Square hole in an ancient skull: Middle East’s earliest brain surgery found in Israel

When archaeologists excavated the remains of two brothers from more than 3,500 years ago in Megiddo, northern Israel, they weren’t expecting one of the brothers to have a square-shaped hole in his skull.

The precisely cut hole is the result of one of the earliest known brain surgeries performed in the Middle East, also known as a “trephination,” in which a piece of the skull is removed.

Trephination, sometimes called trepanation, is one of the oldest known surgeries, and civilizations around the world have been practicing the procedure for thousands of years. In France, one site dating back 6,500 years was found to hold 120 skeletons, 40 of which had undergone trephination. 

Around a dozen ancient skulls with trephination holes have been discovered across the Middle East, said Rachel Kalisher, a PhD student at Brown University’s Joukowsky Institute for Archaeology and the Ancient World and the lead author of the study, which was published in the PLOS ONE journal this week.

Doctors today still use a variation on this surgery, called a craniotomy, to relieve swelling in the brain after a traumatic brain injury.

The two brothers from Megiddo were likely from a wealthy family and lived between 1550 BC and 1450 BC in the late Bronze I Age. They were buried underneath a house in one of the richest parts of the city. One of the brothers, who had an intact skull, died sometime during his late teens or early 20s. He died a few years before his brother, and was exhumed and reburied together with him when the second brother died.

The other brother, who had the trephination procedure, was between 21 and 46 years old when he died. There was no evidence of healing from around the trephination site, so he likely died immediately or soon after the operation occurred. The healing would have started a few weeks after the operation.

What has fascinated archaeologists involved in the study is that both of the brothers show evidence of being ill for an extended period of time. The bones recovered from both brothers were exceptionally porous and marked with lesions, leading archaeologists to hypothesize they suffered from a systemic illness such as leprosy, tuberculosis, or even a genetic disease.

Certain skeletal indications, including the presence of an extra molar and atypical face structure in the brother with the trephination, point to developmental disruptions that could point to a genetic disorder such as Cleidocranial dysplasia or Down’s syndrome. Both brothers showed evidence of being severely anemic, which can also stunt growth.

“These brothers were elite, they were part of the most wealthy class living at Megiddo, which was itself quite a wealthy city,” said Kalisher. “They weren’t part of the average population, and that’s what we believe allowed them to survive as long as they did with the illness that they had.”

“The location where they were found is very close to the palace of Megiddo,” explained Prof. Israel Finkelstein, the director of the School of Archaeology and Maritime Cultures at the University of Haifa and one of the co-authors of the paper. “You can see the elite manifestations from the architecture and other aspects.” The lower classes lived in the southeastern part of Megiddo, he said.

The brothers were buried on top of an elaborate stone tomb filled with gold, bronze, silver, and bone ornaments, which made headlines when it was discovered in 2016 due to its extravagant nature. Archaeologists discovered the remains of three people in the tomb bedecked with jewelry that predate the brothers by roughly 50 to 70 years.

Both the brothers and people buried in the tomb below them suffered from similar lesions on their bones, which could mean that they may have suffered from the same disease.

Researchers are still working to determine whether the brothers are genetically related to the people buried in the tomb below them, Kalisher said. Experts in Germany are researching whether the bone lesions are related to leprosy, which would make it one of the earliest cases of leprosy in the Middle East.

Revelation at Megiddo

Meggido is known by Christians as Armageddon (a corruption of the Hebrew “Har Megiddo,” or Mount Megiddo). The site in northern Israel was inhabited continuously from around 7,000 BCE to 500 BCE. Christians believe that Megiddo will be the site of the Final Battle for the end of the world, as mentioned in the Book of Revelations.

Megiddo appears in “all the great archives of the Middle East,” said Finkelstein. It’s mentioned in the Hebrew Bible, the New Testament, as well Assyrian, Egyptian, and Hittite documents. The city was a prosperous and important trade hub along the Via Maris, a crucial land route that connected Egypt, Syria, Mesopotamia and Anatolia.

“When a site is mentioned in so many historical records, you can make a link between the site and historical processes,” said Finkelstein in a video from the 2016 dig season. Finkelstein, one of Israel’s preeminent archaeologists who has published more than 400 articles and a dozen books, has been digging at Tel Megiddo since 1994.

Kalisher joined the dig as part of her dissertation research into family structures at Megiddo, which includes understanding the makeup of multigenerational households. During part of Megiddo’s history, including the time when these brothers lived, people were buried beneath their houses.

“The context at Megiddo is really different because we’re not talking about a cemetery with all types of different people together,” she said. “People are directly tied to their houses, which means they’re directly tied to their socioeconomic status.”

This gives her a window into the types of people that lived and died in each household. Kalisher is working with the Harvard Medical School and Hebrew University to map the DNA of bone fragments and genetic relationships between the people buried beneath each house.

The practice of burying people beneath their homes was abandoned by 1400 BCE after the area became a province of the Egyptian empire, Finkelstein explained. Most of the human remains that archaeologists excavate at Megiddo are located in cemeteries and burial sites outside of the ancient city.

Did you take part of my skull?

Kalisher helped with the excavation of the remains of the two brothers in the summer of 2016, but it wasn’t until 2017 when she was back in Israel and cleaning the bones that she noticed there was a large hole carefully cut out of one of the skulls.

“My first thought was that someone came in and took a bone sample for DNA,” she said. “I was sitting in the room with the area supervisor at the time, and when I saw [the hole] it took my brain a few seconds to understand… I was just really confused.”

While she’s not looking to make trephination the focus of her research, Kalisher said the subject has been a fascinating side project to her dissertation about family structures. The trephination at Megiddo is both the earliest example of brain surgery in the Middle East and the only example where archaeologists have also found pieces of the skull that were removed. Finding the pieces that were removed helps archaeologists understand how the procedure was completed.

By combing through bone fragments that were excavated with the body, Kalisher found two of the pieces of the skull that was removed. Whoever performed the procedure likely removed the pieces of the skull in around five separate wedges, Kalisher believes.

The fact that the brothers were able to survive for years with a systemic illness means they were not ostracized and someone was likely caring for them — either a family member or servants, Kalisher said. She hasn’t seen similar examples of illness in skeletons excavated in the poorer parts of the city, likely because people from lower classes who got sick did not live long enough for their bones to bear marks of the disease over time. “These individuals are probably coming into contact with the same illness, but just dying,” she said.

Kalisher acknowledged that while there’s much archaeologists will never know, the stories revealed by the bones provide some important information, including that ancient societies took care of their weaker members — at least if they were part of powerful families.

“In antiquity, there was a lot more tolerance and a lot more care than people might think,” Kalisher told Brown University. “We have evidence literally from the time of Neanderthals that people have provided care for one another, even in challenging circumstances. I’m not trying to say it was all kumbaya — there were sex- and class-based divisions. But in the past, people were still people.”

The brothers’ survival for many years with their illness does suggest that even thousands of years ago, rich people got better healthcare and lived longer than poor people. “Their socioeconomic status allowed them to survive much longer,” Kalisher said.

Although the brother did not survive the procedure, it was carried out by someone who made clean cuts with a deft hand. A wealthy family would likely retain “the most experienced partitioner they could find,” she added. “The cuts themselves show precision and experience, and I would assume it’s not going to be [the surgeon’s] first time doing it.”

The whole trephination procedure is still a mystery. Kalisher doesn’t know why it was performed, if it was supposed to heal the brother, or done as a desperate last resort. It could also be a religious, magical, or spiritual practice. “We’re calling it a medical treatment, but it’s speculation,” she said.