What a Head Operation Under a Tree Taught Me

The most remarkable thing I ever witnessed was this: a woman sitting on the ground under a tree, her father and husband behind her. Another man cleans a razor blade and several homemade metal instruments—retractors, scrapers, and saw—with soap and water in a metal bowl. The woman is silent and unmoving as the man takes the blade and cuts an X on her bald head, then draws back the skin to reveal her skull bone.

This was the beginning of a four-hour-long trepanning operation, a practice still carried out in Kisii, Kenya, in 1966, where I had been invited to watch the traditional surgeon perform this extraordinary procedure. Periodically throughout the craniotomy, the omobari calls me close to him to show me the fracture he had exposed as he proceeds to smooth the bone with a chisel-like tool.

Records of trepannings have been found throughout the world, although all such practices disappeared by the advent of the 20th century, except for those carried out in the verdant highlands near Lake Victoria. How the Kisii came to adopt the practice and why they continued it so late is an open question.

A decade after I watched the procedure, David W. Furnas, clinical professor of plastic surgery at the University of California Irvine, and colleagues conducted field studies of the operation over three years. They write, “Kisii traditional craniotomies are done for acute trauma or post-traumatic headache. The rationale is an anatomical one. The mortality rate is low, and the satisfaction rate is high.”

The smoothing of the fracture lines complete, the surgeon washes the wound with cow’s fat, packs the opening with herbal leaves, washes blood from around her eyes, and then wraps her head with cloth. The wound is not sutured. She is lifted to her feet by her husband and father to be walked back to her house nearby, where she will stay a week or two until she is strong enough to care for herself.

No anesthesia is given, no antiseptic is used, and no sterile bandages wrap the wound. Yet, infections or serious complications are rare. To underscore the effectiveness of the operation, the omobari said to me he receives payment only if the operation is successful. At the Western-style government hospital in town, the chief surgeon pointed out to me a boy whom she failed to treat successfully and dismissed him, expecting a dire outcome. As a last resort, he underwent a trepanning, and now, years later, he is playing with mates on the street.

Trepannings in Kisii worked, but why? The placebo effect is a possibility. As a Harvard Medical School bulletin states, “Now science has found that under the right circumstances, a placebo can be just as effective as traditional treatments.” (In this instance, “traditional treatments” refers to science-based, empirical medicine.) But this leaves unexplained why there was no placebo effect for those who sought treatment in the hospital, their first treatment of choice, yet recovered under the surgery of an omobari.

Furnas and colleagues note that traditional surgeons they interviewed had great manual skill, having been in apprenticeship for many years, and the operation “is probably therapeutic on occasion, proving drainage of intracranial hematomas.” This is the same explanation offered by the American Peace Corps doctor who witnessed a trepanning I had arranged for. The skull is an enclosed box, so an aneurysm may form when the head is struck. Removing a section of the bone to release pressure is still used occasionally in modern medicine.

Despite my initial skepticism, I have come to accept that the trepanning is far from quackery but rather is a valid medical practice.

I have unanswered questions regarding the operation, such as why infections were nearly non-existent and why some were cured when Western medicine had failed them. What I do know is that it was a privilege to have witnessed the traditional operation, perhaps the last such operation anywhere in the world, which sadly has now ended even in Kisii, as no young person has taken up the arduous task of years of apprenticeship. This skill has been passed down through countless generations. The procedure is now gone in Kisii.

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As reported to me by Matunda Nyanchama, a prominent Kenyan publisher who is a Kisii himself, “Most chiefs banned it in the 1960s, and those with the skill attracted few apprentices. There was an attempt at a revival in the 1980s with a view to integrating it into modern medical practices, but the efforts did not attain much.”