Craniotomy through the ages.

Today, the Specialist in Otorhinolaryngology often has to perform surgery requiring an endocranial approach, as, for instance, in the case of neoplastic or inflammatory disorders, or even in malformations. These specialists should, therefore, not forget one of the most important Chapters in the History of Medicine and Ethnology: that related to the evolution of craniotomy over thousands of years, probably the surgical procedure that has been practiced longer than any other and certainly that for which we have, by far, the oldest tangible evidence. In fact, the first findings related to perforation of the skull date back to the neolithic period (8000-5000 BC) and were found in France already in 1685 1. But the foramen, round or oval, present primarily in the parietal or occipital bone, had, for a long time, been attributed to trauma, until, in 1783, the anthropologist Prunières 2, having observed the regularity in the loss of substance and the marks on the edges due to repeated action of sharp instruments, showed the French Association for Progress in Science that the origin of these marks could be attributed, without any doubt whatsoever, to a purposeful human procedure, in a broad sense, to some type of surgical intervention. Thanks, in particular, to Paul Broca 3, the father of Neurology, who later dedicated a large number of publications to this topic, interest rapidly grew in the scientific world and as a result there was an enormous increase in new findings. By the end of the 19th Century, all those interested in this particular field had now accepted that those holes in the skullcap were not due to accidental traumas, but to perforations made by instruments for well-defined purposes. Indeed, doubts were being expressed concerning the meaning of these perforations, the methods and types of instruments used in making those holes. Following those early findings, from the end of the 19th Century onwards, an extraordinary number of skulls showing signs of craniotomy were found throughout the world, especially the countries bordering on the Mediterranean, Central and Eastern European countries, Scandinavia, in fact in practically all those areas in which evidence of Neolithic settlements had been found, while several more, belonging to a later period, were discovered in Mexico and Peru 1 4 5. According to the most popular theory, the very first cases of craniotomy were probably performed, by prehistoric man, for reasons related to magic or religious rituals, or as an initiation practice, as hypothesised by Broca 3, or as part of a ritual related to exorcism, to offer a way of escape to the demons and malignant spirits whom they believed had infested the person. As proof of the great religious importance attached to those who had been subjected to drilling, it is worthwhile recalling that, from some of these skulls, diskettes of bony tissue were removed post mortem, which were then worn as amulets around the neck (the so-called “rondelles”, described for the first time, by Prunières, in 1783) 3 4. Later, craniotomy was used for treatment purposes: the finding that this procedure could, thanks to encephalic decompression, lead to an improvement in certain pre-existing neurological symptoms, such as headache, paresis, convulsive states, probably led to it being employed in the presence of these symptoms and, in particular, in traumatic lesions. These very soon became the principal therapeutic indication of drilling which, allowing the removal of embedded fragments, of bone fragments and clots, led to results quoad vitam that were extraordinary for prehistoric culture. Almost 50% of the patients survived the operation, some of them for years, as demonstrated by the finding of signs of regenerated bone in many of the skulls despite the very high risk of complications due to haemorrhage or infection. The medicine men of neolithic times had thus reached an incredible technical ability in performing this type of surgical procedure despite the fact that they only had primitive tools such as pointed or sharp cutting tools derived from silica or obsidian 2 4. Only much later were metallic instruments used, made of copper or bronze, such as gouges, curettes, scalpels, knives of various forms, some of which very special, such as the “tumi”, or scalpel, in ancient Perù 5. It is worthwhile taking a closer ACTA OTOrHINOLAryNgOLOgICA ITALICA 2007;27:151-156