Early cranial surgery from Late Iron Age Switzerland Introduction Material and Methods Results Discussion Sandra Lösch 1, Negahnaz Moghaddam 1, Simone Mailler-Burch 1, Christian Jackowski 2 1 Department of Physical Anthropology, Institute of Forensic Medicine, University of Bern, Switzerland 2 Department of Forensic Medicine and Imaging, Institut of Forensic Medicine, University of Bern, Switzerland  Moghaddam N, Mailler-Burch S, Kara L, Kanz F, Jackowski J, Lösch S (accepted) Survival after trepanation – Early cranial surgery from Late Iron Age Switzerland. International Journal of Paleopathology Fig. 2: Skull A53 is determined as an adult male. There is an elliptically shaped lesion on the left os parietale with partly irregular margins and a funnel shape at the anterior and posterior area. The lesion measures 50x 37mm. No signs of healing are detectable on its margins. Skull A103 is determined as a mature male. This skull shows two nearly symmetric funnel-shaped openings on both ossa parietalia. The lesion on the left side measures 25x 22mm and broadens towards the outside. The lesion on the right side measures 44x 37mm. Both lesions show outward bevelling. A bony reaction is detectable on the right lesion. Trepanations are the oldest surgical procedures with archaeological evidence and are defined as intentional perforation of the calvarium through removal of skull bone. Underlying soft tissues are usually not damaged. Trepanations have been carried out to treat head injuries or other diseases, also mental ones. In Europe, they have been practiced at least since the Neolithic by four main techniques: scraping, grooving, drilling with cutting, and sawing. This study presents two skulls with lesions from the Late Iron Age burial site of Münsingen-Rain in Switzerland. The aim was to analyse the lesions and to determine whether they were caused by intravitam surgery or postmortal manipulation. Furthermore, the work surveys all trepanations found in Switzerland so far, calculates survival rates and considers sex, age and localization. Tab. 1: In total, 34 individuals with 43 alleged trepanations are found in Switzerland. Three cases were excluded due to insufficient information (*). Most cases are adults between years. The number of trepanations per cranium varied from one to four. 32% of the trephined skulls are from the Neolithic, 29% from the Iron Age, and 26% from the Early Middle Ages. A total of 57% (23/40) of the surgeries were described as intra vital due to bony reactions. Therefore, the survival rate during the Iron Age is 78%. For the Neolithic it is 72%, for both the Bronze Age and the Late Antiquity it is 100%, whereas a survival rate of 50% was found for the Early Middle Ages. One case with four trepanations from Pre-Modern times was described for which the survival rate was 75%. Acknowledgement We are grateful to Christine Cooper for language editing and Levent Kara for support with CT imaging. References Skull 53Skull 103 The Late Iron Age in Switzerland spans from 450 to 15BC. Little is known about the population as written sources are scarce. The burial site of Münsingen- Rain ( BC) is situated near Bern. It was excavated in 1906 with an abundance of grave goods. In total, 220 burials were found. Skulls of 77 individuals and a few long bones are preserved. The site showed a horizontal stratigraphy with individuals buried chronologically from north to south. Sex and age were investigated using current anthropological methods and imaging was performed with a multislice CT scanner. Additionally, all reported trepanations from different periods found in Switzerland were compiled and a survival rate was calculated. Every single trepanation rather than the individuals were taken into consideration by following formula (iv = intravitam, perim = perimortem): Survival rate = [iv / (perim + iv)] * 100 DatingSiteGraveSexAgeLocation Time of surgery Survival rate Neolithic Locras/Lüscherznd n.d.occipitalend 72% Auvernierndf35-40r frontoparietalperim Saint-Aubinnd adult+r occipitalnd Collombey-Muraz14f37-41r orbitalperim Sion, Petit-Chasseurndm?adult+frontal and parietaliv / iv Sion, Petit-Chasseur III (H15-204)ndm20-44l parietaliv Sion, Petit-Chasseur III (H15-209)ndm25-35sutura sagittalisiv Sion, Petit-Chasseur III (H )ndf25-35l frontal, l and r parietaliv / iv /iv Corseaux-sur-Vevey1965-3f?35r frontoparietaliv Zurich, Grosser Hafnerndf?20-30r parietalperim Bronze Age Cressier *ndmadult+r frontoparietalpm 100% Glandndf?adult+l frontaliv Iron Age Basel, Gasfabrik (1)80nd17r parietaliv 78% Basel, Gasfabrik *(2)ndm29l parietalpm Stettlen-Deisswil33m20-25l parietalnd Münsingen-Rain, (A53)16madultl parietalperim Münsingen-Rain, (A103)152madult+l and r parietalperim / iv Sion, Bramois10m40-60l and r parietaliv / iv Sion, Sous-le-Scex430f23-45l parietaliv Sion, Sous-le-Scex436nd> 40l frontaliv Sion, Sous-le-Scex439m50-70l frontoparietalnd Sion, Sous-le-Scex546m40-50l parietaliv Late AntiquityWindisch7m45r parietaliv100% Early Middle Ages Villigen10f?> 60l parietalnd 50% Villigen *25nd6-7frontalend Arlesheimnd 2frontaleiv Basel, Aeschenvorstadtndm30-39l parietaliv Basel, Kleinhüningen108m50l parietalpm Riaz184f?20-30r frontalnd Bonaduz40m20-29r parietaliv Bonfolndm70occipitaleperim MelsB1madult+l and r parietalperim / perim Middle AgesBasel, Münsternd adult+l parietalnd0% Pre-Modern Times Steinhausenndf> 35l frontal, l parietaliv / iv /iv/perim75% Fig. 1: Two individuals with lesions on the skull were found at Münsigen-Rain. Skull A53 The individual probably died during or shortly after the surgery due to the absence of a bony reaction. The treatment was carried out most likely with a combination of techniques. The anterior and posterior funnel-shaping suggests that scraping was performed and the middle part was probably drilled before removal. The elongated lesion leads to the suggestion that the surgery was performed after a trauma caused by a sharp or half-sharp weapon such as a sword. Skull A103 The trepanations were performed by the scraping technique and the right side shows evidence of healing. The right trepanation was done first, followed by the second one at the left side during or shortly after which the individual probably died. Due to their symmetry and shape a previous injury was probably not the reason for the surgery. Trepanations in Switzerland The trepanation frequency in Münsingen is relatively high with 2.6% (2/77) compared to 1% in central European Iron Age. The abundance of weapons found in male graves might suggest that “warriors” were buried here. Only one trepanned individual from Iron Age Switzerland was female (11%), two were not determined, and six (67%) were male. This unbalanced distribution suggests that trepanations may have been carried out as surgery of injuries sustained through violence. Additionally, most individuals show trepanations on the left os parietale. A previous combat with a right-handed adversary is suggested as an explanation. Survival rate Scraping technique showed the highest survival rates in ancient trepanations. Although this technique was applied to both individuals, none of them survived. During Swiss Iron Age the medical skills and knowledge may have varied between the different tribes or periods. All individuals from Sion and Basel, which date to BC show healing. An explanation for this, compared to the earlier individuals of Münsingen, could be that an improvement might have taken place over time. The chances of survival appear to be relatively high from the Neolithic to the Late Antiquity, but decreases after the Late Antiquity until the Pre- Modern time. This suggests limited infections through natural antiseptics and a certain medical knowledge in prehistoric times.