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When archaeologists uncovered the burial site of two brothers who lived during the 15th century BC in Israel, they were surprised to discover that one of them had brain surgery shortly before he died.
The finding marks the earliest example of trephination, a type of cranial surgery, found in the ancient Near East.
Trephination, also known as trepanation, involves cutting a hole in the skull — and there are examples of the medical procedure dating back thousands of years.
The remains of the brothers, who lived during the Bronze Age between 1550 BC and 1450 BC, were found during an excavation of a tomb in the ancient city of Tel Megiddo.
The older brother, estimated to be between 20 and 40 years old, had angular notched trephination. His scalp was cut and then a sharp, beveled-edge instrument was used to make four intersecting lines on the frontal bone of the skull that made a 30-millimeter (1.2-inch) square-shaped hole.
A study detailing the findings published Wednesday in the journal PLOS ONE.
“We have evidence that trephination has been this universal, widespread type of surgery for thousands of years,” said study author Rachel Kalisher in a statement. She is a doctoral candidate at Brown University’s Joukowsky Institute for Archaeology and the Ancient World in Providence, Rhode Island.
“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.”
Oddly enough, the bone pieces removed from the skull were included in the grave — but it wasn’t the only unusual discovery made about the brothers as researchers studied their bones.
The city of Tel Megiddo was part of the Via Maris 4,000 years ago. This crucial land route connected Egypt, Syria, Mesopotamia and Anatolia, according to study coauthor Israel Finkelstein, director of the University of Haifa’s School of Archaeology and Maritime Cultures.
Tel Megiddo controlled part of this trade route, making it a wealthy and cosmopolitan city full of palaces, temples and fortifications.
“It’s hard to overstate Megiddo’s cultural and economic importance in the late Bronze Age,” Finkelstein said.
The tomb was found in an area adjacent to a late Bronze Age palace in Tel Megiddo, leading researchers to believe the two men were either high-ranking elite members of society or perhaps even royals. DNA testing revealed the two were related and likely brothers.
The men were buried with Cypriot pottery, food and other valuable possessions similar to those found in other local high-status tombs.
And in life, both brothers were severely ill. Their skeletons are marked by signs of disease, including extensive lesions suggesting chronic, debilitating conditions. But both were able to survive for many years despite their ailments.
“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.”
The younger brother died in his teens or early 20s, likely succumbing to an infectious disease like tuberculosis or leprosy.
The older brother had an extra molar, so he might have experienced a genetic condition like Cleidocranial dysplasia that impacts teeth and bones, according to the researchers.
The researchers can’t tell why the older brother required trephination. The practice was used to relieve pressure in the skull or treat symptoms of epilepsy and sinusitis. Ancient Mesopotamian texts also suggest that the operation might have been “curative to supernatural or otherworldly conditions,” Kalisher said.
“The skeletal evidence tells us that this individual endured illness for a prolonged time, which, assuming it was left untreated, likely progressed,” Kalisher said. “This elite individual was privileged enough to endure infection for a long time, and also had a high-level cranial operation, which leads us to posit that the trephination was done in direct response to a declining state.”
Regardless of why the older brother had the surgery, he died within days or hours afterward, based on the lack of bone healing researchers noted during their analysis.
Many questions remain after studying the bones of the two brothers, Kalisher said.
While the skeletal evidence suggests the brothers had leprosy, more research is needed to make a clear determination. If the analysis reveals bacterial DNA that aligns with leprosy, the brothers may have experienced one of the earliest documented cases of the disease.
“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.
Kalisher is also puzzled as to why the skull pieces removed from the older brother were included in his burial. Only two other examples of this have been found in the past, in England and Peru.
“In our study, we consider if the excised bone pieces were reinserted into the head because the practitioner thought it would facilitate healing,” Kalisher said. “But, I also come back to the medicinal/magical dichotomy we impose on the past. It is possible that the excised bones also held some other, non-medical purpose, leading to its inclusion with the individual. It is simply unknowable to us. So for now, this mystery remains unsolved.”
There are larger questions about ancient trephination researchers want to answer, like why some were made using analog drills to create round holes, while others are square or triangular.
But in regards to the brothers, it’s clear that the two men were not considered outcasts or “othered” because of their health issues. People close to the brothers cared for them and made sure they were laid to rest with proper burial traditions, the researchers said.