Gusii and Kuria - Trepanation (Brain Surgery)

Much of this page has been adapted from "Trepanation of The Skull by The Medicine-men of Primitive Cultures, With Particular Reference to Present-day Native East African Practice", by Edward Lambert Margetts (in Proceedings of the Third World Congress of Psychiatry, Montreal: University of Toronto Press/McGill University Press, Vol.II, 1962). Extracts published on the internet by the International Trepanation Advocacy Group (ITAG), from where this information was taken.
In this page:
The art of trepanation
Motives for trepanation
Trepanation by the Gusii and Tende (Kuria)
Three case studies

The Art of Trepanation

The Hilton-Simpson skullThe art of trepanning (or trephining, from the Greek trypanon, borer), is the unusual medical practice of drilling or boring holes into the skull of a patient to relieve pain or cure disease. In the narrowest sense, it implies the boring of a hole through the intact skull of a living person.
   A wider interpretation includes the making of a depression in one or both tables of the cranium, or the removal of bone fragments already present from trauma or infection. The hole or depression is usually made by scraping (raclage, grattage), rasping, and cautery, but may also be accomplished by drilling, boring with a gimlet (vrillage) or knife-tip, cutting (burinage), and sawing (sciage).
   Although it sounds horrific, trepanation is almost certainly the most ancient form of brain surgery known to man: evidence of it has been found in 40,000 year-old Cro-Magnon sites, as well as in various Mesolithic Stone Age sites, in Ancient Egypt, in Ancient Greek and Roman texts (detailed instructions for the operation were put down on paper by Hippocrates), and in pre-Colombian South American cultures. Skulls with holes bored into them have been found and dated back as far as 7300-6220 B.C.
   The practice was widely spread geographically, and was found in the Far and Middle East, among the Celtic tribes (saws and other trepanation tools used by battle surgeons have been found dating to 300 B.C in Germany and Hungary), in China (ancient and recent), India, among the Mayans, Aztecs and Incas, among Brazilian Indians (Karaya and Eugano), central and southern Polynesia, in North Africa (notably the Berber Kabylie of Algeria), and in sub-Saharan Africa, notably among the Hausa, and the Gusii and Kuria of Kenya. Trepanning was also popular in Europe, especially from the Middle Ages to around 1900, when modern medicine took over.

Motives for trepanation

With so many different and disassociated cultures practising trepanation, one cannot simply dismiss the operation as mere quackery (or insanity), and indeed, several studies of large numbers of trepanned skulls have shown that between 55% and around 75% of such skulls found showed calussing (healing) on the edges of holes made in the bone, which indicated recovery.
   The motives for trepanning are not always the same across different cultures. For the Gusii, the motive is generally to relieve strong and persistent headaches after a blow to the head, such as those inflicted during war. Physical pressure due to skull fractures can certainly be relieved by trepanation, as can osteomyelitis, encephalitis, elevated intracranial pressure due to hematomas, hydrocephalus and brain tumors.
   A few hundred miles away, the Lugbara of Uganda practise trepanation to let out or 'liberate' a bad spirit, which might be causing the pain. This kind of motive has been called shamanic, as it involves religious, psychological and psychiatric elements in addition to the physical act. Yet this, too, has been seen to work: 'shamanic' procedure can cure diseases such as epilepsy, some forms of blindness, vertigo, deafness, and mental disorders.

If all the reasons for trepanation are put together, the common mechanism behind all the conditions in the list is to remove something. There is a continuum, from immaterial to material, from magic and thaumaturgy to science - evil spirits and demons, vapors, humors, air, hypothetical "pressures," actual pressures, real and fictional foreign bodies, "unknown substances," pus, blood and finally, pieces of bone.

Trepanation by the Gusii and Tende (Kuria)

Since the early days of British and German colonization, and no doubt before, traditional healers in the hills east of Lake Victoria have operated on the cranium. The colonial service doctors, police and magistrates have documented the practice at length in government files. Trepanation in the narrowest sense, making a hole in the intact skull, is still carried out there by two Bantu tribes, the Kisii (Gisii or Gusii) or South Nyanza in Kenya, and, to a lesser extent, the Tende (Kuria) farther south and into Tanzania. How the custom of trepanation came to be so frequent in this area of East Africa is not understood. The practice was perhaps introduced by an itinerant patient or medicine man, and was continued and promoted as a local custom which was encapsulated by the geography and limited migrations in the area. While government officials have always known about the practice of trepanning the skull by medicine men in Kisii, the custom was apparently not recorded in other than government sources until 1958.

Trepanning in the Kisii highlands is done primarily for the complaint of headache (ogwatigwa omotwe; head, omotwe; ache or pain, ogwatigwa) after an injury to the head, with or without fracture of the skull. Trepanation is not ordinarily done for headache without previous head injury, and the operation is not customary for psychosis, epilepsy, dizziness or spirit possession.
   The operation is a simple but painstaking and sometimes long drawn out procedure, taking one to four hours. The operators are not usually specialized trepanners, but general medicine-men who do the operation as part of their total work. They are usually apprenticed until they are sufficiently skillful and responsible to do the operation on their own.
   They can learn from a non-relative or may be taught by their fathers. Women apparently do not practise the trepanning art.

The "head surgeon" (singular omobari omotwe, plural ababari emetwe; surgeon, omobari; head, omotwe) may pray or go through other individualized magical procedures before the operation (okobara), but there is no set ritual. The patient's head may or may not be shaved and washed. He is then placed in a sitting or lying position and restrained.
   He is usually requested to lie on a bed of leaves with a small log under his head. One operator rather preferred to have his patient lie on a small European style bed with his head over the edge, then to sandwich him by placing another bed upside down on top of him with a relative sitting at each corner of it! The scalp is incised in a linear or cruciate manner over the site of the headache and the flaps if need be are retracted by the fingers of assistants. As a rule nothing is added to the wound, but occasionally, a medicine (unidentified) is sprinkled in the site to assuage pain, and sometimes an agent like charcoal or local pressure is applied for haemostasis. Any fragments of bone, foreign bodies or clotted blood are removed, and any discolored bone or fracture line is removed by scraping the skull (ekeore) with a sharp scraping knife having an acutely curved tip, curved to avoid puncturing the dura and brain. The scraping is usually continued until the inner table is pierced and the brain membranes exposed. Less frequently, a saw is employed to make the hole (enseke).
   Most operators are able to distinguish the cranial sutures from fracture lines, and seem to realize the danger of puncturing the dura, though in ignorance this is sometimes done in the case of subdural haematoma. Usually, both inner and outer tables of the skull are holed, but not always. After sufficient bone has been removed, the wound is washed with water. One omobari is said to have spewed water from his mouth onto the wound - no doubt an effective stream but not very aseptic.

Gusii trepanation instruments

Fat or butter may then be applied with a feather or other applicator. Sometimes herbal medicines are added to promote healing. The wound is usually allowed to heal by granulation; the scalp may rarely be sutured with figure-of-eight sutures over thorns. The operation is said to cause only very little pain, except initially as the soft tissues are cut and retracted. Anaesthesia is not employed. If any beer is drunk, it is probably taken by the operator, not the patient. "Pain killing" medicines are more likely to have a magical than a pharmacological effect. The omobari omotwe watches the patient carefully during the postoperative period, visiting him regularly until good prognosis is assured.

It is not uncommon for a patient to have multiple operations, although these more likely to be enlargements of previous openings rather than additional holes at different sites. The fee paid by the patient varies according to the demand of the omobari, to the circumstances, and perhaps least to the ability of the patient to pay - the amount charged, in money or in staple goods, has been known to vary from 40 to as much as 700 shillings in cash plus goods [note: this was in 1958 or thereabouts].

The mortality is low, perhaps 5 per cent. The bad results usually end up at government hospitals with local infections or meningitis, or are investigated by the police as deaths. A court case against an omobari usually starts out with a charge of murder, but almost invariably this is modified to one of manslaughter or practising medicine without a license.
   The courts generally recognize that the operator has no ill-intent in mind and perhaps is ignorant of the law.

Three case studies

The following three cases, as reported by Edward Lambert Margetts, were interviewed and photographed several times between 1958 and 1959.

Case One

This man was about thirty-five years old. He was a policeman on duty at the District Commissioner's office in Kisii. He suffered a blow to the forehead apparently without fracture. For persistent headaches several years after the injury he went to a doctor who carried out a trepanation, probably by scraping with a curved knife. The patient was mentally normal, and at the time of examination he had no complaints of headache. Cured!

Case Two

This man was serving six months for stock theft and four months for escape, in H.M. Prison, Nairobi. A tree fell on his head about 1 March 1958 and this produced a headache. He then had three trepan operations, about 15 April, 15 July and 15 November 1958. The reason given by him for three operations was "to finish the job." His omobari was a famous doctor who had an enviable reputation that none of his patients would die.
   Before the operation, the patient was fed gruel containing a medicine "to stop the blood coming out too quickly." A powder was applied topically "to prevent pain." The patient claimed that only the cutting of the scalp was painful, scraping the bone did not hurt him. He said the operator used a curved scraping knife, and each session took about four hours. During this time he lay sandwiched between two European-style beds with his head sticking out, and helpful relatives sat one at each corner of the top bed, which was upside down over the patient. He said there was not much bleeding.
   After the procedure was completed, medicine was sprinkled over the wound and boiled fat was applied with a feather. A loose dressing was applied and the wound allowed to granulate. The operation was "to remove something that hurts the bone, he took the bad bone out."
   The patient had to sell most of his property to pay the omobari's fee. He claimed he paid the doctor 700 shillings, one sheep, one goat, three chickens and three four-gallon drums of millet beer. This patient was somewhat withdrawn and depressed, but maybe this was because he was locked up in "King Georgi hoteli" (the prison at Nairobi).
   He did no work for fear it would "spoil" his head. He had no definable physical illness and no diagnosable psychiatric one.
   The man's sister was also trepanned twice by the same operator. Her husband had beat her on the head with a stick and caused her headaches.

Case Three Case Three with his Omobari

The third example of trepanation was the most spectacular curiosity that one would ever hope to see. The author [Margetts] likes to describe him as "Hat on, hat off." When he had his battered old hat on, he looked unobtrusive and normal enough. But when he took his hat off, one was amazed to see the whole top of his head missing. X-ray photographs revealed an oval hole about 30 square inches in area in the vault of his skull.
   This man was about fifty years old. He came to notice because he brought his son to see the European doctor. The son had been absent-minded, was neglecting his work in the father's shop, and was constantly reading the Bible and praying. He recovered without specific treatment. This was perhaps a schizophrenic withdrawal.
   About 1940, "Hat on" was a tribal policeman. One day, while entering a hut, he hit his head on the door lintel. Subsequently, he developed vertex headaches. In 1945 he had a trepanation, and over the next seven or eight years he had several more operations. The exact number was not known. The fewest claimed by the patient was five - but his story varied and on one occasion he even claimed thirty. Enough of his skull was missing to make either the lower or the higher figure quite possible.
   This man said his operations were very painful; nothing was given to assuage pain.
   Because of the extensive deficit in "Hat On’s" cranium, it was feared for his safety, so he was fitted with a plastic skull-cap to wear under his hat. At last report he was wearing this and quite proud of it.

The omobari who trepanned this patient was an interesting old fellow of about seventy or eighty years. He had been doing the operation since he was a young man of twenty, and he could not recall how many patients he had trepanned, certainly well over a hundred. He was taught the technique by his father, and claimed he had never lost a patient. According to this operator, the only indication for trepanning was headache following a blow.
   He used a curved scraper and disapproved of the saw. He expected to find a fracture at operation. He would know he was in the right place because the blood there was black (ie. clotted). Many of the skulls opened probably never did show an actual fracture line, and the extensive amount of bone removed at some of the operations might have been the result of seeking for something that did not exist.


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