LEGACY
Discovering Trepanation: The Contribution of Paul Broca
William T. Clower, Ph.D., Stanley Finger, Ph.D.
Department of Neurobiology (WTC), University of Pittsburgh, Pittsburgh,
Pennsylvania, and Department of Psychology (SF), Washington University,
St. Louis, Missouri
PAUL BROCA WAS an icon of neuroscience and neurosurgery who also happened to be intrigued by trepanned
skulls. His anthropological work established that, thousands of years ago, individuals not only trepanned skulls but
also successfully performed these operations on living persons. After first commenting on a pre-Columbian Peruvian
skull in 1867 (the first case of trepanning on a living person widely recognized as such), he turned to even older
trepanned skulls found on French soil. In the 1870s, he theorized that the procedure originated as a means to treat
convulsions in infants. As he saw it, Neolithic man attributed such convulsions to evil spirits, for which trepanation
provided a ready means of escape. Because simple infantile convulsions resolve on their own, the practice would
have seemed successful, and therefore it would have been propagated and expanded by later generations. Broca’s
theory skillfully integrated his anthropological and medical knowledge and helped to create the exciting environment in which scientists pondered what Neolithic and primitive people really knew regarding the brain and surgery.
(Neurosurgery 49:1417–1425, 2001)
Key words: Broca, Convulsive disorders, Epilepsy, Horsley, Neurosurgery, Trepanation
D
uring the 1870s, the scientific community was
shocked to realize that they had long misinterpreted
some fundamental data. The skulls of people living in
France as long as 5000 years ago sometimes exhibited holes.
For a long time, these openings had been thought to result
from weapons, posthumous tampering, or accidental breakage. However, it was realized that some of the openings were
actually caused by an intentional surgical procedure performed during the Neolithic or New Stone Age period.
Trepanation (from the Greek trypanon, meaning auger or
borer) has garnered the interest of neurosurgeons, neurologists, psychologists, and anthropologists since it was realized
that ancient human hands not only made holes in skulls, but
they performed the procedure on the living. The individual
who deserves the most credit for successfully bringing ancient
trepanned skulls to the attention of the scientific community,
and for providing an early theory to account for trepanation,
was Paul Broca. How Broca first became involved with trepanned skulls, what he thought regarding the origins of the
surgical procedure, and how his theory was received are the
subject matter of this article.
PAUL BROCA
Paul Broca (1824–1880) (Fig. 1) was born in Sainte-Foy-laGrande, a town east of Bordeaux (for biographical and scientific information, see Refs. 31 and 65). After graduating from
medical school in Paris in 1848, he remained in the French
capital for the rest of his life. Throughout his impressive
career, Broca published more than 500 scientific articles; he
was highly respected for his keen intellect and ability to
observe things from many perspectives. In addition, he applied his exceptional talents to a wide array of disciplines,
including neurology, neuroanatomy, comparative anatomy,
human evolution and diversity, pathology, oncology, and
therapeutics. He was instrumental in merging laboratory science with medicine, in revolutionizing thinking regarding the
cerebral cortex, and in founding modern anthropology.
Broca began his distinguished scientific career in the 1850s,
studying such illnesses as cancer, muscular dystrophy, and
rickets. He became even better known during the next decade;
first for the discovery of the language area that now bears his
name (5), and then for suggesting that the left hemisphere
plays the leading role in speech (6).
Broca was elected President of the Paris Surgical Society in
1865 and became Professor of Clinical Surgery in 1868. In the
surgical domain, he introduced a procedure known as cranial
cerebral topography, which uses cranial and scalp landmarks
to localize underlying parts of the brain (9). He successfully
applied his new method to one of his patients, a man who
exhibited impaired speech after a closed head injury. He was
able to localize the site of his infliction, trephine the cranium,
and drain the abscess. Although Broca (16) did not report the
case until 1876, this was, in fact, the first use of neurosurgery
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Clower and Finger
FIGURE 1. Photograph of Paul Broca (1824–1880) in his 50s
(courtesy of the National Library of Medicine).
based on the new theory of cortical localization of function
(58, 68).
During this same time period, Broca was also deeply involved with physical and cultural anthropology. But just like
everyone else before the mid-1860s, he had no reason to think
about ancient trepanation practices on French soil, much less
in South America. The situation changed dramatically for
him, and subsequently for scientists around the world, when
he was shown an old Peruvian skull with cross-hatched cuts
in 1867 (Fig. 2).
BROCA AND SQUIER’S PERUVIAN SKULL
Ephraim George Squier, an archeologist, writer, and diplomat, originally had been sent to Peru by the United States
government to settle some conflicting international claims.
Once his job was completed, he began to travel to collect
material for a book regarding Peru’s geography, people, and
past. During his travels, he encountered a wealthy woman in
Cuzco who enjoyed collecting and filling her home with fine
antiques and artifacts. By far the most exceptional piece in her
collection, at least from Squier’s perspective, was an incomplete skull with a rectangular opening near the top. It had
come from an ancient Inca cemetery in the nearby Valley of
Yucay.
In his monograph of 1877, Squier described the skull with
its 15 ⫻ 17 mm opening as “a clear case of trepanning before
death,” the opening having been made “with a burin, or tool
like that used by engravers on wood and metal” (65, pp
456–457). Impressed by the potential significance of the specimen, he added:
The señora was kind enough to give it to me for
investigation, and it has been submitted to the criticism
FIGURE 2. Drawing of the Peruvian skull with a cross-hatch
opening that was obtained by Ephraim George Squier. Squier
took it to New York and then to France, where Paul Broca
concluded that the opening was made before the European
conquest on an Inca who survived the surgery by 1 or 2
weeks (from, Squier EG: Peru: Incidents of Travel and Exploration in the Land of the Incas. New York, Harper and Brothers, 1877 [66]).
of the best surgeons of the United States and Europe,
and regarded by all as the most remarkable evidence of
a knowledge of surgery among the aborigines yet discovered on this continent (65, p 456).
Although a trepanned skull from South America had been
depicted in 1839 in a book by Morton on American crania (51),
its significance had not been recognized at the time. Morton
thought the hole had been made by a blunt instrument, possibly the back of an axe, during battle. Unlike most trepanned
skulls, which have smooth, round openings that might not
have suggested surgery, the cross-hatched cuts on Squier’s
Peruvian skull could have been crafted only by skilled human
hands.
Squier brought his skull to New York, where Dr. A.K.
Gardner presented it to members of the New York Academy
of Medicine in the winter of 1865. The notes from the meeting
read:
The skull showed that during the patient’s life an
operation for trephining had been performed. . . by
what would appear to be a gouging instrument. At one
portion of the opening there seemed to be evidences of
the attempt on the part of nature to form new bone, to
repair the injury done by the operation (28, p 530).
The audience’s reaction, however, was mixed. Although
many members of the academy agreed with Gardner, in the
minutes we also find:
Dr. Post stated that he did not see any of the evidences of the reparative process sufficiently marked to
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Discovering Trepanation
decide positively that the operation was not performed
after death (28, p 530).
Without uniform agreement regarding the specimen, and
perhaps also because Squier wanted to enhance his own fame,
he now decided to solicit an expert opinion. The skull was
sent to France and shown to Broca, who not only had founded
the Société d’Anthropologie de Paris in 1859, but was considered by many to be the leading anthropologist in the world, as
well as an authority on the brain and its pathology.
After careful examination, Broca concluded that the Peruvian skull represented a case of “advanced surgery” from the
New World before the European conquest (7, 8). As he explained to the members of the Société d’Anthropologie, the
features of the circle of bone around the opening were denuded of its periosteum, which proved that the surgery was
performed while the individual was still alive. The sharp
edges around the hole and signs of inflammation suggested
that death probably occurred 1 or 2 weeks later.
This knowledge opened up a plethora of new questions.
Why, for example, was such an operation performed? Under
what conditions? And was it successful?
One possibility was that the bone was removed to treat a
cranial fracture. Josiah Nott, an American researcher who was
shown the skull, favored this idea, as did Squier, who had also
observed other skulls from Peru that had been penetrated by
sharp weapons such as lances and arrows (65). But there were
problems with the fracture theory, the most important of
which was that no unusual cracks or lines were found anywhere on the Peruvian skull to suggest an injury.
Finding no fractures, Broca considered a related medical
possibility. It was one that he was familiar with—namely that
the operation might have been performed after a closed head
injury to relieve a buildup of blood and intracranial pressure:
Did the operation succeed in evacuating a fluid
poured into the cranium? I am far from affirming this,
but I am tempted to believe it. . . .These peculiarities
and several others. . .are well explained, if we suppose
that there had been for some days before the operation
an effusion of blood under the dura mater (7, p 407;
translated in Ref. 65, pp 578–579).
Broca continued:
To trepan on an apparent fracture at the bottom of the
wound is a sufficiently simple conception. . .; but here
the trepan was performed on a point where there was
no fracture, or probably even no wound, so that the
surgical act was preceded by a diagnosis. . . .We are
. . . authorized to conclude that there was in Peru, before the European epoch, an advanced surgery (7, p 408;
translated in Ref. 65, p 579).
MORE DISCOVERIES
Broca’s observations, insights, and conclusions regarding
the Peruvian skull generated considerable excitement. Among
other things, they led French anthropologists to look for even
older trepanned skulls in their own backyards. To his delight,
hundreds of Neolithic skulls with perforations were soon
discovered on French soil. Many are now estimated to be 4000
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to 5000 years old. The older idea that craniotomies were first
performed by the Greeks at the time of Hippocrates in the
context of humoral theory clearly was no longer tenable (2, 33,
48).
Additional Neolithic discoveries were made later in the
19th century in Spain, Portugal, Germany, Czechoslovakia,
Scotland, Denmark, Sweden, Austria, Poland, Italy, and Russia (34, 41, 52), and in the 20th century, even older skulls were
unearthed (29, 38, 39). Many drilled, scraped, and gouged
skulls also were unearthed in Peru and Bolivia, and to a lesser
extent from other countries in the Americas. Among the most
notable of the New World skulls were two found in Peru, one
displaying five separate openings and another with seven
holes exhibiting healing (44, 53, 56). Especially in some Peruvian burial sites, the operation had a high frequency of occurrence, and overall survival rates were estimated to be in the
range of 50 to 60%. But in contrast to the Old World discoveries, the Inca and pre-Inca skulls are less than 2500 years old.
Elaborate scraping instruments called tumis and some Mochica pottery exhibiting trepanations being performed also
have been uncovered in Peru; these discoveries are without
parallel among the older European finds (30, 71, 72).
The wealth of new discoveries, beginning with those made
in France, forced scientists to reexamine some of the perforated skulls that had been collected years earlier. They were
astonished to find that some probable examples of ancient
trepanned skulls were already sitting on their shelves.
THE DISCOVERY OF FRENCH TREPANNED SKULLS
With characteristic intensity, Broca immersed himself in
analyzing the ancient skulls found in France during the 1870s.
Although he found few skulls himself, he studied the findings made by many others, especially those unearthed by
P. Barthélemy Prunières, his friend and associate.
In the central region of France, Prunières (59) explored and
excavated the megalithic granite dolmens (from the Breton
language, meaning stone tables). In the dolmens of Lozère, he
discovered some skulls with large openings (more than 200
skulls would eventually come from these sites). He also found
rounded, polished, and beveled pieces of cranial bones nearby
and even within some of these skulls. Prunières (60, p 189)
called these fragments rondelles, and both he and Broca (18, 21)
agreed that they were probably worn or carried as charms or
amulets (Fig. 3; see Ref. 52 for a lengthy discussion of these
amulets). In 1873, Prunières presented a notable report on
these rondelles, followed a year later by two important articles on the skulls.
Of particular significance was a skull with three elliptical
cut-out areas along the parietal wall, the central of which
seemed to have been smoothed or polished (Fig. 4). Prunières
(61) pondered the significance of the cut-out regions, particularly the smoothed central one, and concluded that this skull
once had served as a celebratory goblet. Although the idea
may seem outlandish, the word skoal, meaning skull, has long
been used in Scandinavian countries as a toast to one’s health
before drinking.
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Clower and Finger
FIGURE 3. Drawing of an “irregular” amulet from the
Prunières collection with a hole for suspending it from a
cord (from, Broca P: On cranial trepanation and the cranial
amulettes in the Neolithic epoch: International Congress of
Prehistoric Anthropology and Archeology (Budapest Session)
[in French]. Rev Anthropol 5:101–196, 1876 [19], p 200).
Broca praised Prunières for his sharp eyes and mind, and
for the care with which he worked. Nevertheless, in the discussion after Prunières’ presentation and elsewhere, Broca
(11, 12) offered a very different interpretation for the features
characterizing this unique find. To Broca, the central issue
was why one of the cut-out regions was smooth and the two
others were not. He postulated that the openings had been
made by scraping with a sharp stone, such as a piece of flint,
and that the smoothed surface resulted not from the use of the
skull as a cup, but from an extended period of healing. In
short, Broca contended, a large piece of cranial bone had been
removed long before this individual died. Most likely, he
went on, the operation was performed quite early in life,
possibly in some religious or social context. He noted that
priestly ceremonies and initiations involving blood and surgery were well known to anthropologists, and therefore completely plausible among the “savages” of the more distant
past.
THE FOUNDATIONS AND EMERGENCE OF
A THEORY
Broca (13–26) published many articles and gave many talks
on trepanation after making these remarks. He now sought to
do two things. First, he wanted to convince more people that
some of the holes observed in these skulls were not caused by
infectious processes, congenital defects, tumors, gnawing animals, accidents, or battle wounds (19). Second, he wanted to
incorporate all of the facts into a single theory that could
readily account for the reason trepanation was performed in
the Neolithic period. Along these lines, he hoped to demonstrate that the surgery was largely or exclusively performed
during childhood, that it was associated with some sort of
FIGURE 4. Drawing of a trepanned Neolithic skull found in
a dolmen in France by Prunières. Broca concluded that this
skull was trepanned both before and after death (from, Broca
P: On cranial trepanation and the cranial amulettes in the
Neolithic epoch: International Congress of Prehistoric
Anthropology and Archeology (Budapest Session) [in French].
Rev Anthropol 5:101–196, 1876 [19], p 136).
problem, that it could be viewed as curative, and that it and
the rondelles could be tied to primitive religious beliefs.
To quote:
I propose to establish the two following facts. 1) We
practiced in the Neolithic epoch a surgical operation
that consisted of opening the cranium to treat certain
internal diseases. This operation was made almost exclusively, maybe even exclusively on infants (surgical
trepanation). 2) The crania of the individuals who survived this trepanation were considered to enjoy particular properties, of a mystical order, and when these
individuals died, we often cut out from their cranial
walls the ovals, or fragments, which served as amulets
and that we would preferentially take even from the
borders of the healed trepanation opening (19, p 111).
First, Broca established the cultural period in which he was
working. He made his assessment on the basis of the artifacts
found along with the skulls. On his initial trip with Prunières
to the Cavern de l’Homme-Mort (in 1872), he studied the flint
and pottery found at the site (10). From these artifacts, and
with his knowledge of cremation, he concluded that the skeletal fragments spanned almost the entire Neolithic or New
Stone Age era, the era associated with polished stone tools,
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community life, farming, and the domestication of cattle (17,
23; see also the opinion of M. de Baye in Ref. 17, p 285).
He next set out to establish that at least some of the cranial
openings were made by human hands. Broca had wrestled
with this issue since 1873, when he saw a perforated skull
with a hole in the right parietal bone “larger than a 5 franc
piece.” At the time, he was uncertain as whether it resulted
from an “aggressive blow,” which would have disqualified it
as a potential trepanation opening (10, cranium #8, p 18; see
also Ref. 11). He was also suspicious of some skulls with
bilaterally symmetric openings that he subsequently interpreted as congenital malformations (13, 14).
Broca was conservative as he culled out the false-positives.
Despite this, many skulls and cranial fragments still met his
criteria for trepanation during life. The consistency of the
characteristic oval holes provided the most convincing evidence that some of the openings were created intentionally
during life—as he put it, moved by the patient hand of “a
methodical operator, not a furious enemy” (11, p 197).
His proposal also had indirect supporting evidence. No
strong sex or laterality biases seemed to exist among the skull
openings. Moreover, bone was never taken from a place that
would alter or distort the visage. If these were simply battle
wounds, one would expect to find a preponderance of male
skulls with these holes. They would also be more likely to
appear on the left side of the skull (if, that is, they were struck
by a right-handed adversary). Finally, one would expect frontal attacks to land a large number of blows to the facial region,
which was scrupulously avoided. On the basis of these data,
he thought the operations on the living were more likely
performed to address “internal maladies.”
Broca now outlined the difference between trepanation on
the living, which he called “surgical trepanation,” and trepanation on the dead, which was designated “posthumous trepanation.” The two could be distinguished by the shape and
orientation of the openings and whether the edges were
smooth. In some cases, the same specimen exhibited evidence
of both types of openings.
Broca’s “textbook” case was Prunières’ specimen exhibiting
both smooth and rough openings (Fig. 4). When he first saw it,
he noted that the coronal and lamboidal sutures were fused,
indicating that the person had lived to a reasonably mature
age. But dark material obscured the bone over the midline
sagittal suture and had to be cleaned off with an alkaline
solution. When Broca did this, he observed that this suture
was abnormally deviated. The deviation was maximal (12
mm) at the level of the smooth trepanation hole, and not
aligned with either of the other two more rugged openings.
Broca argued strongly that, to sustain this type of marked
deviation, the smooth opening must have been made when
the cranial bones were still developing. As for the other two
rough openings, they were probably made after death.
Although Broca concluded that “surgical trepanation” must
have been performed largely, if not entirely, on infants, there
is no evidence to demonstrate that he came across either
additional specimens with abnormal sutures or the skulls of
trepanned children. Nevertheless, he argued that his conclusion made a certain amount of practical sense. After all, an
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infant’s soft, thin cranium is much easier to penetrate than an
adult’s, and it also heals far more rapidly.
To drive home the first point, he conducted experiments to
demonstrate just how quickly immature crania could be penetrated with “primitive” flint or glass scrapers (22). He found
that he could scrape a hole in the skull from a deceased
2-year-old child in just 4 minutes, whereas it took 50 minutes
to open the thicker skull of an adult (he had to rest his hands
because of fatigue and pain). Craniotomy experiments also
were performed on living dogs, further demonstrating that it
is relatively easy to trepan a skull, avoid damaging the dura
mater, and still leave the subject alive and healthy (25, 26).
Finally, Broca commented on the oval amulet that was
found in the earth inside the same skull. By its thickness and
color, Broca concluded that the amulet was not cut from the
same skull that housed it. Rather, it could have been a charm
carried by or given to the deceased.
Thus, Prunières’ one cranial specimen illustrated all the
points Broca had hoped to make: 1) on the basis of the
deviated sagittal suture line, the trepanation procedure was
performed very early in life, 2) this person survived to old
age, as evidenced by the fusion of the lambdoid and coronal
sutures, 3) the amulet placed inside the skull indicated that
this individual might have had special significance in the
tribe, 4) the goal of posthumous trepanation was the fabrication of these cranial amulets, and 5) the amulets were protective, serving to ward off evil spirits and acting as a source of
good luck.
As Broca put it:
It is therefore natural to think that these individuals
were considered in their tribe as having a character
of sanctity, and it is this idea that represents the spirit of
what I would present. . . .The cranium where the spirit
had inhabited, the opening through which the spirit exited, was marked by a supernatural seal; and the relics
that were provided came to have the property of good
luck, of averting the evil spirits, and in particular of
preserving the individual and their families of terrible
evil from which the trepanned subject had luckily escaped (19, pp 162, 168).
WHY TREPAN? COMPLETING THE THEORY
Broca and Prunières agreed that a therapeutic component
must have been the reason for surgical trepanation. Their
specific ideas, however, were quite different. Prunières contended that cranial fractures or depressed bone pieces would
have caused serious problems, including convulsions and
delirium. He maintained that surgical trepanation originated
to remove the source of these problems and alleviate the
symptoms (20, 61). He envisioned the Neolithic surgeon using
something like observation-based medicine, similar to that
practiced in his own day.
Broca disagreed. “I think for my part that they were inspired, not by observation, but by superstition” (19, p 164).
After all, he explained, the French skulls with surgical trepanation display no evidence of fractures. In addition, the anthropologist in Broca did not think for a moment that Neo-
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Clower and Finger
lithic people had any understanding of the physiological
functions of the brain or, for that matter, anything like a
sophisticated medical surgery.
Still, surgical trepanation must have addressed a practical
problem. It was “a goal with an immediate utility, and because a large number of families decided to operate on their
infants, it could only be to avoid a danger, which could
otherwise be more or less imaginary” (19, p 162). With this in
mind, Broca thought about infantile convulsions.
He knew trepanation had been a common treatment for
spontaneous epilepsy in the past. Even in his own day, trepanation was still being performed in some parts of the world
to exorcise demons thought to cause seizures. It made sense,
therefore, to propose that Stone Age humans probably
thought much like modern aborigines. “That which engenders superstition,” he reasoned, “is the unexplainable diseases” (19, p 166). Indeed, disorders such as uncontrolled
convulsions invite the speculative mind to insert whatever
explanations are supported by its belief system.
In a lengthy article published in Budapest in 1876, Broca
(19) cited Jean Taxil, a physician from Arles who lived in the
early 17th century. Taxil wrote an entire chapter on the connection between epilepsy and demonic possession (69, p 149–
159). He maintained that it was not possible to find a demoniac who was not an epileptic (see also Ref. 70). To Taxil and
others at the time, the unconscious and powerful movements
of epilepsy created the image of an imprisoned spirit. If one
could create an opening, these physicians reasoned, the mischievous spirits would have a means of escape.
Taxil also thought that cranial bone fragments might serve
as protective talismans. He wrote that human cranial bones
possessed special curative powers for epilepsy. Shavings,
powders, and cinders of human cranial bones all were recommended. They could be applied to the coronal suture, taken as
potions and pills, or worn or carried in small pouches. At the
time, flasks labeled Ossa Wormiana graced the shelves of pharmacies, and they were filled with suture bones for treating
epilepsy. To complete the picture, Taxil even commented on
the incidence of epilepsy in the young. In his opinion, it was
more common in children than in adults.
Taxil’s notions regarding epilepsy and children provided
indirect historical support for Broca’s theory that Neolithic
trepanation was probably performed to treat seizure disorders in children. Broca, however, recognized that Taxil was
using the term “epilepsy” too loosely. To Taxil and others of
his day, it was an umbrella term, one that included true
epilepsy and a myriad of other convulsive disorders.
Broca was careful to point out that true epilepsy is relatively
rare before age 10. He therefore concluded that this condition
was not likely to have motivated surgery on children in the
Stone Age. If young children did have epilepsy, trepanning
would not have helped them—and the same can be said
regarding trepanning the crania of adults (12, 19, 24). Similarly, he dismissed seizures caused by meningitis. If a child or
adult had this disease, they would not have survived it,
whether trepanned or not.
This process of elimination left children with “simple” convulsions, like those commonly produced during teething or by a
rapid fever spike. From Broca’s perspective, these children were
ideal candidates for the procedure because such conditions are
benign and typically resolve on their own. Trepanning children
who experienced simple convulsions, who would have gotten
better anyway, would have provided the needed illusion of
success. A belief in the effectiveness of the procedure, even if
erroneous, was essential for it to prosper and spread.
Broca thus combined his medical and historical knowledge
with what he thought he knew about the primitive mind to
interpret his Neolithic data. Although he disagreed with
Prunières on the extent to which Neolithic trepanation was
born of rational medicine or superstition, as well as whether it
was routinely performed on children, both men thought a
specific medical condition resulted in a procedure to cure
individuals of serious problems. From Broca’s perspective,
Neolithic people used trepanation to provide an exit for the
demons that caused childhood convulsions; for Prunières, it
represented a logical way to alleviate the consequences of
depressed fractures.
RECEPTION OF THE THEORY
Broca provided a theory of trepanation that addressed why
trepanation was performed, who was trepanned, when it was
done, and how it fit into the culture of the time. One of the
most interesting aspects of his theory was his proposal that
“surgical trepanation” was passed on through false-positives.
To many of his contemporaries, especially those in anthropology, Broca’s synthetic hypothesis represented a reasonable
first step toward understanding the data.
Broca, however, also had his share of critics. Many thought
that the overall theory had merit but some of its details did
not. One such person was a woman named Buckland (27),
who hoped to stimulate comparable anthropological work on
English soil. She went to Paris and interviewed Broca just
before he died. Although she was impressed by his knowledge, descriptions, and logic, which linked trepanation to
mystical beliefs, she doubted his contention that craniotomies
were routinely performed on children. She knew the procedures would have killed more than a few children, but no
children’s crania had yet been identified by French skull
collectors. When she politely asked Broca about this, he responded that the softer, thinner bones of a child, especially
those specimens with cranial defects, would not have survived the ravages of time. Broca, of course, knew that he
would have been able to make a much stronger case if he
actually had such specimens.
Another critic of Broca’s theory, albeit a few years after
Broca died in 1880, was Victor Horsley, the so-called “father
of neurological surgery” (35, 43). At the time, Horsley (43),
Macewen (45–47), and Godlee (3, 4) were giving neurosurgery
its modern look, basing it on cortical localization, aseptic
procedures, and experimentation. In the mid-1880s, which
was when he was first beginning to operate on patients with
cortical epilepsy, Horsley took the opportunity to examine the
Broca skull collection in Paris. He took photos and walked
away convinced that the openings were regularly placed over
the so-called “motor cortex.” To Horsley (36), this meant that
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the operation must have been performed as a way to treat
posttraumatic epilepsy caused by cranial fractures above the
motor cortex, not internal maladies (see Ref. 32).
In 1929, Lambert Rogers (64), a general surgeon, challenged
Horsley’s assertion regarding locus of the openings. (The
motor cortex was thought to be much larger when Horsley
first presented his theory than in Rogers’ day.) He thought
that, in terms of his general orientation, Broca was probably
closer to the truth than Horsley. He joined with those anthropologists who maintained that demonology, religion, culture,
and the primitive mind had to be brought into the equation.
Rogers made his comments a decade after Sir William
Osler, one of the most respected men of medicine at the turn
of the century, gave his Silliman Lectures at Yale University.
In 1913, Osler favored a modified version of Broca’s view
when he stated:
The operation was done for epilepsy, infantile convulsions, headache, and various cerebral diseases believed to be caused by confined demons, to whom the
hole gave a ready method of escape (55, p 8).
Osler did not, however, contend that the operation was performed exclusively or even largely on children. Many others
adopted a modified pro-Broca orientation that deleted the parts
regarding children. To quote from an article written in 1939:
Making the hole in the skull of such a person may
have been considered a sacred operation because the
hole would permit the escape of the imprisoned spirit,
devil, demon, or other supernatural being. If the individual survived the operation, perhaps he was the object of veneration (74, p 167).
Clearly, Broca’s general theory had become more palatable
once the age requirement was dropped.
where the operation was fairly commonplace. In terms of the
“big picture,” the commonality seems to be that the operation
was performed for any of a number of medical conditions,
especially seizures and headache. There is little evidence to
suggest that trepanning was routinely performed for nonmedical reasons, such as for a rite of passage or for social status.
In closing, it is worth remembering that speculation regarding
how our distant ancestors thought about illness, injury, surgery,
and the brain may persist for a myriad of reasons. One reason is
that they may have some indirect support, and another is that
certain ideas are just plain intriguing. A third reason has to do
with the great names associated with these ideas, and a fourth is
the Zeitgeist these people, their findings, and their ideas helped
create. To these four considerations we can add yet another
possibility, one which was not lost on Broca and the other
surgeons and anthropologists who first examined these mutilated skulls and cranial fragments. It is the realization that our
Neolithic ancestors, like the pre-Columbian Peruvians, actually
may have performed seemingly dangerous and invasive surgery
with unprecedented and surprising success.
POSTSCRIPT
REFERENCES
The modified Broca theory is still alive and well (new
evidence for extensive childhood trepanation still has not
emerged). But also very much alive is the fracture theory first
favored in general form by Prunières and then overembellished by Horsley, who tried to tie trepanation to cranial
fractures above the motor cortex and the likelihood of Jacksonian epilepsy. Today, however, the best evidence for the
fracture theory comes from the warring tribes that inhabited
Peru, not from Neolithic Europe (35, 37, 50, 57, 63, 67, 73).
Many questions remain regarding the origins of trepanation, especially in Neolithic times. For example, why were the
openings not filled in more over time, especially because
reasonably long-term survival would allow progenitor bone
cells to migrate into the margins of the wound to rebuild the
bone inward? Did the surgery emerge in one place and then
spread to different cultures? And, of course, why were
craniotomies first performed?
The study of tribes that still practiced “surgical trepanation”
into the 20th century provides some suggestions (1, 40, 42, 49, 54,
62). Among natives of the South Pacific Islands, it was performed to treat fractures, epilepsy, insanity, and headache, as
well as for preventive reasons. It also was performed for headache with or without cranial fractures in Kenya and Tanganyika,
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ACKNOWLEDGMENTS
We thank Drs. Shawn Bengston and Buddy Capawano for
insightful comments on our current conceptions of bone repair and regrowth after trepanation.
Received, October 26, 2000.
Accepted, January 22, 2001.
Reprint requests: William T. Clower, Ph.D., Department of Neurobiology, University of Pittsburgh, W1640 Biomedical Science Tower,
Pittsburgh, PA 15261. Email: [email protected]
Neurosurgery, Vol. 49, No. 6, December 2001
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Clower and Finger
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COMMENTS
Paul Broca is a name well known to all neurosurgeons;
most of us learned about “Broca’s area” very early on. However, most are not aware of his multifaceted contributions to
the medical and scientific literature. Not only a skilled neurologist and surgeon, he also contributed considerable research to the anthropology literature. I have had in my own
library for some 20 years his five-volume work on Mémoires
D’Anthropologie (1871–1888), which includes a majority of Broca’s writings. After reading this article I pulled those volumes
off the shelf and went through them for several hours, astonished on how wide and varied his research efforts were. As
the authors so clearly point out, Broca always went to the
source for his data and his work on trepanation. His attempts
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to explain why it was done were accomplished by looking
and studying the recently exhumed skulls. As a result of these
studies, Broca branched out even further and developed some
of the earliest studies on craniometrics and cranioscopic instruments. As a result of these efforts, he provided some of the
earliest studies developed on cerebral localization, cerebral
anatomy, and stereotaxy. He was a truly gifted man and one
who comes to life in this article on early trepanation.
James T. Goodrich
Bronx, New York
This fascinating historical article combines both an excellent history of trepanation of the cranium with the contributions of Paul Broca in the area of anthropology and medical
history. These aspects of his career and his intellect are certainly less well known than his description of the Neuroanatomy of Speech. It is exciting to see yet another dimension of this
outstanding pioneer in neurology.
Edward R. Laws, Jr.
Charlottesville, Virginia
This is a nice article on the contribution of Paul Broca to
interpretation of Neolithic and pre-Columbian skull openings.
It is very interesting to discover this aspect of Paul Broca’s
talents, which is not well known. Reading this article, I discovered that Paul Broca founded la Société d’Anthropologie
and was a real expert in this field. It is amazing to note that
the interest of a neurologist toward ancient skull openings
occurred just before the first neurosurgical trepanations. This
gives the impression that current neurosurgeons are at the
end of a long line of people who have questioned themselves
regarding the cranium and the brain.
By the Seashore, Martinique, by Paul Gauguin, 1887. Courtesy, Ny Carlsberg
Glyptotek, Copenhagen.
Bernard George
Paris, France
The White Horse, by Paul Gauguin, 1898. Courtesy, Musée d’Orsay, Paris.