First Skull Surgery in Iran: The Burned City and a 4800-Year-Old Skull

In 1977, an Italian archeological group made a great discovery while excavating the Burned City (Shahr-e sukhteh). They found a skull dating back to 2800 BC with a triangular surgery scar showing the removal of a piece (1) (Fig. 1-A & B). The other remarkable feature of the skull was the dimensions that were significantly big compared to the age of the person it belonged to (1). Based on the investigations, the skull belonged to a girl who was approximately 13 yr old (1). A neurologist could immediately and without any diagnostic measures diagnose congenital hydrocephalus in her (1). The abnormal enlargement of the skull, particularly the parietal regions on both sides (1) is the common view in congenital hydrocephalus. Since surgery can be a method of treatment in case the patient is symptomatic, it is assumed that this ancient surgery was conducted for treating the girl. In the present manuscript, I am intending to study the allegation to find relevant supporting documentation. It should be born in mind that performing similar surgical interventions on skull has a long history and was mostly conducted as a magical intervention (1). However, performing such a surgical intervention indicating an underlying disease in the patient is a very noticeable case. In order to partially presume the event, some information on congenital hydro-cephalus, its causes and the reason for performing the skull surgery at a certain age (13 years in this case) would be helpful. Hydrocephalus is the abnormal accumulation of cerebrospinal fluid in ventricles that may have several causes, the most prevalent of which include infections, strokes, bleeding and tumors. Congenital hydrocephalus is a type that takes place prior to/immediately after birth. The disease may cause impatience, drowsiness and vomiting in children. Almost 45%-53% of the patients die, if remain untreated (2); yet, others may survive with the slow growth or the spontaneous discontinuation of the disease (3). However, the patients do not always have stable conditions and hydrocephalus may suddenly become unstable due to a minor stroke (4). At this point, this girl's case is reviewed. First, we are aware that the girl was among those who could survive until 13 years of age; i.e. her hydrocephalus had discontinued. The point that her enlarged head had made her look unusual can be true but the data show that skull enlargement was not extraordinary in the Burned City because two other skulls representing …