numerous ancient cul-tures flourished and disappeared in thisarea, and for decades, researchers havebeen scrupulously studying various aspectsof everyday life, clothing, armaments, art,and religion as well as anthropological andsocial structure of the prehistoric Altaipopulations. However, only more recentlyhave researchers started asking how peopleof the past protected themselves from in-fections and general diseases and about the

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WORLD NEUROSURGERY 82 [5]: e649-e6

treatment of wounds and traumatic in-juries. A multidisciplinary approach withresearch targeted toward the concretepractice of ancient healers preserved inpaleoanthropological materials yielded re-sults to answer some of these questions.Archaeological studies of ancient burial

complexes of the Pazyryk culture thatexisted in the Altai region about 2500 yearsago through the end of 600 BC to thebeginning of 200 BC provided paleoan-thropologists with abundant researchmaterials. Cases of lifetime trepanationwere chosen for careful examination. Thetraces of complex manipulations on hu-man skulls performed by ancient healersindicated that systematic ideas about thehuman body apparently was an importantaspect of the Pazyryk people’s worldview.The term “trepanation” is commonly

understood as a surgical intervention when

55, NOVEMBER 2014 www

a piece of skull bone of a living individualis removed without any damage to theunderlying blood vessels, meninges, andbrain (9, 19, 39). “Trepanning” meansmaking a hole and exposing the intracranialcontents of a human skull (23). Trepanationcan have medicinal or ritual purposes.Interest to prehistoric trepanations

arose in 1865, when E. George Squier, anarchaeologist, ethnologist, and a specialchargé d’affaires to all the Central Americanstates brought back from Peru an artifactknown as “Inca skull.” Squier’s Inca skulldisplayed 4 perpendicular incisions withthe defect in the right frontal bone slightlylarger than 0.5 inch square (11, 13). Clearhealing signs were revealed at the edgesof the opening indicated the survival ofthe patient for at least a few weeks aftersurgery. Very few scientists believed in thepossibility of a successful trepanation in

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ALEXEY L. KRIVOSHAPKIN ET AL. SCYTHIAN TREPANATIONS IN THE GORNY ALTAI IN HIPPOCRATIC TIMES

primitive ancient medicine, although thefact of bone regeneration at the calvariahole was borne out by the French physician,anatomist, and anthropologist Paul Broca(19, 30). In the middle of the 19th century,owing to ensuing infection and the fact thattrepanation was attempted only in very se-vere cases of head injuries at the very bestEuropean hospitals, the survival rate fromsuch an operation rarely reached 10% (13).At the present time, with modern advancedneurosurgical technologies available, thesuccess of craniotomy depends on thesound knowledge and training of the sur-geon, and the operation itself is not abso-lutely safe (29). Aside from the technicaldifficulties of trepanning the skull and theneed for effective anesthesia, surgeons haveto control bleeding from the soft tissuecovering the skull and bone as well as pre-vent postoperative wound infections.In the present study, we examined ancient

trepanations to discover the motivation andsuccess rate for each case, reconstruct theoperative technique, and assess the compe-tency of nomadic Scythian practitioners(healers) in terms of their manipulationskills. Appraisal of the motivation fortrepanning and adequacy of the decisionsmade by ancient surgeons on how far theinstruments penetrated skull bone and theireffect on the duramater aswell as theoreticalreconstruction of the healing process wasbased on the long-term experience inneurosurgery of one of the authors (A.L.K.).

MATERIALS AND METHODS

Standard osteometric measurements andcareful macroscopic study of the skulls werecarried out. A Dynamic Volume computedtomography scanner with a 320-row 0.5-mmdetector Toshiba Aquilion ONE (ToshibaMedical Systems, Japan) was used for mul-tislice computed tomography (MSCT) anal-ysis (including volume rendering technique[VTR] and multi planar reconstruction[NRR]). In such studies, evidence of bonechanges is more clearly illustrated bycomputed tomography scan than by cra-niography (6). Magnetic resonance imagingwas performedwith a GE Signa Infinity 1.5Tscanner (GE Healthcare, USA).Special trepanning instruments were

not found at the archeological sites wherethe examined skulls originated or amongaccompanying inventory at any other knownsite of the Pazyryk culture.We supposed that

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some particles of materials used for bonecutting could be preserved at the site oftrepanation. We employed 2 highly precisetechniques—inductively coupled plasmamass spectrometry (ICP-MS) and synchro-tron radiationeinduced x-ray fluorescenceanalysis (SR-XRF)—to detect them. Afteracidic decomposition using the CEM Mars5 (CEM Corporation, Germany) microwavesystem, bone samples were analyzed withthe high-resolution mass spectrometerFinnigan MAT Element ICP-MS (FinniganMAT, Bremen, Germany), and Merck(Germany) multielement standard solutionswere used to measure the concentrationrates. SR-XRFwas carried out on the originalVEPP-3 equipment at the Siberian Synchro-tron and Terahertz Radiation Center ofBudker Institute of Nuclear Physics SiberianBranch of Russian Academy of Science(Novosibirsk,Russia) (5). Certified referencematerial phosphorite BCR-32 (CommunityBureau of Reference, Brussels) was used asanexternal reference sample. Trace evidenceanalysis was used to determine constructivecharacteristics of the instruments used andto discover the marks on bone fragments ofthe removal process while the skull defectwas formed.

Archaeological and AnthropologicalContextThe Pazyryk cranial collection consists of 153skulls, 3 ofwhichhaveevidenceof intravitamtrepanations. These 3 skulls were carefullyexamined. Two of the skulls were found atthe Kyzyl-Dzhar tumulus complex locatedwithin natural boundaries of the Kyzyl-Dzhar mountain valley 7e8 km from Beltirvillage, Kosh-Agach region of the GornyAltai Republic (24). They are kept in theanthropological collection of Tomsk StateUniversity. The first skull fromKyzyl-Dzhar-V site tumulus 3 belonged to a 40- to 45-year-old man. The second skull, belonging to awoman who died at about 30 years of age,was found at Kyzyl-Dzhar-IV site tumulus 2.The third skull, which belonged to a man50e60 years old based on age-relatedchanges, was discovered by Kubarev (18) attumulus 3 of the Bike-III burial site at themiddle stream of the Katun River Valley.This skull is in the anthropological collec-tion of the Institute of Archaeology andEthnography. The biological age of oursubjects was determined in accordance withphysical anthropology criteria for the humanfossil bone remains, such as the skull suture

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obliteration and degree of effacement ofteeth (3, 40). Archaeologists who took partin the excavations concluded that the 3 in-dividuals most likely belonged to differentethnic groups in the Pazyryk culture thatexisted in the time range of 500e300 BC.Characteristics of the burials and amountand composition of the accompanying in-ventory confirmed that all 3 individuals werecommon members in their tribal groups.The combination of craniometrical featuresindicates that all 3 of them can be attributedto a single anthropological type with thelarge size of the brain capsule and the facialregion. The ratio of the transverse and lon-gitudinal braincase diameters are meso-morph. The horizontal facial profile isflattened, and the vertical one is orthog-nathic. The angle of the nasal bones is me-dium, and the nose bridge is medium-high.This anthropological type was commonamong early nomads of the Gorny Altai.

RESULTS

Cranial SurgeryThe observed defects of the skull are clearlyartificial and cannot be explained by a bone-damaging disease (21). The skull fromKyzyl-Dzhar-V tumulus 3 belongs to a man,40e45 years old. A linear fracture of tem-poral and parietal bones going up to thesagittal suture was detected on this skull(Figure 1A). This fracture crosses thesagittal suture 80 mm from the coronarysuture and 90 mm from the occipital ridge.It was most likely the result of a blow by aright-handed person in the left parieto-temporal area. Many researchers of ancienttrepanation surmise that most of the per-forations found in the left parietal bone area consequence of interpersonal violencebetween 2 right-handed opponents (25, 38).A rounded skull defect with internal di-

mensions of 40mm� 41mmcan be seen inthe left parietal bone 12 mm from themiddle line. The perforation edge is slant-ing because the outside part of the bone hasbeen removed. The total size of the bonedefect is 63 mm� 64mm. The thickness ofthe bone at the site of trepanation is 3 mm.Visual observation revealed signs of a newlyformed bone both on the edges of theperforation and along the fracture. Healingof linear skull fractures extends over manyyears (29). MSCT also indicated goodregeneration and bone healing (Figure 1B

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Figure 1. Trepanation defect on male skull from Kyzyl-Dzhar-V site, tumulus 3. (A) General view.(B) Multislice computed tomography vertical-lateral projection of a cut through the trepanation defect.(C) Multislice computed tomography horizontal cut through the surface of the trepanation defect.Clear signs of bone regeneration can be observed.

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and C). Because sagittal sinus is locateddirectly under the sagittal suture, in the caseof fracture running toward the suture, wecan expect development of an epidural he-matomawith traumatic rupture of the sinusedge. Taking into account the proximity ofthe damage to the central motor area, wecan assume that the victim not only hadcerebral symptoms of headache, nausea,vomiting, and disturbances of conscious-ness but also had a movement disorder inhis right leg and less so in his right hand.The clinical picture also could haveincluded manifestations of partial (tonic-clonic spasms in right limbs) or generalepileptic seizure.The Pazyryk surgeon of Scythian Siberia

carried out trepanation in strict accordancewith the recommendations of Hippocrates,who lived in the same time period from460e377 BC. The world became aware of thePazyryk culture after archaeological exca-vation of “Tzar’s” Kurgans and frozengraves in the Altai Mountains. Unique ar-tifacts made of wood including gildedgriffins, felts, leather, and wool have beenwell preserved in the eternal frost. It seemsthe world was already small 2500 years ago.The Greek poet Aristey Prokonessianpraised the people with “griffins watchingover gold” living in the remote Scythianareas (4, 28). There is evidence of connec-tions betweenGreek art and Pazyryk culture(15). We can also speculate that the troops


of Alexander Macedonian (334e325 BC) inthe same period of the Pazyryk culturereached over the Syr Darya river (Jaxartes inGreek) and provoked tremendous popula-tionmigration and cultural exchange on thevast territory of Asia and Siberia.The greatGreekphysician considered that

bones injured near the suture in most casesrequire trepanation. Hippocrates warnedagainst making a hole over the suture itself(27, 34). Hippocrates did not mention thesinuses or other vascular structures under-neath the sutures (23). The sutures wereconsidered as points where the skull bonesare weaker, and perhaps trepanation overthose regions was thought to be moredangerous and to entail a higher likelihoodof injuring the intracranial contents whileusing trepan of the Hippocratic time.Hippocrates offered strange recommen-

dations regarding the technique of trepana-tion. He stated that the bone should besawed down until only a very thin layercovering the meninges remained. Thisstatement has subsequently prompted sus-picion that Hippocrates was not personallyacquainted with trepanation (22); in fact,this is not surprising. Hippocrates neveradvised trepanation as a treatment forhematomas, abscesses, or any otherintracranial manipulation. Hippocrates alsorecommended against trepanation incases of depressed skull fractures. Accord-ing to Hippocrates, injuries that require


trepanation include cases of linear fractures;this is confirmed by another recommenda-tion of Hippocrates stating that both theparietal and the temporal bones are thethinnest andweakest ones (34). Hippocrateswas firmly against any incision over thetemple because of potential injury to a large“vein” in that region, which led to contra-lateral convulsions of the patient (34).At the present time, >70% of epidural

hematomas requiring trepanation are in thetemporal area. To all appearances based onthe successful trepanation carried out bythe Pazyryk surgeon, the aim of skullopening was a manipulation of the intra-cranial contents. The hole is big enoughand is centered on the fracture line; alllayers of the parietal bone are removed. Theperforation is very suitable for the evacua-tion of intracranial hematoma.According to the literature, prehistoric

trepanations were highly successful withan overall survival rate of 50%e90% andfew ensuing complications (2, 14). Thesuccess of these ancient operations couldbe explained by the small diameter ofmost perforations, which were made insecure locations so that they did not crossinto superior sagittal sinus, and zones ofdura mater were avoided (42). To preventmassive bleeding, which even today re-quires special technologies and materialsto stop it, the Scythian surgeon was cor-rect to place the hole >1 cm away from thesuture at the margin of sagittal sinus.However, we cannot say that the Pazyrykhealer made a small burr hole. In a similarsituation, a modern neurosurgeon wouldhave made a hole of not smaller diameter.The skull from the Kyzyl-Dzhar-IV be-

longs to a woman about 30 years old. Bothvisual observation and MSCT indicated se-vere head injuries including the middlecranial fossa skull base and right temporalbone fractures. Judging by the nature of thedamage, we can assume that the injurieswere a result of falling from a height. Acircular hole with an outer diameter of39 mm � 36 mm and inner diameter of23 mm � 16 mm is located in the posteriorarea of the crown exactly on the midline ofthe sagittal suture. A through perforationwas made to remove the outer layer of thebone, diploë, and the inner (vitreous) plate(Figure 2A). There are no signs of newlyformed bone, and MSCT did not revealthe reorganization of bone trabeculae(Figure 2B and C). These findings imply



Figure 3. Trepanation defect on male skullfrom Bike III burial site. (A) General view.(B) Multislice computed tomographyhorizontal cut through the surface of thetrepanation defect. Clear signs of boneregeneration can be observed on the edgeof the defect.

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that the patient died either during surgeryor shortly after. Another plausible expla-nation for the findings is that this was apostmortem operation. The technique ofthe operation, as discussed later, is signif-icantly different from the trepanation in thefirst case.The third skull of a 50- to 60-year-old

man was recovered from the Bike-III burialsite. Visual assessment of the skull sug-gests that it contains a congenital defor-mation in the form of unilateral flatteningof the occiput (right lambdoid plagioce-phaly). No trace of injury was found on theskull. The size of the semioval trepannedarea measures 45 mm � 52 mm of thelamina externa and 22 mm � 34 mm ofthe lamina interna. The perforation itselfis located 15 mm back from the coronalsuture and 50 mm from the sagittal suture.The skull opening was put over the motorarea of the left hemisphere. The thicknessof the bone at the trepanation area is 2mm (Figure 3A). MSCT confirmed pro-nounced signs of new bone formation(Figure 3B), which indicated a long life ofthe individual after trepanation.

Operative Technique and InstrumentsThe successful outcomes for 2 of the 3above-described cases render it worthwhileto discuss the technical details of theseoperations. There were 5 main methods oftrepanation used across time and space (19,35). The first method has already been

Figure 2. Trepanation defect on female skull from tum(B) Multislice computed tomography frontal cut throucomputed tomography horizontal cut through the surfregeneration are observed at the edges of the defec


mentioned and is represented by rectan-gular intersecting cuts in the bone done toremove a part of the skull as was done on“Inca skull” from Peru. The perforationswere made with obsidian or flint knives.The secondmethod studied by Broca was

scraping. Broca demonstrated that when apiece of glass was used for scraping, theskull of an adult could be trepanned for 50minutes (41). The third method was cuttinga circular groove followed by lifting off thedisc of the bone. This method was stillwidely used in Kenya until recently (23). Thefourthmethod can be described asmaking arounded opening by using the crown-saw.This method was described by Hippocratesand modernized by Roman surgeons andwas in use in neurosurgery until morerecently. The fifth method is to drill closelyspaced circular holes and then cut or chiselthe bone between the holes. This methodwas recommended by the Romans, wasaccepted by Arabs, and was widely used inthe Middle Ages. Despite the availability ofhigh-speed electrical and pneumatic drills,equipped with craniotomes and routersmade of high-strength steel alloys, essen-tially the same method is still used when aGigli saw (a sharp edgewire) is put under thebone over the duramater to saw it between aset of small trepanned or drilled holes.The Pazyryk surgeons could have used

flint, iron, copper, or bronze tools for trep-anations. High-field open magnetic reso-nance imaging did not reveal the presence of

ulus complex Kyzyl-Dzhar-IV. (A) General view.gh the trepanation defect. (C) Multisliceace of the trepanation defect. No signs of bonet.


ferromagnetic material (iron) in bonecrosscuts of the trepanned skulls. Copper isa pretty soft metal for cutting bones. ThePazyryk healers should have started usingmore durable andhandy bronze instrumentsinstead of flint tools of the Paleolithic era.Chemical elements trace analysis of bone

tissue samples at the site of trepanationtaken from all 3 skulls pointed to such apossibility. SR-XRF showed that the coppercontent in relation to the standard externalsample was 78.0%, 23.8%, and 94.0% inthe Kyzyl-Dzhar-IV, Kyzyl-Dzhar-V, andBike-III samples with 20.0% error, whereastin content in the same samples was 2.7%,6.0%, and 636.0% with 15.0% error(Table 1). ICP-MS demonstrated 97.00mkg/g, 21.00 mkg/g, and 87.00 mkg/g forcopper and 6.60 g, 5.30 g, and 480.00mkg/g for tin accordingly (Table 1). Rela-tively high levels of titanium (Ti), vanadium(V), chromium (Cr), nickel (Ni), and iron(Fe) in bone tissue can be explained by thenature of surrounding soil because theseelements are contained in the compositionof rock-forming minerals in significant

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Figure 4. Typical bronze knife of the Pazyrykculture.

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quantity. Manganese (Mn2þ), zinc (Zn2þ),and strontium (Sr2þ)may be included in theisomorphic form of the hydroxyapatitestructure in human bones, replacing Ca2þ,and consequently there is high content ofthese elements in skull bones.We surmisedfrom this analysis that the Pazyryk healersused instruments made of copper and tinalloy—bronze.Excavations of the Pazyryk sites did not

yield any specialized tools that could beidentified as medical instruments for trepa-nation. However, regardless of social statusof the buried person, bronze knives werediscovered in almost all of the Pazyryk graves(Figure 4). Such knives were an irreplaceabletool of cattlemen in everyday life.As noted by many researchers, the

scraping method was associated with thehighest survival rate after ancient trepa-nations (16). Observations made on manycases of trepanation from Anatolia indi-cate that compared with boring and cut-ting, the probability of healing andsubsequently surviving is the highest withthe scraping technique (9). Trepanationcontinued to be practiced throughout thevast territory where ancient Celts were

Table1. Traces of Chemical Elements in Bone

ChemicalElement

SR-XRF (% Compared with ExternaStandard Sample)

Kyzyl-Dzhar-IV Kyzyl-Dzhar-V Bike

Ti 781.00 68.00 163

V 46.70 29.70 28

Cr 47.10 0.00 14

Mn 546.00 2655.00 533

Fe 6230.00 1293.00 1739

Ni 12.60 9.30 10

Cu 78.00 23.80 94

Zn 276.00 377.00 367

Sr 474.00 605.00 484

Mo 1.49 1.15 2

Ag 0.28 0.40 0

Sn 2.70 6.00 636

As 0.00 0.00 2

SR-XRF, synchrotron radiationeinduced x-ray fluorescence analysTi, titanium; V, vanadium; Cr, chromium; Mn, manganese;Mo, molybdenum; Ag, silver; Sn, tin; As, arsenic.


living from France and the Danube to theBlack Sea (22); at the same time, thetechnique of drilling, although known,was used only in a few places.Hippocrates described 4 instruments

for trepanation. They included 3 differenttypes of bone-penetration instruments: thetrepan, the serrated trepan, and the probethat was used while trepanning to deter-mine the depth of the hole and the mobilityof the underlying bone. The fourth instru-ment was the raspatory used in cases inwhich the wound was explored and thecontused bone and fracture were scrapeddown to the level of healthy bone (34). Forthe Scythian surgeon, the use of a universalbronze knife seemed to be sufficient.Trace evidence assessment was used to

identify the marks of operation and recon-struct the technique of the bone fragmentremoval process while skull defect wasformed. The operation was carried out in2 stages. First, themost durable cortex of thebone was removed by rotational movementswithout perforation of the skull. The bonecutting angle is tangent to the sphericalsurface of the skull. In the second stage ofthe operation, the ancient surgeon most

Samples Taken from Trepanation Sites

lICP-MS (mkg/g)

-III Kyzyl-Dzhar-IV Kyzyl-Dzhar-V Bike-III

.00 188.00 43.00 46.00

.00 9.30 13.00 7.40

.20 11.00 5.40 7.70

.00 440.00 1800.00 450.00

.00 6000.00 1700.00 2900.00

.80 13.00 7.90 11.00

.00 97.00 21.00 87.00

.00 150.00 240.00 230.00

.00 — — —

.19 0.78 1.10 2.70

.32 0.13 0.11 1.30

.00 6.60 5.30 480.00

.30 — — —

is; ICP-MS, inductively coupled plasma mass spectrometry;Fe, iron; Ni, nickel; Cu, copper; Zn, zinc; Sr, strontium;


likely used the same instrument undera steeper angle to lift carefully and thenremove vitreous plate contiguous to the duramater. During the first stage of the opera-tion, movements appear to have a relativelylong “cutting pass,” whereas during thesecond stage, traces of the comparativelymore frequent, short movements of thesurgeon’s hand can be observed. Compari-son of the operative techniques of all 3 casesshowed that hand movements were coarserand sharper during trepanation of the fe-male skull, where perforation is located inthe sagittal suture area.No signs of bone infection were detec-

ted in our study. Both SR-XRF and ICP-MSof bone samples at the trepanation defectdemonstrated abundant copper and tin(Table 1). It would be feasible to suggestthat in the Pazyryk culture of the Scythianperiod, the antimicrobial copper effectcould have prevented infection after skullopening. Ancient healers observed naturalbactericidal properties of copper for cen-turies. More recent research around theworld reconfirmed the antimicrobial effi-cacy of copper alloys (26). In 2011, it wasdemonstrated that intensive care unitswith copper surfaces had 97% reduction insurface pathogens, and patients had 40%lower risk of contracting a hospital-acquired infection compared with patientsin rooms without copper surfaces (36).Impressively, 355 copper alloys were foundto kill methicillin-resistant Staphylococcusaureus and vancomycin-resistant entero-cocci completely for a few hours (26).These pathogens have become the greatestscourge for surgery at the present time.Modern surgeons have been using quitesophisticated technologies to provideaseptic surgery. Apparently the Pazyrykancient healers with their copper alloyinstruments practiced antiseptic surgery.



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DISCUSSION

The Pazyryk culture left no written evi-dence or rock carvings related to medicalactivities, which renders it a challenge todetermine the motivation of Scythian sur-geons to perform a trepanation. Althoughtrepanation was widely practiced in theNeolithic period, with a few exceptions(43) it is difficult to understand why and bywhom such operations were done (17, 20,33), and this phenomenon is yet to becomprehended by paleoanthropologists.At the same time, in the Pazyryk culture,all manipulations on the human skull werecarried out by professionals with certainknowledge of the human body structureand its diseases; all operations were defi-nitely of therapeutic significance. Cranialand brain traumas were the main reasonsprompting such interventions. Similar totoday, blows to the head causing injurieswere common in violent disputes andbattles.A primary motivation for the first case

presented (Kyzyl-Dzhar-V) was trepanationas a medical treatment of a serious cranio-cerebral trauma. Location of the hole in thecenter of the fracture at a certain distancefrom the sagittal suture, the size of thisperforation, and precise movements of theScythian surgeon indicate that he was askilled diagnostician and a trained physi-cian with a good knowledge of anatomy.The nature of this operation was clearlymedical, and most likely it was performedfor the removal of intracranial hematoma.Taking into account the conclusionsof Hippocrates, who was an esteemedcontemporary of the Pazyryk people, thisindication is unexpected.The second case (Kyzyl-Dzhar-IV) can

also be assessed as an attempt to treat ahead injury. Failure of the operation couldbe explained by various reasons, and theseverity of the initial injury should beconsidered first. Even today with the mostadvanced neurosurgical and intensive caretechnologies available, we lose patients af-ter trepanation because of serious initialbrain damage or other associated injuries.The inexplicable choice of location for theperforation directly above the largest brainvenous collector where the risk of extensivebleeding is particularly high might haveplayed a fatal role. It is also possible thata less sophisticated trepanation techniquecaused the failure of the operation.


Probably the choice of physician was ascrucial in ancient times as it is nowadays.It is unlikely that trepanation was per-

formed as a ritual because evidence thatsuch a ritual existed has not been found yet.At the beginning of our era, written sourcesalready bear evidence that healers whoperformed trepanation were fully awarethat it is quite risky. Aretaeus of Cappadociacalled trepanation “a bold remedy for thedisease” (1). Describing the risks of damageto the brain during trepanation, Galenstressed the need for repeated practice tobecome a master of the operation (32).Analyzing 40 cases of trepanation in ancientAnatolia over the period of time from theAceramic Neolithic period to the LateOttoman period, authors concluded that noclear evidence supporting the religious ormagic purpose was discovered, but trainingand treatment of tumors can be consideredas likely causes of trepanations (9). Otherauthors also came to the same conclusionabout training when ancient skulls fromItaly were analyzed (10).In the third case, no signs of skull trauma

were found. The trepanation was per-formed over the functional area of thebrain; the patient survived surgery for a longperiod of time and died as a rather oldman,so the motivation for this operation re-mains unclear. Quite possibly it was thetreatment of a head injury that did not leavemarks on the skull. However, we cannotexclude the other indications for surgery. In2003, a case of trepanation in the earlyMiddle Ages was reported. The operationwas performed on the right frontal bone of apatient with craniographic symptoms ofconvexity meningioma (37).Neurosurgery has been known as a

medical specialty since 1879, when theScottish surgeon William Macewen per-formed hisfirst removal of a left frontal lobemeningioma and the patient survived (12).The correct recognition of the illness wasmade on the basis of topical diagnosis.Computed tomography analysis of thePazyryk male skull revealed no bone alter-ations related tomeningioma.However, wecannot exclude parasitic brain damage. Atthe present time, there are still many casesof cerebral cysticercosis and echinococ-cosis requiring surgical intervention inSiberia and the Altai. Pastoralists of theAltai region 2500 years ago bred cattle,sheep, goats, pigs, and horses (7). The high


level of topical diagnosis and successfulintracranial interventions of Scythian sur-geons could point to the possibility of somehelminthes being extracted from the brainof the individual from Bike-III site. Furtherresearch is needed to understand theimprovement of neurosurgical technologyover the ages and ascertain capabilities ofthe ancient physicians in southern Siberiaand the Altai.

CONCLUSIONS

Appraisal of ancient surgical technologies inthe Altai region demonstrated that 2500years ago Pazyryk healers were practicingtrepanation, and motivation for skull open-ing was medical rather than ritual. The highsurvival rate after such manipulations wasbased on the impressive level of both di-agnostics and surgical techniques of theancient curers. During the Scythian Period,Pazyryk society had impressive knowledge ofhuman anatomy and in particular of intra-cranial venous sinuses. Altai surgeons verylikely used trepanation to perform theintracranial procedures that were not yetindicated by Hippocrates during the sametime period. ICP-MS and SR-XRF showedabundance of copper and tin at the site oftrepanation, which indicates tools made ofbronze. In 500e300 BC, this alloy was widelyused in Southern Siberia. It is astonishingthat no signsof bone infectionweredetectedin all 3 skulls examined. On one hand,possibly the Pazyryk healers applied strongantiseptics to prevent wound infection. Onthe other hand, more recent research hasestablished the bactericidal properties ofcopper ions. We surmise that the bronzetools used by Scythian healers might be theimportant factor in why inflammation didnot occur after trepanation. Pazyryk healersconceivably practiced cranial surgery bothfor the treatment of patients with head in-juries and for the management of otherintracranial pathology.

ACKNOWLEDGMENTS

The authors thank Marina P. Rykoun forpermission to examine skulls discovered atthe Kyzyl-Dzhar tumulus site, which arenow located in the anthropological collec-tion of Tomsk State University. Specialthanks go to Yu. P. Kolmogorov and I.V.Nicolaeva, who analyzed bone samples atthe Siberian Synchrotron and Terahertz

dx.doi.org/10.1016/j.wneu.2014.06.045



PEER-REVIEW REPORTS


Radiation Center of The Budker Instituteof Nuclear Physics Siberian Branch ofRussian Academy of Science.

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Conflict of interest statement: This research was funded bythe Russian Foundation for Basic Research, Grant RFBR No.13-06-00153.

Received 3 February 2014; accepted 24 June 2014;published online 5 July 2014

Citation: World Neurosurg. (2014) 82, 5:e649-e655.http://dx.doi.org/10.1016/j.wneu.2014.06.045

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