Evidence of disease and injuries among ancient humans and other animals is incomplete for epidemiological purposes, but more than sufficient to establish the general notion of their abundance. Therefore, we would like to be able to determine when uniquely human responses to the suffering caused by disease and injury began. For example, a CT scan of a 36,000-year-old Neanderthal skull which had obviously suffered a blow with a sharp stone implement revealed a degree of healing around the wound. To have survived the injury for at least several months would have required care and perhaps wound treatment by other members of the group. Such cases lead to the question: at what stage did human beings begin to administer care that would be recognized as a form of medicine or surgery?
Clues to the existence of paleomedicine must be evaluated even more cautiously than evidence of disease. For example, the ''negative imprints" that appear to be tracings of mutilated hands found in Paleolithic cave paintings may record deliberate amputations, loss of fingers to frostbite, magical symbols of unknown significance, or even some kind of game. Early humans may have learned to splint fractured arms or legs to alleviate the pain caused by the movement of injured limbs, but there is little evidence that they learned to reduce fractures. Moreover, well-healed fractures can be found among wild apes. Thus, the discovery of healed fractures, splints, and crutches, does not necessarily prove the existence of prehistoric bonesetters.
Ancient bones and skulls may try to tell us many things, but the enemies of preservation often mute their testimony and generate false clues leading to pseudodiagnoses. Except for violent deaths in which a weapon remains in the body, ancient bones rarely disclose the cause of death. A hole in the skull, for example, might have been caused by a weapon, the bite of a large carnivore, postmortem damage caused by burrowing beetles, a ritual performed after death, or even a surgical operation known as trepanation. A discussion of a Peruvian trepanned skull at the 1867 meeting of the Anthropological Society of Paris stimulated the search for more examples of prehistoric surgery. Eventually, trepanned skulls were discovered at Neolithic sites in Peru, Europe, Russia, and India. The origin and dissemination of this prehistoric operation remain controversial, but the procedure certainly appeared in both the Americas and the Old World before the voyages of Columbus. Whether the operation developed in one culture and spread to others or evolved independently in different regions is still the subject of heated debate. It is impossible to determine just how frequently such operations were performed, but some scholars believe that the operation was performed more frequently during the Neolithic period than in later prehistoric times.
Although trepanation is sometimes mistakenly referred to as ''prehistoric brain surgery,'' a successful trepanation involves the removal of a disk of bone from the cranium, without damage to the brain itself. When scientists first encountered such skulls, they assumed that the operation must have been performed after death for magical purposes. However, anthropologists have discovered that contemporary tribal healers perform trepanations for both magical and practical reasons. Prehistoric surgeons may also have had various reasons for carrying out this difficult and dangerous operation. The operation might have been an attempt to relieve headaches, epilepsy, or other disorders. In some cases, the operation might have been a rational treatment for traumatic injuries of the skull. Perhaps it was also performed as a desperate measure for intractable conditions, rather like lobotomy, or as a form of shock therapy or punishment. Despite the lack of reliable anesthesia or antiseptic technique, evidence of well-healed trepanations indicates that many patients survived, and some even underwent additional trephinations.
Three major forms of trepanation were used by prehistoric surgeons. One technique involved creating a curved groove around the selected area by scraping away bone with a sharp stone or metal instrument. When the groove became deep enough, a more-or-less circular disk, called a button or roundel, could be removed from the skull. Boring a series of small holes in a roughly circular pattern and then cutting out the button of bone with a sharp flint or obsidian knife was the method most commonly used in Peru. The patient could wear the disk as an amulet to ward off further misfortunes. In some regions, surgeons performed partial or perhaps symbolic trephinations. That is, the potential disk was outlined with a shallow crater, but left in place. Some skulls bear thin canoe-shaped cuts that form a rectangular shape, but square or rectangular excisions may have been reserved for postmortem rituals.
Another prehistoric operation that left its mark on the skull is called ''sincipital mutilation.'' In this operation, the mark is the scarring caused by cauterization (burning). Neolithic skulls with this peculiar lesion have been found in Europe, Peru, and India. In preparation for the application of the cauterizing agent, the surgeon made a T- or L-shaped cut in the scalp. Cauterization was accomplished by applying boiling oil, or ropes of plant fibers soaked in boiling oil, to the exposed bone. In either case, permanent damage was done to the thick fibrous membrane covering the bone.
Most of the prehistoric victims of this operation were female, which might mean that the procedure had a ritualistic or punitive function rather than therapeutic purpose. During the Middle Ages, this operation was prescribed to exorcise demons or relieve melancholy. Doubtless, the operation would dispel the apathy of even the most melancholic patient, or would give the hypochondriac a real focus for further complaints.
In looking at the decorative motifs for which the human frame serves as substrate, objectivity is impossible. What is generally thought of as cosmetic surgery in our society—face-lifts, nose jobs, and liposuction— would be considered mutilations in societies that treasured double chins, majestic noses, thunder thighs, and love handles. While most of the cosmetic surgery of prehistoric times has disappeared along with the soft parts of the body, some decorative processes affected the bones and teeth. Such customs include deforming, or molding the skulls of infants, and decorating or selectively removing teeth. Unusually shaped heads might also reflect traditional methods of caring for or transporting infants. For example, cradle-board pressure during infancy can alter the contours of the skull. Considerable evidence remains to suggest that tattooing and circumcision were not uncommon in ancient times. Direct evidence can only be found in well-preserved mummies, but studies of similar customs in contemporary traditional societies can expand our understanding of the myriad possibilities for prehistoric cosmetic surgery.
Since the 1990s, women's health reformers have been attempting to end the traditional practice of female circumcision, also known as female genital mutilation, which is still practiced in more than 25 countries in Africa and the Middle East. Generally, the painful ritual is performed with crude instruments, without anesthesia or antiseptics. Although the ritual is prohibited by many African nations, it is often performed secretly. The World Health Organization estimates that 130 million girls and women have undergone some form of cutting of the clitoris. In the most extreme form of female circumcision, still practiced widely in Somalia and Ethiopia, the outer labia are sliced off and the remaining tissue is sewn shut. Female circumcision is seen as a way of ensuring chastity and was often practiced as a coming of age ritual and a prerequisite to marriage.
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