A recent excavation in Megiddo, Israel, unearthed the earliest example of a particular type of cranial surgery in the Ancient Near East — and potentially one of the oldest examples of leprosy in the world.
BROWN UNIVERSITY
IMAGE: A-B: MAGNIFIED EDGES OF THE TREPHINATION, EACH WITH A 2 MM SCALE BAR. C: ALL FOUR EDGES OF THE TREPHINATION, SCALE BAR IS 1 CM. D: RECONSTRUCTED LOCATION OF TREPHINATION ON HEAD. view more
CREDIT: RACHEL KALISHER ET AL
PROVIDENCE, R.I. [Brown University] — Archaeologists know that people have practiced cranial trephination, a medical procedure that involves cutting a hole in the skull, for thousands of years. They’ve turned up evidence that ancient civilizations across the globe, from South America to Africa and beyond, performed the surgery.
Now, thanks to a recent excavation at the ancient city of Megiddo, Israel, there’s new evidence that one particular type of trephination dates back to at least the late Bronze Age.
Rachel Kalisher, a Ph.D. candidate at Brown University’s Joukowsky Institute for Archaeology and the Ancient World, led an analysis of the excavated remains of two upper-class brothers who lived in Megiddo around the 15th century B.C. She found that not long before one of the brothers died, he had undergone a specific type of cranial surgery called angular notched trephination. The procedure involves cutting the scalp, using an instrument with a sharp beveled edge to carve four intersecting lines in the skull, and using leverage to make a square-shaped hole.
Kalisher said the trephination is the earliest example of its kind found in the Ancient Near East.
“We have evidence that trephination has been this universal, widespread type of surgery for thousands of years,” Kalisher said. “But in the Near East, we don’t see it so often — there are only about a dozen examples of trephination in this entire region. My hope is that adding more examples to the scholarly record will deepen our field’s understanding of medical care and cultural dynamics in ancient cities in this area.”
Kalisher’s analysis, written in collaboration with scholars in New York, Austria and Israel, was published on Wednesday, Feb. 22, in PLOS ONE.
Two brothers, up close
Israel Finkelstein, who co-authored the study and serves as director of the School of Archaeology and Maritime Cultures at the University of Haifa, said that 4,000 years ago, Megiddo stood at and controlled part of the Via Maris, an important land route that connected Egypt, Syria, Mesopotamia and Anatolia. As a result, the city had become one of the wealthiest and most cosmopolitan cities in the region by about the 19th century B.C., with an impressive skyline of palaces, temples, fortifications and gates.
“It’s hard to overstate Megiddo’s cultural and economic importance in the late Bronze Age,” Finkelstein said.
According to Kalisher, the two brothers whose bones she analyzed came from a domestic area directly adjacent to Megiddo’s late Bronze Age palace, suggesting that the pair were elite members of society and possibly even royals themselves. Many other facts bear that out: The brothers were buried with fine Cypriot pottery and other valuable possessions, and as the trephination demonstrates, they received treatment that likely wouldn’t have been accessible to most citizens of Megiddo.
“These brothers were obviously living with some pretty intense pathological circumstances that, in this time, would have been tough to endure without wealth and status,” Kalisher said. “If you’re elite, maybe you don’t have to work as much. If you’re elite, maybe you can eat a special diet. If you’re elite, maybe you’re able to survive a severe illness longer because you have access to care.”
In her analysis, Kalisher spotted several skeletal abnormalities in both brothers. The older brother had an additional cranial suture and an extra molar in one corner of his mouth, suggesting he may have had a congenital syndrome such as Cleidocranial dysplasia. Both of the brothers’ bones show minor evidence of sustained iron deficiency anemia in childhood, which could have impacted their development.
Those developmental irregularities could explain why the brothers died young, one in his teens or early 20s and the other sometime between his 20s and 40s. But Kalisher said it’s more likely that the two ultimately succumbed to an infectious disease. A third of one brother’s skeleton, and half of the other brother’s, shows porosity, legions and signs of previous inflammation in the membrane covering the bones — which together suggest they had systemic, sustained cases of an infectious disease like tuberculosis or leprosy.
Kalisher said that while some skeletal evidence points to leprosy, it’s tough to deduce cases of leprosy using bones alone. She’s currently working with researchers at Germany’s Max Planck Institute for Evolutionary Anthropology to conduct DNA analyses of specific lesions in the bones. If they find bacterial DNA consistent with leprosy, these brothers will be among the earliest documented examples of leprosy in the world.
“Leprosy can spread within family units, not just because of the close proximity but also because your susceptibility to the disease is influenced by your genetic landscape,” Kalisher said. “At the same time, leprosy is hard to identify because it affects the bones in stages, which might not happen in the same order or with the same severity for everyone. It’s hard for us to say for sure whether these brothers had leprosy or some other infectious disease.”
It’s also difficult to know, Kalisher said, whether it was the disease, the congenital conditions or something else that prompted one brother to undergo cranial surgery. But there’s one thing she does know: If the angular notched trephination was meant to keep him alive, it didn’t succeed. He died shortly after the surgery — within days, hours or perhaps even minutes.
Digging into medical history
Despite all the evidence of trephination uncovered over the last 200 years, Kalisher said, there’s still much archaeologists don’t know. It’s not clear, for example, why some trephinations are round — suggesting the use of some sort of analog drill — and some are square or triangular. Nor is it clear how common the procedure was in each region, or what ancient peoples were even trying to treat. (Doctors today perform a similar procedure, called a craniotomy, to relieve pressure in the brain.) Kalisher is pursuing a follow-up research project that will investigate trephination across multiple regions and time periods, which she hopes will shed more light on ancient medical practices.
“You have to be in a pretty dire place to have a hole cut in your head,” Kalisher said. “I’m interested in what we can learn from looking across the scientific literature at every example of trephination in antiquity, comparing and contrasting the circumstances of each person who had the surgery done.”
Aside from enriching colleagues’ understanding of early trephinations, Kalisher said she hopes her analysis also shows the general public that ancient societies didn’t necessarily live by “survival of the fittest” principles, as many might imagine.
“In antiquity, there was a lot more tolerance and a lot more care than people might think,” Kalisher said. “We have evidence literally from the time of Neanderthals that people have provided care for one another, even in challenging circumstances. I’m not trying to say it was all kumbaya — there were sex- and class-based divisions. But in the past, people were still people.”
In addition to Kalisher and Finkelstein, other authors of the analysis included Melissa Cradic from the University at Albany; Matthew Adams of the W.F. Albright Institute for Archaeological Research in Jerusalem; and Mario Martin from the University of Haifa and University of Innsbruck. The study’s associated excavation was funded by the Shmunis Family Foundation.
JOURNAL
PLoS ONE
DOI
10.1371/journal.pone.0281020
METHOD OF RESEARCH
Case study
SUBJECT OF RESEARCH
Not applicable
ARTICLE TITLE
Cranial trephination and infectious disease in the Eastern Mediterranean: The evidence from two elite brothers from Late Bronze Megiddo, Israel
ARTICLE PUBLICATION DATE
22-Feb-2023
COI STATEMENT
The study’s associated excavation was funded by the Shmunis Family Foundation.
Two high status brothers had access to “brain surgery” in Bronze Age Israel
Both brothers suffered chronic illness, and one underwent rare trephination around 1500 BC
Peer-Reviewed PublicationIMAGE: BIOARCHAEOLOGICAL CONTEXT OF THIS STUDY. A: THE AREA H (H-15) DOMESTIC STRUCTURE, WITH TOMB 45 HIGHLIGHTED IN YELLOW. B: IN-SITU PHOTOGRAPH OF EARLY EXPOSURE OF BURIAL CONTEXT. C: COMPOSITE DRAWING FEATURING ALL LAYERS. INDIVIDUAL 1 IS BLUE, INDIVIDUAL 2 IS GREEN, FAUNAL REMAINS ARE ORANGE. view more
CREDIT: KALISHER ET AL., 2023, PLOS ONE, CC-BY 4.0 (HTTPS://CREATIVECOMMONS.ORG/LICENSES/BY/4.0/)
Two high status brothers buried in a Bronze Age tomb in Israel were severely ill but apparently had access to rare treatments including trephination, according to a study published February 22, 2023 in the open-access journal PLOS ONE by Rachel Kalisher of Brown University, Rhode Island, and colleagues.
In this study, authors examined the remains of two individuals buried in a tomb beneath an elite residence in the archaeological site of Tel Megiddo in Israel. The tomb dates to the Late Bronze Age (around 1550-1450 BC), and DNA testing suggests the buried individuals are brothers. Both skeletons show evidence of disease, providing an opportunity to study how illness was treated during this time period.
Extensive lesions on the bones of both individuals are evidence of chronic, debilitating disease, possibly a condition to which the brothers shared susceptibility. The advanced state of the lesions indicates that, despite the severity of the condition, these individuals survived many years, possibly due to the privileges of wealth and status.
Additionally, one of the individuals has a ~30mm square hole in the frontal bone of the skull where a piece of bone was surgically removed, a procedure known as trephination which has been used to treat various medical disorders by relieving pressure buildup in the skull. This was likely intended to treat the patient’s ailment, but the lack of bone healing suggests the individual died during or shortly after surgery.
It is notable that the brothers’ tomb was adorned with high quality food and fine ceramics similar to other nearby high-status tombs. This suggests these individuals were not “othered” nor excluded from burial traditions due to their poor health. This serves as an important case study for continuing investigation into the intersections of status, illness, and treatment in societies through time.
The authors add: “Among the study’s multiple findings, we wish to highlight the special type of cranial trephination, the earliest of its kind in the region. This uncommon procedure was done on an elite individual with both developmental anomalies and infectious disease, which leads us to posit that this operation may have been an intervention to deteriorating health.”
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In your coverage please use this URL to provide access to the freely available article in PLOS ONE: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0281020
Citation: Kalisher R, Cradic MS, Adams MJ, Martin MAS, Finkelstein I (2023) Cranial trephination and infectious disease in the Eastern Mediterranean: The evidence from two elite brothers from Late Bronze Megiddo, Israel. PLoS ONE 18(2): e0281020. https://doi.org/10.1371/journal.pone.0281020
Author Countries: USA, Israel, Austria
Funding: The excavation of Burial 16/H/45 was funded by the Shmunis Family Foundation. In 2016 the Megiddo Expedition was also supported by the Dan David Foundation, Mr. Jacques Chahine and Mr. Mark Weissman. Finally, the purchase of the Leica microscope used in this study was possible through the support of the Society for Classical Studies, Women’s Classical Caucus. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
JOURNAL
PLoS ONE
METHOD OF RESEARCH
Observational study
SUBJECT OF RESEARCH
Not applicable
ARTICLE TITLE
Cranial trephination and infectious disease in the Eastern Mediterranean: The evidence from two elite brothers from Late Bronze Megiddo, Israel
ARTICLE PUBLICATION DATE
22-Feb-2023
COI STATEMENT
The authors have declared that no competing interests exist.
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