What Is The Correct Construction Of A Term That Means Surgical Repair Of The Skull?

Abstract

Archaeological inquiry in the Dolmen of El Pendón (Reinoso, Burgos, Spain) has brought to low-cal the complex biography of a megalithic monument used throughout the 4th millennium cal. BC. The ossuary of this burial holds the bones of almost a hundred individuals who suffered from diverse pathologies and injuries. This study presents the discovery of a skull with two bilateral perforations on both mastoid bones. These evidences point to a mastoidectomy, a surgical procedure perchance performed to relieve the pain this prehistoric individual may accept suffered equally a event of otitis media and mastoiditis. The hypothesis of surgical intervention is likewise supported past the presence of cut marks at the anterior border of the trepanation made in the left ear. Furthermore, the results of this paper demonstrate the survival of the individual to both interventions. Given the chronology of this dolmen, this find would be the earliest surgical ear intervention in the history of flesh.

Introduction

The archaeological excavation carried out since 2022 at the Dolmen of El Pendón (Fig. 1) have uncovered the circuitous biography of a megalith that, since its construction, went through several phases of use (Fig. ii, Supplementary Text S1 and Text S2) until its permanent abandonment as a tomb and its transformation into a commemorative monument—with completely unlike functions to the i it originally had (Supplementary Text S1, Text S2 and Video).

14C dates identify its construction and starting time funerary uses to the start of the 4th millennium cal. BC (Fig. 2: Phase Pendón I, Supplementary Table S1). Its builders conceived a megalithic architecture widespread in the Iberian Peninsula that corresponds to a passage grave typology (Supplementary Fig. S2). Information technology is composed of a funerary enclosure, a chamber formed past large upright orthostats, and an entrance passage of approximately eight metres of length. Around this internal construction, there is a mound made of stone and soil, which probably surpassed 25 m in diameter. Still, the monument present look is completely different from the original considering of an intentional and perfectly planned integral transformation process (Supplementary Text S1).

During the terminal quarter of the 4th millennium cal. BC, continuing with the usual behavioural pattern of megalithic tombs in the region¹, the bodies were diachronically placed inside the megalithic chamber—almost ane hundred in this 2d phase of use. This burying space was transformed into a commonage ossuary where simply a few anatomical connections were preserved over time, due to the evolution of ritual practices, such every bit the disarticulation and repositioning of the skeletal remains, which sought to intermission the individuality of the corpses buried there (Fig. 2: Phase Pendón 2 and Supplementary Text S1). In this phase, two dissimilar burial levels have been documented, characterised by the presence of repositioning practices every bit well as regrouping and pick of specific skeletal pieces (Supplementary Fig. S3 and S5). The exceptional detect of the intentional assemblages of skulls and pelvises—documented in up to 15 unlike groupings—must exist emphasised (Supplementary Text S1).

At the end of fourth millennium cal. BC (Fig. two: Phase Pendón III and Supplementary Text S1), the monument was closured through a complex ritual that transformed its architecture. Only six of the big limestone orthostats that composed the original burial chamber are withal standing. All the built structures of the passage take disappeared and the mound has been reduced to a pile of stones of a few metres in diameter. The site was no longer used as a tomb, even though it kept its symbolic value every bit a territorial reference, ceremonial centre, and a place of community congregation (Supplementary Text S1).

The ossuary features a collective and diachronic burial (Supplementary Fig. S1) in which man remains were repositioned in the same space where decomposition took identify. Therefore, strictly speaking, it is a principal burying eolith, later on altered past an anthropogenic intentional action. This is demonstrated by the presence of some anatomical connections, such as the spine, the tarsal and carpal bones and the limbs, also as the usual documentation of labile skeletal parts—small-scale ear bones, hyoids or ossified thyroid cartilages, which would about certainly be lost during a hypothetical relocation of corpses (Supplementary Fig. S4).

This newspaper presents a comprehensive assay of a skull from i of the burying levels in the second phase of this monument using an osteoarchaeological, chronostratigraphic, palaeopathological and histological approach. Its discovery has great scientific interest, since there are two perforations on both mastoid processes, most likely associated with a double mastoidectomy, with articulate signs of survival (Supplementary Figs. S10 and S11).

Results

Description of the skull and its pathologies

This paper focuses on the finding of a skull from the Dolmen of El Pendón in July 2022. Its chronostratigraphic context corresponds to the second phase of use of this megalith. The skull was lying on its right side with the face pointing southward, towards the entrance of the burying chamber (Fig. 3). It retained a complete neurocranium, including frontal, both parietal and temporal basic, and the occipital bone without the basilar section. Of the facial basic, the nasal os, the zygomatics, and the lower region of the maxillary os (without teeth nor alveolar cavities except for the first left molar) remained. Furthermore, root impressions were visible in the cortical surface of the frontal and parietal regions (Supplementary Fig. S6 and Video).

Analysis indicates that it is a mesocephalic skull that belonged to a adult female, who probably died at an advanced age. While the obliteration of the cranial sutures is consequent with a middle-aged individual—35–50 years old, the loss of all the maxillary teeth long earlier death—given the alveolar reabsorption of the teeth and the loss of bone density—suggests an age range closer to elderly. This argument is based on the general proficient oral health of the community whose remains are deposited in the dolmen. Therefore, the loss of all teeth in life points to elderly individuals. The presence of elder individuals is confirmed by the documentation of fully ossified thyroid cartilages. This particular ossification is estimated to end at 65 years of age².

The external auditory canal is enlarged on both sides in a postero-superior and junior direction, connecting the mastoid cells and the tympanic cavity with the outside (Fig. 4). The edges are smooth and circular; on the right side, its diameter is 12 mm, while on the left side it is nine mm. No fracture zones, fissures, or bone calluses are visible on either side. The inner surface of both cavities shows typical speculated bone formations, which reverberate mutual bone reabsorption changes in inflammatory mastoid processes^3,iv. However, both cavities reflect no of import lack of mastoid pneumatisation, something common in individuals suffering from middle ear inflammatory pathologies in childhood⁵, suggesting a late onset of an underlying disease. It is important to emphasise that the bony wall separating the ear canal from the mastoid—scutum—has been preserved on both cavities (Fig. 4).

Signs of bone regeneration and remodelling are axiomatic. Traces of mastoiditis or mastoid abscesses found in palaeopathological analyses of ancient skulls show major osteolytic defects without repair signs, which, in the absence of medication or acceptable surgical drainage, oft have a tragic end⁶. Nevertheless, the surface histological assay show that signs of bone remodelling are manifest in the performed trepanation of this skull, thus evincing the survival of the individual. Remodelling field are binary features presenting forming or resorbing surfaces⁷. During adulthood this procedure is a "secondary remodelling", in which bone resorption and bone deposition occur at the same site replacing erstwhile and damaged bone in highly regulated cycle⁸. In the dry basic we can detect four distinctive surfaces: resorptive, characterized past osteoclasts and resorption lacunae; depository, characterized by osteoblasts; resting—or neutral, characterized by cells performing no bone activity and remodelling reversals, which are interfaces between fields of resorption and deposition⁹.

Our results shows that bone resorption and resting are the merely action states present over the expanse of intervention in the left ear (Supplementary Fig. S10). The resorptive surface is identified for the presence of Howship's lacunae and could be related to the replacement of damaged bone due to infection. Indeed, we do not notice whatsoever bespeak of pathological bone. The most plausible interpretation of these results is that subsequently the intervention this adult female survived, since the resorption is ongoing, simply the pathological bone has been eliminated. In contrast, in the right ear conspicuously visible resorption areas equally well as a bone deposition area provides evidence that remodelling reversal is ongoing (Supplementary Fig. S11). The resorption phase is approximately two weeks in elapsing. After this stage, the reversal one lasts approximately four to five weeks^x. Thus, the presence of a well-defined reversal line in this right ear means that this adult female survived to the intervention.

Differential diagnosis

The hypothesis proposed in this enquiry is that the individual to whom the skull belonged was probably surgically intervened on both ears, with an undetermined period between both interventions. Based on the differences in bone remodelling betwixt the two temporals, it appears that the process was first conducted on the right ear, due to an ear pathology sufficiently alarming to require an intervention, which this prehistoric woman survived. Subsequently, the left ear would have been intervened; even so, it is not possible to decide whether both interventions were performed back-to-back or several months, or fifty-fifty years had passed. It is thus the earliest documented evidence of a surgery on both temporal bones, and, therefore, about likely, the first known radical mastoidectomy in the history of humankind.

A well documented affliction in palaeopathological studies of ancient skulls are cholesteatomas¹¹. A cholesteatoma is a subversive injury of the temporal bone, which tends to aggrandize and progressively erode the adjacent structures, causing hearing loss, vertigo and intracranial complications; it is treated surgically¹². A rare type of cholesteatoma is the built cholesteatoma, characterised by the presence of epithelial embryological remains in the middle ear, generally associated with well-pneumatised mastoids in young patients, where the destruction of the tympanic crenel predominates^v. Acquired cholesteatomas are more than frequent; they are associated with sclerotic or diploic mastoids, in which epithelial remains are introduced in the center ear through tympanic perforation or invagination. This tends to occur in postero-superior quadrants, starting with the initial erosion of the scutum or the bony wall of the atticus^xiii. It is likewise known as the external auditory culvert cholesteatoma, which is usually unilateral and characterised by an epithelial accumulation that may evolve into extensive temporal bone erosion in patients with a history of injuries or surgery. Its spontaneous appearance is quite rare¹⁴. Lastly, malignant external otitis, histiocytosis, or tumours tin produce extensive bone destruction. Notwithstanding, they are rarely bilateral and often cause the premature death of the individual.

Hither, acquired cholesteatoma of the eye ear must be ruled out, since the scutum is present on both temporal bones. Other diseases, such as malignant external otitis or temporal os tumours are as well discarded a priori, since they are rarely bilateral and by and large outcome in an untimely death, for which the documented bone remodelling previously described on both temporals would be incommunicable. Finally, a bilateral congenital cholesteatoma or one from the external auditory canal—both rare—tin can hardly be the cause of the mastoid condition found in the tympanic crenel that led to the performance of this pioneering surgery.

Surgical instruments

Together with the above-mentioned macroscopically visible evidences in the temporal bones, seven cut marks at the inductive edge of the surgical trepanation fabricated in the left ear have been identified. They are parallel, brusk (two–4 mm) and linear with a clear triangular or "V" department. Notwithstanding, these marks are not visible on the correct side, probably due to the bone remodelling process that was ongoing (Fig. 5).

This finding is further potent evidence that this is the primeval mastoidectomy documented to date. Given the pre-metallurgical chronology of the site, this surgical intervention had to exist performed with a lithic instrument. Several pieces were deposited as grave goods or ritual offerings next to the dead. The most important were tools made of flint of different provenance, of which several typologies have been identified: elementary and retouched blades of different sizes, geometric microliths and arrowheads of unlike shapes (Fig. 6).

A blind traceological analysis was conducted on a set of lithic tools from the dolmen with the purpose of identifying the possible technique or tool that allowed performing this particular surgery. One piece showed signs of having been used for butchering and probably came into contact with os material: a flint blade, 31 mm in length and seven mm wide at its distal cease, with simple straight retouches that formed slight indentations (Fig. half-dozen). The traceological analysis has revealed that afterward being extracted from the core the blade was subjected to heating that did non exceed 300/350 °C, given the lack of fire-cracks and other blazon of heat treatment marks (Supplementary Fig. S9 and Text S3).

Discussion

The findings advise that the intervention could be acquired by an acute otitis media, further complicated with mastoiditis, and acquired a sub-periosteal abscess with rupture of the mastoid cortex. The ensuing infection affects the mucous membrane of the tympanic crenel and can spread to the pneumatised spaces of the mastoid process. Its hive-like construction provides an platonic environs for the proliferation of pyogenic bacteria¹⁵. These infections are oftentimes caused by the proliferation of bacteria or other pathogens in the middle ear. Mastoiditis per se is a consequence of otitis media and it is clinically diagnosed when the infection spreads from the mucous membranes to the underlying os³. If left untreated, the infections could effect in hearing loss and even meningitis. In a prehistoric context, this pathology would exist detectable since it presents itself as a fluctuating and painful retroauricular mass. The first otological surgeon executed a systematic cleaning and drainage process by removing the afflicted bone and connecting the mastoid bone with the tympanic cavity. This procedure was facilitated by the prior existence of a Gellé fistula—destruction of the posterior wall of the external auditory culvert. All these facts paved the style for the pioneering mastoidectomy known in the history of humankind.

Middle ear infections are common modern human diseases. They were already known in ancient Arab republic of egypt and Mesopotamia, equally evidenced by some papyri^sixteen. The palaeopathological analyses had already identified these illnesses in the Palaeolithic period^17,18, although there is greater bear witness from the Neolithic menstruation onwards^{4,19,twenty,21,22,23}.

Mastoidectomy was a relatively common surgical process for the handling of astute ear infections in the pre-antibiotic era. The outset descriptions of mastoid surgery, dated to the seventeenth century, were implemented past Johannes Riolanus the Younger²⁴. The earliest documented osteological evidence of mastoidectomy comes from the island of Thassos during the Proto-Byzantine menstruation²⁵. In addition, an eleventh century skull with mastoidectomy was found in Croatia²⁶. Another two possible cases were identified in an Italian ossuary from the belatedly eighteenth century and early nineteenth century²⁷. Finally, a 19th or twentieth century skull recovered from the Assistens Kirkegård Cemetery (Copenhagen) also shows evidence of an ear surgery²⁸.

Surgery in other areas of the skull is one of the earliest surgical procedures. Cranial trepanations have been documented with Mesolithic chronologies in Ukraine, Portugal, and Northern Africa^29,30, even though most prehistoric cases date back to the Late Neolithic and Bronze Age. This intervention is well documented in Europe, and the Iberian Peninsula stands out with 184 identified cases of trepanation in 135 skulls³¹. The example of the Dolmen of Las Arnillas is exceptional (Sedano, Burgos). Located only xl kms in a straight line from the Dolmen of El Pendón, up to six trepanations were carried out in five skulls, all of them with clear signs of survival³². Although there are no documented lesions or pathological evidences that could justify such surgical procedures, an increasing number of researchers informs of the presence of otological pathologies in individuals with trepanations, by and large mastoiditis^{33,34,35,36,37,38}.

This is a plausible interpretative hypothesis to ostend that the evidence presented in this paper corresponds to the earliest documented otological surgery in History. In this instance, the prehistoric surgeon located the focus of the problem—probably because the infection was evident to the naked center—and successfully intervened, as proven by the bone regeneration observed in both mastoid bones (Fig. four and Supplementary Figs. 10 and 11).

The intervention itself would have consisted of a progressive circular and abrasive drilling causing unbearable pain nether normal weather condition. Thus, in order to carry out this surgery, the affected individual had to be either strongly restrained by other community members or previously administered some psychotropic substance with the purpose of relieving the pain or losing consciousness. There are references to the utilise of plants with natural analgesic and antibiotic backdrop in prehistoric times³⁹, as well every bit psychoactive drugs like opium²⁴ or hyoscyamine⁴⁰, as it is the example in ii skeletons from Can Tintorer⁴¹ (Gavà, Barcelona).

Despite the to a higher place-mentioned evidences of cut marks (Fig. 5), it is difficult to conclude the blazon of tool used to remove the bone tissue, nigh likely a sharp instrument with a circular movement. The researchers cannot decisively state that the thermally altered flintstone blade presented higher up, whose utilise-wear traces are compatible with the ones used on basic, was the tool employed in this intervention (Supplementary Fig. S9). Nonetheless, the results of the traceological analysis suggest that it could have served as a cautery, thus becoming a surgical tool used in a healing procedure for organic tissues through the application of high estrus (Supplementary Text S3). Several studies demonstrate the use of stone instruments heated with fire as tools to cauterise wounds and to perform trepanations, in primitive villages of the Canary Islands⁴² and among the megalithic populations of the region between the Oise and Sena rivers to the north of Paris⁴³. L. Manouvrier, in a bold and fifty-fifty romantic way, based on the many trepanations documented in megaliths in this French region, surmised the beingness of remarkable chirurgiens who travelled effectually offer their wisdom and skill⁴³.

Methods

CT and virtual reconstruction of the skull

This study analysed and photographed the skull with a Zeiss surgical binocular magnifying glass (Model 800). In add-on, a multi-slice computed tomography (CT) of the entire skull was conducted, comparing it with the skull of a present-24-hour interval individual with a good for you ear (Fig. 4), using a Toshiba tomography with 64 detectors (Aquilion Model); 2 mm slices were fabricated every i.v mm. The virtual 3D reconstruction was generated using 3DSlicer© software. Further, the 3D photogrammetric model was developed from 267 photographs taken with a Nikon D750 reflex photographic camera and were later processed using the Agisoft Metashape Professional software (Supplementary Fig. S6). The images of the skull included in this paper were taken with that reflex camera and a TAMRON 90MMSP F2.8 macro lens.

Osteology

The sex interpretation was based on the analysis of morphological and morphometric features of the skull, following the criteria set past Buikstra and Ubelaker⁴⁴. To determine the age at expiry, we used the assay of the degree of ectocranial obliteration, according to the method employed by Meindl and Lovejoy⁴⁵, given the absence of the teeth and postcranial skeleton of the individual (Supplementary Text S1).

Histological analysis

The surface histological analysis were performed in the Laboratory of Human being Evolution (LHE) of the University of Burgos. Negative impressions of surfaces of both temporal bones were fabricated with silicone cast material (President, light torso micro System). These silicone molds were used to generate resin casts by placing polyurethane resin (Feropur Pr-55, Feroca) onto negative impression and letting it dry. These replicas were and then coated with gold. The golden-coated loftier-resolution replicas were imaged using a scanning microscope JEOL JSM-6460lv in vacuum mode at 100×.

Chronometric analyses

The chronometric analyses and the calibration and modelling graphs of the 14C dates presented were done with OxCal v4.four.ii software (available online http://c14.arch.ox.ac.uk/)⁴⁶, applying the IntCal20 atmospheric scale curve⁴⁷ (Supplementary Text S2).

Traceological analysis

The use-wearable and traceological analysis of the lithic tools were conducted as a 'blind examination' to avert conditioning the results based on the characteristics of the archaeological site. The specialist researcher was completely unaware of the provenance of the sample under study. 2 blades and two arrowheads, both made of flint, were selected for this analysis (Fig. 5 and Supplementary Text S3). Its study involved the combined use of a Leica MZ16A binocular magnifying glass, with 10× to xc× magnification, and an Olympus BH2 metallographic microscope, with objectives ranging from l× to 400× magnification. The images were taken with a Canon 450D camera and processed with a photographic software called Helicon Focus v.four.62.

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Acknowledgements

The research project at the Dolmen of El Pendón was funding past the Municipality of Reinoso village (Burgos, Espana), the Provincial Quango of Burgos (Spain) and the Castilla & León Regional Regime (Espana). Further analyses were carried out within the scope of Manuel Rojo Guerra's project, "Parallel biographies? Bioarchaeology of two exceptional megaliths (BIOMEX)" (PID2020-116548GB-I00) funded past the Ministry of Scientific discipline and Innovation of Spain. The contribution of SDN in this study was supported past a Predoctoral Fellowship awarded past the Castilla & León Regional Authorities and European Social Fund (ORDEN EDU/574/2018). The contribution of CTR in this study was supported past a Postdoctoral Fellowship awarded by Juan de la Cierva Program-Incorporation Grants, of the Ministry of Science and Innovation, Regime of Kingdom of spain (ref. IJC2019-041820-I). Some of the unpublished radiocarbon dates presented in this work were funded by the Palarq Foundation (Spain). Special thank you due to all the people of Reinoso for their warm welcome, specially to the mayors, Mr. Álvaro Vilumbrales-Sorrisqueta and Mr. Roberto Arsenio Zuñeda-Vilumbrales, for their invaluable and generous help, too as Soledad Hernández-Castillo for her efficient project direction. We want to brand a special mention of the Archeology visitor Patrimonio Inteligente SL, specifically Ángel Palomino and María Negredo, for being the offset ones to implement an archaeological intervention and value enhancement projection of El Pendón'south dolmen. We do non desire to forget the of import and disinterested in kind collaboration: Bou Coffees, Mahou-San Miguel Group, La Hoguera Cold meat, Tomás Bodero Group and Ruíz de la Peña Bakery. Finally, special thanks to Santiago Sánchez de la Parra-Pérez for his excellent and professional work when making the photogrammetric 3D model of the skull that is the subject of report of this paper.

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Author notes

These authors contributed equally: Sonia Díaz-Navarro, Cristina Tejedor-Rodríguez and Manuel Rojo-Guerra.

Affiliations

Department of Prehistory and Archaeology, University of Valladolid, Valladolid, Spain

Sonia Díaz-Navarro, Cristina Tejedor-Rodríguez & Manuel Rojo-Guerra
Independent Archeologist, Zaragoza, Spain

Héctor Arcusa-Magallón
Department of Beefcake and Radiology, University of Valladolid, Valladolid, Espana

Juan Francisco Pastor-Vázquez
Otolaryngology Service, Clinical University Hospital, University of Valladolid, Valladolid, Spain

Jaime Santos-Pérez
RadiodiagnoticsService, Clinical Academy Hospital, Academy of Valladolid, Valladolid, Spain

Israel Sánchez-Lite
Spanish School of History and Archeology in Rome, Spanish National Research Quango (CSIC), Rome, Italy

Juan Francisco Gibaja-Bao
Laboratory of Homo Development (LEH), University of Burgos, Burgos, Kingdom of spain

Rebeca García-González

Contributions

Conceived and designed the paper: Due south.D.N., C.T.R. and K.R.G. Analyzed the data: Southward.D.Due north., C.T.R., J.F.P., J.Southward.P., J.G.B. and R.G.Thou. Conceived, designed and performed the osteological assay: S.D.N. Conceived, designed and performed the radiocarbon dating assay: C.T.R. Performed the palaeopathological analysis: J.F.P. and J.S.P. Performed the traceological assay: J.1000.B. Performed the histological assay: R.Chiliad.G. Contributed visualization tools: H.A.M. and I.Southward.L. Wrote and reviewed the newspaper: Southward.D.N., C.T.R., J.F.P. and Thou.R.G. Supervised inquiry: Thou.R.One thousand.

Corresponding writer

Correspondence to Manuel Rojo-Guerra.

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Díaz-Navarro, S., Tejedor-Rodríguez, C., Arcusa-Magallón, H. et al. The first otologic surgery in a skull from El Pendón site (Reinoso, Northern Spain). Sci Rep 12, 2537 (2022). https://doi.org/ten.1038/s41598-022-06223-6

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Received: 10 June 2022
Accustomed: 25 Jan 2022
Published: 15 Feb 2022
DOI : https://doi.org/10.1038/s41598-022-06223-six

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