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The skeletal remains of two elite brothers at Megiddo, the focus of this study. Source: Kalisher, R et al / PLoS ONE

High Status Brothers Had Access to Cranial Surgery in Bronze Age Israel


In ancient Megiddo, a city on the crossroads of major trade routes, two upper-class brothers underwent "angular notched trephination," the earliest example of its kind found in the Ancient Near East. The procedure, which involves cutting the scalp and carving four intersecting lines in the skull, is a form of cranial surgery that could have been used to treat various illnesses. Both brothers had skeletal abnormalities and were buried with valuable possessions, suggesting they were elite members of society.

Brain Surgery in Bronze Age Megiddo

Some 3,500 years ago, during the Bronze Age in Northern Israel, the town of Megiddo was a thriving center of trade, standing at and controlling part of the Via Maris, an important land route that connected Egypt, Syria, Mesopotamia, and Anatolia. As a result, the city had become one of the wealthiest and most cosmopolitan cities in the region by about the 19th century BC, with an impressive skyline of palaces, temples, fortifications, and gates.

"It was already quite influential and powerful in the region, and had a very cosmopolitan population," says Rachel Kalisher, a bioarchaeologist at Brown University and lead author of the study. "It's one of the most important sites in the ancient Near East because it is sitting at the crossroads of these major trade routes that connected the East and West."

It is here that evidence of ancient people practicing this particular cranial trephination (i.e., a medical procedure involving cutting a hole in the skull) has been found, although the general practice has been recorded for thousands of years, across the globe, from South America to Africa.

The skull showing evidence of angular notched trephination from Megiddo. (Kalisher, R et al / PLoS ONE)

The skull showing evidence of angular notched trephination from Megiddo. (Kalisher, R et al / PLoS ONE )

Angular Notched Trephination: A Cutting Edge Technology?

Kalisher is the lead author of this new study published in the journal PLOS One . Kalisher's findings show that this trephination – ‘angular notched trephination’, is the earliest example of its kind found in the Ancient Near East. Kalisher’s analysis was written in collaboration with scholars in New York, Austria, and Israel.

An analysis of the excavated remains of two upper-class brothers who lived in Megiddo around the 15th century BC forms the backbone of this study. Kalisher and her team found that not long before one of the brothers died, he had undergone this cranial surgery.

The procedure involves cutting the scalp, using an instrument with a sharp beveled edge to carve four intersecting lines in the skull, and using leverage to make a square-shaped hole. In the case of this older brother, estimated to be between 20 and 40, a 30-millimeter (1.2-inch) square-shaped hole was made in his skull, according to a press release by Brown University. Interestingly, the parts of the skull that had been removed in the trephination were included in the burial.

Rachel Kalisher working in the field in Megiddo. (Rachel Kalisher/PLoS ONE)

Rachel Kalisher working in the field in Megiddo. (Rachel Kalisher/ PLoS ONE )

Up Close: The Medical Abnormalities of the Two Brothers

The two brothers whose bones Kalisher analyzed were buried with fine Cypriot pottery and other valuable possessions. This clearly suggests that the pair were elite members of society and possibly even royals themselves.

Kalisher noted that the burials were very humane, despite the brothers suffering from disabilities. This implies no signs of ostracization as they were honored in death with a shared grave, alongside food offerings and fine ceramics. This is of particular cultural and anthropological importance.

“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. 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,” observed Kalisher.

The skeletal abnormalities Kalisher spotted in both brothers included an additional cranial suture and an extra molar in one corner of the older brother's mouth, which could have indicated a congenital syndrome such as Cleidocranial dysplasia. Both brothers’ bones showed minor evidence of sustained iron deficiency anemia in childhood, which could have impacted their development, reports NPR.

Kalisher believes that they both ultimately succumbed to an infectious disease. A third of one brother's skeleton and half of the other brother's show porosity, legions, and signs of previous inflammation in the membrane covering the bones, which together suggest they had systemic, sustained cases of an infectious disease like tuberculosis or leprosy.

Selected skeletal elements from Individual 2 which show the extent and variety of the lesions and bone porosity. (Kalisher et al/PLoS ONE)

Selected skeletal elements from Individual 2 which show the extent and variety of the lesions and bone porosity. (Kalisher et al/ PLoS ONE )

Kalisher is currently also working with researchers at Germany’s Max Planck Institute for Evolutionary Anthropology to conduct DNA analyses of specific lesions in the bones. If they find bacterial DNA consistent with leprosy, these brothers will be among the earliest documented examples of leprosy in the world.

“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. “At the same time, leprosy is hard to identify because it affects the bones in stages, which might not happen in the same order or with the same severity for everyone. It’s hard for us to say for sure whether these brothers had leprosy or some other infectious disease.”

Despite all the evidence of trephination uncovered over the last 200 years, there's still much archaeologists don't know. It's not clear why some trephinations are round, suggesting the use of some sort of analog tool, while others are square or linear, like the one discovered at Megiddo.

“We have evidence that trephination has been this universal, widespread type of surgery for thousands of years,” Kalisher said. “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.”

Top image: The skeletal remains of two elite brothers at Megiddo, the focus of this study. Source: Kalisher, R et al / PLoS ONE

By Sahir Pandey


Daniel, A. 2023. Clues to Bronze Age cranial surgery revealed in ancient bones . Available at: https://www.npr.org/sections/health-shots/2023/02/22/1158721573/clues-to-bronze-age-cranial-surgery-revealed-in-ancient-bones.

Kalisher, R. et al. 2023. Cranial trephination and infectious disease in the Eastern Mediterranean: The evidence from two elite brothers from Late Bronze Megiddo, Israel . Available at: https://doi.org/10.1371/journal.pone.0281020

Kimball, J. 2023. Brown Ph.D. student uncovers early evidence of brain surgery in Ancient Near East . Available at: https://www.brown.edu/news/2023-02-22/megiddo.

Strickland, A. 2023. An elite Bronze Age man had brain surgery more than 3,000 years ago . Available at: https://edition.cnn.com/2023/02/22/world/bronze-age-brain-surgery-scn/index.html.

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I am a graduate of History from the University of Delhi, and a graduate of Law, from Jindal University, Sonepat. During my study of history, I developed a great interest in post-colonial studies, with a focus on Latin America. I... Read More

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