LEGACY

NEW WORLD CRANIAL DEFORMATION PRACTICES:

HISTORICAL IMPLICATIONS FOR PATHOPHYSIOLOGY
OF COGNITIVE IMPAIRMENT IN
DEFORMATIONAL PLAGIOCEPHALY
Gregory P. Lekovic, M.D., INTRODUCTION: Throughout history, prehistoric and even some contemporary civ-
Ph.D., J.D. ilizations have practiced various forms of intentional and unintentional cranial defor-
Division of Neurological Surgery, mation. Plagiocephaly can be the result of craniosynostosis, infant positioning, or
Barrow Neurological Institute,
St. Joseph’s Hospital
other unintentional or intentional deformation.
and Medical Center, MATERIALS: We reviewed the medical and anthropological literature and utilized the
Phoenix, Arizona
anthropological collections of Arizona State University and the San Diego Museum
of Man for evidence of cranial deformation and its possible physiological and cogni-
Brenda J. Baker, Ph.D.
tive side effects. Evidence of cranial shaping was also sought among art or stone work
Department of Anthropology,
Center for Bioarchaeological Research, from representative cultures.
School of Human Evolution RESULTS: The anthropological record and literature attest to the presence of much more
and Social Change,
Arizona State University,
severe forms of deformation than that seen as a result of contemporary infant position-
Tempe, Arizona ing. Despite this evidence, there is no anthropological evidence as to the possible cog-
nitive effects that such deformation may have, although some evidence is reviewed that
Jill M. Lekovic, M.D. suggests a possible physiological mechanism for the same.
Department of Pediatrics, CONCLUSION: Because we can only view these cultures through the relics of time, any
St. Joseph’s Hospital
and Medical Center, conclusions one might draw from the anthropological and historical record regarding
Phoenix, Arizona the cognitive effects of head deformation can only be inferred through generalized
observations and are tenuous. Nevertheless, there does not seem to be any obvious
Mark C. Preul, M.D. evidence of negative effect on the societies that have practiced even very severe forms
Division of Neurological Surgery, of intentional cranial deformation (e.g., the Olmec and Maya). On the other hand, the
Barrow Neurological Institute,
St. Joseph’s Hospital
physical anthropology and the contemporary developmental literature suggest possi-
and Medical Center, ble mechanisms for such an effect.
Phoenix, Arizona
KEY WORDS: Cognitive impairment, Cranial deformation, Craniosynostosis, Neurosurgical history,
Plagiocephaly
Reprint requests:
Mark C. Preul, M.D.,
c/o Neurosurgery Research, Neurosurgery 60:1137–1147, 2007 DOI: 10.1227/01.NEU.0000255462.99516.B0 www.neurosurgery-online.com
Barrow Neurological Institute,
350 W. Thomas Road,

P
Phoenix, AZ 85013. lagiocephaly can be caused by craniosyn-
Email: neuropub@chw.edu ostosis or deformation and has been asso-
ciated with impaired cognition (22–26).
Received, September 14, 2006.
This issue has become more pressing because
Accepted, January 31, 2007.
the incidence of deformational plagiocephaly
has increased since the American Academy of
Pediatrics adopted the Back to Sleep campaign
(50). However, whether or not plagiocephaly
per se plays a causative role in such impair-
ment remains controversial. To gain perspec-
tive on this issue, we examined the historical
and archeological records of cultures that rou-
tinely practiced severe forms of cranial defor-
mation. These practices created deformational
plagiocephaly that was far more acute than
what is typically encountered by practitioners
of pediatric neurosurgery today. Clearly, the
effects of these practices on cognition can only
be surmised. Nonetheless, such a survey may
offer insights relevant to the current concerns
about positional plagiocephaly.
We examined human skeletal remains from
the collections of Arizona State University and
the San Diego Museum of Man and reviewed
the anthropological literature on the inten-
tional deformational practices among prehis-
toric Native Americans to examine whether or
not the possible effects on cognition could be

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LEKOVIC ET AL.
inferred from the anthropological record. Several reviews
describe the general practices of intentional cranial deformation
in many parts of the world (5, 19–21, 38, 51). None, however,
concentrate on its possible effects on cognition. Current
thought on the treatment of head deformation in pediatrics
and neurosurgery is a convenient context for this historical
examination. It is impossible to assess the cognitive abilities of
individuals or groups in cultures that once practiced cranial
deformation. However, their remains, coupled with cultural
evidence, may suggest implications relevant to the contempo-
rary debate on the effect of positional deformational plagio-
cephaly on cognition.
MATERIALS AND METHODS
The anthropological, neurosurgical, and pediatric literature
on cranial deformation was reviewed, specifically from readily
available New World cultural evidence. Representative exam-
ples of cranial deformation in archaeological collections of
human skeletal remains, mainly from ancient cultures of the
Southwest United States, from the School of Human Evolution
and Social Change at Arizona State University in Phoenix and
from the San Diego Museum of Man were used to demonstrate
types of alteration in past peoples and for purposes of illustra-
tion. Evidence of cranial shaping was sought among art or
stone work from representative ancient cultures of the New
World, including the Maya, Olmec, and Inca, and various
ancient Indian cultures of North America.
The Problem: Does Deformational Plagiocephaly
Cause Cognitive Impairment?
Interestingly, the debate about the impact of artificial head
shaping on cranial and brain development and cognition
intrigued even some of the most prominent of mid-19th cen-
tury neuroscientists such as Rudolf Virchow and Pierre-Paul
Broca (16). Likewise, in the late 1950s, nearly the same discus-
sions on potential impacts of cranial deformation were taking
place at the Johns Hopkins Hospital between George Ander-
son, then assistant professor of pediatrics, Earl Walker, chief of
neurosurgery, and the noted anthropologist, anatomist, and
scientist, Ashley Montagu. Their discussions and letters docu-
ment interest in better treatment for plagiocephaly or other
malformations of the cranium, and were related to a large
National Institute of Neurological Disease and Blindness “col-
laborative project into identifying the etiology of neurological
disease and defect in children” (44).
The Back to Sleep recommendation of the National Institute
of Child Health and Human Development and the American
Academy of Pediatrics was adopted in 1992. This campaign
was an attempt to reduce the incidence of sudden infant death
syndrome, which has been linked in epidemiological studies to
infants sleeping in the prone position. Since the adoption of
the campaign, the rate of sudden infant death syndrome has
dropped by an impressive 40%. However, an unintended con-
sequence has been an increase in the incidence of plagio-
1138 | VOLUME 60 | NUMBER 6 | JUNE 2007
cephaly attributable to infant head positioning (3, 50). In a
community-based practice environment, for example, more
than 15% of patients measured prospectively showed evidence
of at least mild positional deformation, whereas 1.5% had a
severe deformity associated with concomitant facial and cra-
nial base deformation (32).
Recognizing that a supine sleep position may contribute to
deformational plagiocephaly, the American Academy of
Pediatrics Task Force on Infant Sleep Position and Sudden
Death Syndrome recommended “tummy time” (i.e., prone
positioning when awake and observed) for infants to promote
upper shoulder girdle strength and to avoid plagiocephaly. The
Task Force also recommended alternating head position weekly
to prevent children from developing a preference for one side
over the other (26).
Recently, the use of dynamic orthotic cranioplasty has gar-
nered publicity as an alternative treatment to changing infant
head position. In uncontrolled studies, the apparatus restored
normal head shape better than standard repositioning tech-
niques (26). Whether or not the mildly superior performance
of orthotic cranioplasty over repositioning justifies the
expense of the orthosis depends partially on the indications
for treatment.
Supine-sleeping infants were found to have gross motor
milestones later than prone-sleeping children (15). This differ-
ence has been attributed to relative weakness in upper shoul-
der girdle strength among infants sleeping supine and disap-
pears after 18 months of age (14). Overall, these initial
concerns that supine sleeping may be associated with adverse
developmental effects have received little support. However,
several studies have provided evidence of adverse cognitive
effects from plagiocephaly caused by positional occipital
deformation. Indeed, increases in the incidence of learning
disabilities among patients with persistent deformational pla-
giocephaly may be comparable to those found in patients with
craniosynostosis. Miller and Clarren (35) found that the rate of
learning disabilities among 63 patients with persistent defor-
mational plagiocephaly was 39.7% compared with 7.7% of the
siblings of affected children who served as controls. Parents
were interviewed about their child’s school performance and
participation in an early intervention program, special educa-
tion classes, or other special aid. Compared with the controls,
significantly more children with deformational plagiocephaly
required such services.
Among 35 patients ranging from 4 to 48 months of age with
pure deformational plagiocephaly (i.e., excluding patients
with any diagnosis of genetic disorder, prematurity, or syn-
drome), Habal et al. (28) found a 51% incidence of language
delays or disorders. Between 1997 and 1999, Panchal et al.
(43) used the Bayley Scales of Infant Development to assess
42 consecutive infants with deformational plagiocephaly.
These infants had a significantly elevated incidence of severe
developmental delay (8.7%).
Differences in auditory-evoked responses predictive of later
cognitive functioning have been studied in infants with plagio-
cephaly (9, 36). Balan et al. (4) evaluated auditory-evoked
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potentials in 15 patients with plagiocephaly, including 10 with
positional plagiocephaly, two with lambdoid synostosis, and
three with anterior plagiocephaly. Irrespective of the cause of
plagiocephaly, these infants had smaller amplitude P150 and
N250 responses than normal controls. The findings support a
common etiology of cognitive impairment in craniosynostosis
and deformational plagiocephaly.
The causal relationship between head deformation and
adverse cognitive sequelae is, however, difficult to establish
because many comorbid conditions may predispose a child to
develop deformational plagiocephaly. Hypotonic children,
such as those with mental retardation, chromosomal abnor-
malities, and cerebral palsy, or children with torticollis, are at
risk for deformational plagiocephaly because they develop a
preference for one head position over the other. Still, a strong
circumstantial argument can be made against the likelihood of
deformational plagiocephaly, per se, having a significant
effect on children’s cognitive development, namely that head
deformation, whether unintentional or by design, is a wide-
spread cultural phenomenon among prehistoric and indige-
nous peoples.
Anthropological and Historical Contexts
of Deformational Plagiocephaly
Cranial deformation practices, whether intentional or unin-
tentional, have been a common feature in many ancient soci-
eties. Indeed, in many parts of the world such practices con-
tinue today.
Unintentional Cranial Deformation
Unintentional shaping of an infant’s cranium is the conse-
quence of habitual positioning. Many historic and prehistoric
Native American groups, particularly in the Southwest and
Plains, used cradleboards to contain an infant while it was car-
ried or sleeping, or while the mother was engaged in other
activities. The use of cradleboards flattens the occiput, much
like the deformation seen in contemporary American infants
who are habitually placed on their backs to sleep (Fig. 1A). As
in contemporary infants, the deformation was often asymmet-
rical as a result of an infant’s preference for looking toward one
side or another (Fig. 1B).
Positional plagiocephaly is common in prehistoric South-
western skeletal samples and extends across a considerable
length of time. Cradleboards have been found from the Basket-
maker II period (c. 100 BC–AD 400). Occipital deformation was
also common in the Adena and Hopewell people and at some
Mississippian and protohistoric sites in the Southeast and
Midwest (40). These people, however, did not use a written
language. Thus, the learning disorders thought by some (4, 28,
50) to be associated with deformational plagiocephaly may
have been too subtle to be recognized by people in societies in
which cranial deformation was common.
Intentional Cranial Deformation: “Headshaping”
Intentional shaping of infants’ heads, resulting in more
extreme deformation of the cranium than cradleboarding, was
NEUROSURGERY
IMPLICATIONS OF CRANIAL DEFORMATION PRACTICES
also widely practiced in the past and continues today.
Dingwall’s (16) 1931 book, Artificial Cranial Deformation: A
Contribution to the Study of Ethnic Mutilations, remains
unequaled for its breadth and detail of the topic, surveying
the history of the practice around the world. Gerszten and
Gerszten (20) and Goodrich and Tutino (21) reviewed infor-
mation on intentional cranial deformation as it relates to the
history of neurosurgery and to the development of craniofa-
cial surgery from various parts of the world. Anatomists and
others (17, 27, 29, 34, 47) have been fascinated with artificial
cranial deformation even before the birth of physical anthro-
pology as a formal discipline, as exemplified by works like
Samuel Morton’s (37) Crania Americana; or a Comparative View
of the Skulls of Various Aboriginal Nations of North and South
America, published in 1839. This volume contains 72 plates,
principally of skulls from North and South America and the
Caribbean. Extreme examples are best known from the
Northwest Coast, Peruvian cultures, and the ancient Olmec,
Toltec and Maya in Mesoamerica. Intentional deformation
was also common in the southwestern and southeastern
United States (12, 40, 48). Known European cases date from
the Neolithic period, and have been found in Britain (7),
among the Huns of eastern and central Europe (49), and in
ancient Cyprus (33). In antiquity, head shaping was practiced
on every inhabited continent, with evidence from Iraq as early
as 45,000 BC (42) and in fossilized remains of early Homo sapi-
ens from Australia (2).
Devices used to shape heads include cloth bindings
wrapped around the infant’s head, anteroposterior compres-
sion via boards or stones bound together and placed around
the head, and cradleboard attachments that compress the fore-
head. In some cultures, mothers molded and squeezed the
heads of their infants between their hands while nursing,
changing them from breast to breast so that a desired symmet-
rical appearance could be obtained (16). Most cultures used
cranial modification as a marker of ethnic identity or social sta-
tus. It was also done to appear ferocious in battle and for cul-
tural or racial imitation. Deformation and sex also correlate,
A B
FIGURE 1. Example of unintentional cranial deformation among the
Southwest Native Americans. Lateral (A) and basilar (B) views with
occipital flattening caused by cradleboarding showing plagiocephaly sim-
ilar to the positional plagiocephaly that results from positioning infants
supine. Photographs courtesy of Charles Merbs, Ph.D., with permission.
VOLUME 60 | NUMBER 6 | JUNE 2007 | 1139
LEKOVIC ET AL.
with males usually exhibiting a more extreme appearance,
although in a few cultures, females were more likely to show
such deformation (16, 19, 21, 49).
In Mesoamerica, early Olmec (1400 BC–400 AD) figurines
have a characteristic elongated head (Fig. 2). Such cranial
deformations are thought to have been common throughout
the Olmec civilization. The Olmecs, the forerunners of civi-
lizations in Mexico, are considered to be a dynamic culture
with mathematics, a calendar, a well-developed system of
writing, art, farming, and relatively large-scale engineering
projects (11, 39, 54).
A B
C D
FIGURE 2. A, carved jade figurine of a seated Olmec ruler in a ritual pose
displaying a cone-like cranial shaping, Mexico state of Puebla, San Martín
Texmelucan, Highland Olmec culture, c. 900–500 BC. Photograph cour-
tesy of the Dallas Museum of Art, with permission. B, ceramic figurine
showing cranial deformation in Olmec artwork. Note the lateral concave
shaping. Photograph courtesy of Jorge Pérez de Lara, with permission.
Frontal (C) and side (D) views of a skull from Morton’s Crania Amer-
icana showing a deformation common to the Natchez tribe of the south-
central United States, which was similar to that of the Olmec. The Natchez
may have had origins in or close associations with cultures in Mexico.
From, Morton SG: Crania Americana; or a Comparative View of the
Skulls of Various Aboriginal Nations of North and South America.
Philadelphia, J Dodson, 1839 (37).
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As many as 90% of Mayan skeletal remains exhibit evidence
of intentional, decorative, or cosmetic cranial deformation prac-
tices (48). Patterns of deformation varied according to geo-
graphical regions and periods. However, the prevalence of cra-
nial deformation remained constant throughout the Preclassical
and Postclassical periods of Mayan civilization (100 BC–1521
AD), during which time there was a stable progression of
Mayan arts and sciences.
Unlike the unintentional cranial deformation that occurred as
a consequence of cradleboarding, deformation in Mayan crania
is much more severe. Our ability to conclude that deforma-
tional plagiocephaly did not adversely affect the cognition of
Native Americans who practiced cradleboarding is hampered
by the absence of a written language. Mayan culture, however,
did practice writing. Presumably, adverse effects of head shap-
ing among the literate elite would have been obvious to others,
as cognitive impairment would have hampered reading and
writing capabilities (Fig. 3).
Although it is impossible to assess the effects of Mayan cra-
nial deformational practices on cognition, the anatomic and
archaeological records provide a circumstantial argument
against a negative consequence (Fig. 4). It is logical to assume
that cultures would associate changes in cognition or deleteri-
ous effects on a child’s health with severe head shaping. Such
practices would likely have died out quickly, especially among
the Mayans or Peruvians, for example, where severe inten-
tional head shaping was comparatively widespread. Never-
theless, the practice seems to have been most common among
ruling, religious, or elite classes. The consequential cognitive
sequelae of severe cranial deformation may have been cultur-
ally accepted and identified with these social classes of unique
standing, and thus continued. Or, perhaps the sequelae were
not behaviorly obvious. Among anthropologists of the early to
mid-19th century, it was thought that the skulls of ancient
Peruvians were naturally elongated with retreating foreheads.
The idea of the Peruvian skull as being naturally ‘flat
head’ . . . was discussed in the report of the Council of
the American Antiquarian Association in 1855. . . . It is
not difficult to understand why the earlier inquirers
failed to grasp the fact of Peruvian artificial deforma-
tion. The custom was so widespread, and the sites
which attracted early attention provided such a mass
of specimens, that the theory that such conformations
were natural was easy of acceptance (16).
Among 500 skulls unearthed from Peru (ancient Inca) in the
mid-19th century housed in Paris and another similar number in
the University Museum at Rome, only 10% did not show extraor-
dinary skull deformations (16). Furthermore, 19th century studies
from France on living subjects found no evidence of brain injury
or cognitive impairment associated with severe head shaping (52).
Impact of Deformation on Cranial Growth
and Development
In the anthropological literature, the application of devices to
shape the head have usually been interpreted to act “primarily
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 IMPLICATIONS OF CRANIAL DEFORMATION PRACTICES

A B A

FIGURE 3. A, Mayan codex ves- C

sel from the Middle Classic Period
(AD 400–600) depicting the elon-
gated head of the Maize God being
born from a seed. B and C, two of
a set of three Yaxchilan limestone
lintels, Numbers 24 and 26, (Late B
Classic Mayan Period, AD
600–900), each of which formed
the ceiling of a deep doorway to
one of the Yaxchilan temple’s three
separate rooms. As worshipers
entered, they looked up to see the
scene overhead. The lintels were
commissioned by Lady Xoc and
feature her performing crucial
duties during the reign of her hus-
band. The stonework shows the
flattening of the forehead and elon-
gated, conical head of a famous Mayan king and queen. In royal Mayan
courts, women filled important civic and religious roles denied them in
many Mesoamerican cultures. On the first of these lintels (B), Lintel 24,
commemorating a blood-letting rite in AD 709, Shield Jaguar stands hold-
ing a flaming torch with Lady Xoc kneeling in front of him. As she runs FIGURE 4. A and B, detail of Mayan stone pan-
a rope studded with thorns or spines through her tongue, spots of blood els found in Palenque's Temple XIX, carved in
collect on the paper in the basket in front of her. In Lintel 26 (C), commem- the early 8th century AD. The images show King
orating a ritual in AD 725, Lady Xoc hands a jaguar helmet to Shield Ahkal Mo' Nahb III (K'inich Ahkal Mo' Nahb),
Jaguar, securing his place in the line of kings, or perhaps on his way to bat- who was born on September 16, 678 and died after
tle. Photographs courtesy of Jorge Pérez de Lara, with permission. August 22, 731; he was grandson of the famous
Mayan king, K'inich Hanab Pakal. Note the
oblique tabular cranial shaping in which the fore-
head becomes slanted and elongated. Also, Ahkal
on the outer table and secondarily on cerebrally influenced Mo' Nahb is typically depicted with what appears
regions” (1). Cheverud et al. (10) performed finite-element scal- to be a nose-forehead prosthetic that accentuated
ing on samples of deformed skulls from Peru and the the angle of cranial shaping. The curved line of the
Northwest Coast Salish to investigate the effects of fronto-occip- nose represents the true profile, and the prosthetic
ital shaping. They found that physical reshaping of the neuro- is seen above the nose. Photographs courtesy of
cranial vault results in a series of compensatory bony changes Jorge Pérez de Lara, with permission.
required for normal neural growth, so that the size of the neu-
rocranial vault remains the same. In this case, the compensatory The relationship between cerebrally derived pressure on the
growth involved the mediolateral aspect of the cranium. Thus, cranial vault and sutural fusion, as evidenced by the tendency
a 5% decrease in the anteroposterior dimensions of the face cor- to promote premature sutural fusion in shunted hydro-
responded to a 5% increase in the width of the cranial base. cephalus, has led some to posit a causal relationship between

NEUROSURGERY VOLUME 60 | NUMBER 6 | JUNE 2007 | 1141

LEKOVIC ET AL.
externally applied forces and sutural fusion. Graham et al.
(22–26) and Koskinen-Moffett et al. (31) have argued that per-
sistent deformation in utero may promote premature fusion.
According to this view, deformational plagiocephaly exists on
a continuum with synostosis per se. Although this hypothesis
is widely cited, experimental models of sutural constraint in
rabbits and sheep have failed to demonstrate such an associa-
tion (6, 18). The persistence of sutures in mechanically
deformed skulls is evident in the anthropological literature.
Several anthropological studies have focused on the impact
of artificial cranial deformation on sutural complexity. An
increase in the frequency of wormian bones (sutural ossicles) in
the lambdoidal suture has been suggested (16, 41, 45, 46).
Pucciarelli (45) concluded that higher frequencies of wormian
bones were found in experimentally deformed rat crania and
that such experimental deformation may be an extragenetic
expression of wormian bones. He inferred that this evidence
may be relevant to studies on racial differences based on dis-
continuous cranial traits (16, 46). Konigsberg et al. (30), how-
ever, found that the frequency of coronal ossicles increases
regardless of the type of deformation. They observed that ossi-
cles typically occur near the position of pads or a wrapping
device. Their study suggests that biomechanical forces operat-
ing on the skull as it is shaped promote compensatory growth
at the sutures where force is applied. This idea is supported by
Konigsberg et al.’s (30) statement that nonmetric traits that
develop prenatally are unaffected by deformation.
White (53) found a strong association between sagittal synos-
tosis and lambdoidal wormian bones among Mayans at
Lamanai, Belize. The high frequency of synostosis in unde-
formed skulls suggested an underlying heritability. However,
the increased frequency of wormian bones in individuals with
fronto-occipital deformation reinforces the importance of
sutural development in maintaining overall skull size.
Environmental factors seem to affect posterior sutures more
than anterior sutures, perhaps a result of the rapid growth of
the posterior cranium immediately after birth (41). However,
none of these studies demonstrated a significant increase in
sutural fusion in deformed skulls, irrespective of the extent of
deformation.
Investigating endocranial vascular changes related to both
synostosis and artificial cranial deformation, O’Loughlin (41)
found significant alterations in the patterns of venous sinus
drainage between normal, synostosed, and deformed skulls.
Both artificial deformation and craniosynostosis altered
endocranial vasculature, but the patterns differed. Venous sinus
impressions are shallower under the areas of greatest deforma-
tional stress; those further away from the stress show compen-
satory enlargement. In synostosis, however, the sinuses are
wider and deeper under the fused sutures. Moreover, 71% of
occipitally deformed skulls demonstrated enlarged occipital
and marginal sinus impressions, and the frequency of left trans-
verse sinus dominance increased in right-sided asymmetrically
deformed skulls. This finding demonstrates both developmen-
tal plasticity of venous outflow channels and also testifies to the
ability of external compressive forces to affect them. It could be
1142 | VOLUME 60 | NUMBER 6 | JUNE 2007
the basis for a pathophysiological mechanism common to both
craniosynostosis and external deformation, namely, regional
venous outflow obstruction and subsequent consequential
increases in local intracranial pressure.
Using silicone casts in rats, Burrows et al. (8) compared
the changes in endocranial vascular channels in experimen-
tal conditions of immobilization and synostosis. The dimen-
sions of the posterior dural venous sinus were significantly
reduced in synostosed rats compared with normal or immo-
bilized rats. They concluded that the endocranial events were
secondary phenomena that reflected regionally altered
sutural dynamics, including increased intracranial pressure,
local reductions in intracranial pressure, or accumulations of
cerebrovascular fluid.
Imaging studies seem to point toward a decrease in cerebral
glucose metabolism in the occipital cortex in children with syn-
ostosis. Using positron emission tomographic imaging of chil-
dren with single suture synostosis (metopic, coronal, or sagit-
tal), David et al (13) showed regionally variable signals for
glucose metabolism, whereas there was a consistent decrease in
the posterior occipital region, the area of visual development
and visual spatial coordination. After surgical release of the
suture, there were significant increases in maximal and average
glucose metabolism in the occipital cortex. None of these stud-
ies has focused on cognition or been able to link events sur-
rounding cranial or brain malformation or vascular alteration
to effects on cognition.
Anthropological Literature on Cognitive Ability
Although Dingwall’s (16) compendium is rich in detail on
the scope and means of cranial deformation (especially for
New World cultures), there are only minor relevant com-
ments associating it with cognitive ability one way or the
other; indeed, this was not the object of the work. Dingwall,
in referring to extant cultures of which he had direct contact
stated, “It does not seem that the practice of head deforma-
tion among the North West Coast tribes affects their mental
faculties” (16). In his 1839 Crania Americana: Or a Comparative
View of the Skulls of Various Aboriginal Nations of North and
South America, Morton (37) described the devices used for
shaping heads in detail. Despite the deformation, he noted
that “the absolute internal capacity of the skull is not dimin-
ished, and, strange as it may seem, the intellectual faculties
suffer nothing” (37). He cited journals of travelers to the
area to support this contention. Nineteenth-century
American explorers, including Lewis and Clark, described
the extreme cranial deformations of Native Americans in the
Columbia River Basin. While visiting the Chinook, Dingwall
noted that both sexes had their heads “flattened in a most
disgusting manner” (16), whereas other explorers tended to
discount the deformations as hidden by the hair. However,
the explorer J.K. Townsend, in his 1839 “Narrative of a jour-
ney across the Rocky Mountains to the Columbia River,”
recounts the observation of a young child from whom the
deforming apparatus had just been removed. The entire
frontal region was flattened, causing an enormous projection
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A discolored as were the surrounding orbital areas. However,
B from North, Central, and South America, along with others
FIGURE 5. A, frontispiece of Morton’s Crania Americana. B, skull of a
“Kalapooyah Indian,” a living counterpart to which Morton encountered
among the Chinook who “appeared to . . . possess more mental acuteness
than any Indian [he] had seen” (37). As documented by plates in Crania
Americana, other tribes on the Columbia River that practiced cranial defor-
mation included the Chinook, Cowalitsk, and Killemook. From, Morton
SG: Crania Americana; or a Comparative View of the Skulls of Various
Aboriginal Nations of North and South America. Philadelphia, J Dodson,
1839 (37).
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IMPLICATIONS OF CRANIAL DEFORMATION PRACTICES
behind, and the child’s protruding eyes were inflamed, and
the child seemed to behave and react normally to its mother
and others (16).
“Collectively known at the time as ‘Flatheads,’ these groups
practiced parallelofronto-occipital deformation by a board or
bindings placed across the infant’s forehead while it was posi-
tioned in a cradleboard (Fig. 5). Lewis and Clark are quoted as
finding these people “inquisitive and loquacious, with under-
standings by no means deficient in acuteness, and with very
retentive memories.…Every thing they see excites their atten-
tion and inquiries…all our inquiries they answered with great
intelligence…they are keen, acute and intelligent” (37). Morton
had occasion to meet one “full-blood Chenouk” whose “head
was as much distorted by mechanical compression as any skull
of his tribe in my possession, and presented the very counter-
part to the Kalapooyah figured on the annexed plate” (Fig. 5)
(37). According to Morton, who gained the young man’s con-
sent to measure his skull, “he appeared to me to possess more
mental acuteness than any Indian I had seen” (37).
Although later derided for many of his racial categorizations
and conclusions based on cranial measurements and phreno-
logical observations of various cultures, Morton’s information
on cranial shaping among American continent peoples was
unsurpassed in its day and remains a unique primary source of
information on cranial deformation. He collected ancient skulls
from various extant tribes in the continent. He also interviewed
many explorers of these regions and was familiar with writings
from the age of the Spanish conquistadors.
In fact, a central theme of Morton’s work is that he could find
no evidence of cognitive deficits among peoples practicing
severe cranial deformation. He theorized similar means by
which the tribes on the Columbia river, ancient inhabitants of
Venezuela, the Charibs of the Antilles, some tribes of Peruvians,
and other peoples of North and Central America had foreheads
“compressed by art, the back and lateral parts of the cranium
become proportionately expanded, in order to make room for
the brain that has been displaced from the anterior chamber.…”
(37). Furthermore, Morton wrote that many ancient Peruvians’
heads were “as remarkable for their narrowness as for their
length” (37). He continued,
when nature has denied an imaginary grace, art is
called in to supply the deficiency; and even where
there has been no such deficiency, human vanity
prompts to extravagance.…It would be natural to
suppose that a people with heads so small and
badly formed would occupy the lowest place in the
scale of human intelligence. Such, however, was not
the case…
as Morton quotes accounts of Conquistadors who described
the fabulous architectural structures of pre-Incan and Incan
civilization (37). Morton criticized others for their primitive
view of the Inca:
VOLUME 60 | NUMBER 6 | JUNE 2007 | 1143
LEKOVIC ET AL.
A tians are at least equaled by those of the Peruvians.…a
B are common in the monuments of Peru (Fig. 6) (37).
FIGURE 6. A, a Chinook cradleboard that Morton acquired from a friend.
The neck of the child rested on the ridge to the right of the board (D). C is
a grass pad that was drawn over the child’s forehead. The other parts
marked D were for straps to keep the child’s body in place. The body rested
on a mat of soft grass. E is a support for the cradle or a step to raise the cra-
dle head up in the air for easier lifting. According to Morton, children
reportedly remained in such a cradle from 4 to 8 months, “or until the
sutures of the skull have in some manner united, and the bone becomes
solid and firm” (37). Morton wrote that “…so highly is this deformity val-
ued among the Columbia River tribes, that their slaves (who are for the
most part derived from the adjacent tribes) are not allowed to practice
it.…[The] absolute internal capacity of the skull is not diminished, and,
strange as it may seem, the intellectual facilities suffer nothing. The latter
fact is proved by the concurrent testimony of all travelers who have writ-
ten on the subject” (37). From, Morton SG: Crania Americana; or a
Comparative View of the Skulls of Various Aboriginal Nations of
North and South America. Philadelphia, J Dodson, 1839 (37). B, illus-
tration of a Chinook mother with an infant in the head molding apparatus.
Dingwall writes, “The old Spanish Franciscan Diego de Landa who dealt
with the Maya… and who was Bishop of Merida about 1572, described
how the natives of his day deformed the heads of their children. …Scarcely
four or five days after birth the child was stretched out upon a sort of lit-
tle bed made of reeds or strips of other material, and then the head was
placed between a couple of boards, one at the back and one at the front.
These were then pressed together and fastened. For days at a time the
child was thus left in suffering…and sometimes so much pain was caused
that the children died, [or] had openings behind the ears, a condition of
things which…was not uncommon” (16). From, Dingwall EJ: Artificial
Cranial Deformation: A Contribution to the Study of Ethnic
Mutilations. London, John Bales, Sons & Danielson Ltd., 1931 (16).
1144 | VOLUME 60 | NUMBER 6 | JUNE 2007
Thus the seemingly superhuman efforts of the Egyp-
people destitute of horses, oxen, or any beast of bur-
den except the feeble lama; and yet they have left
monuments which sufficiently attest their great inge-
nuity and indomitable perseverance.…The arts of the
present day, with all the refinements of successive
generations of ingenious minds, would perhaps be
inadequate to achieve those remarkable ends which
Morton also discussed Incas in the province of Chicuito who
molded their children’s heads “for the purpose of increasing
the ferocity of countenance in war…and adding to the health
and strength of the body” (37). For one Peruvian tribe, “all
their attention is bestowed on preserving a firm texture of the
body, and on flattening the forehead and hinder part of the
head [in an upward direction] with a view of resembling…the
full moon, and of becoming the strongest and most valiant peo-
ple in the world” (37). The Inca Huyna Capac, through a pas-
sage from Garcilaso de la Vega in Morton’s work, mentioned a
culture that he conquered that achieved a remarkable appear-
ance with severe cranial deformation: “ …they deform the
heads of their children by placing, at birth, a small board on the
forehead and another on the occiput, and drawing them tighter
day by day until the child has attained the age of four or five
years. By this process the head becomes broad from side to
side, and narrow from back to front. Not satisfied with this
deformity they shave the hair from the top of the head, and the
nape of the neck, letting it grow on the sides only; and this not
being combed or arranged, but rude and entangled, adds to the
hideousness of their physiognomy” (37).
As among the Maya, Morton noted “the custom of molding
the cranium into artificial forms is of great antiquity and preva-
lence in Peru.” (37) In fact, it was so common that in 1585, the
Ecclesiastical Court of Lima forbade parents, under specified
penalties, “to compress or distort the heads of their children in
the various modes which were in vogue even at that late
period” (37).
More recently, Ortner (42) stated that, the complications of
cranial deformation are mainly cosmetic, while noting that
compression could disrupt normal growth at the cranial
sutures and give rise to minor abnormalities. Citing Moss’s
1958 study indicating that the magnitude of growth is not
reduced, Ortner concluded that “the practice probably did not
produce any serious health problems” (42).
In most societies in which intentional cranial deformation is
practiced, deformed crania are typically associated with people
of high status. Therefore, it seems unlikely that significant cog-
nitive impairment results from such shaping (Fig. 7). That far
more extreme intentional cranial deformation than that found
in modern American children has been practiced across cul-
tures for long periods suggests that such adverse cognitive
effects are unlikely. In his letter to George Anderson, Ashley
Montagu replied,
www.neurosurgery-online.com

All the evidence we have indicates that no form of
head binding has any untoward effect upon the
growth of either the brain or the development of the
mind.…My experience with artificially deformed cra-
nia strongly suggests that no alterations are produced
except 1) alteration in the form of the bones and 2)
pressure may approximate the squama temporalis
toward the frontal bone, or rather, the other way
round, if the pressure is occipito-frontal, or merely
frontal. The sutures remain unaffected, that is to say,
there is no premature synostosis, and this is an
important point because it enables one to distinguish
between those pathological cases in which there has
been premature synostosis of endogenous origin
from those cases which, as in artificial cranial defor-
mation, are of exogenous origin. I have never heard
of a case of artificially produced microcephaly as a
result of artificial cranial deformation. Anything can
happen, but I think it extremely unlikely that such a
result is likely to follow upon any of the large vari-
eties of artificial cranial deformation. What some-
times happens is that the visceral layer of the dura
mater tends to adhere to the cranial layer, and that
the arachnoid may also be involved, and sometimes,
also, the pia, in forming adhesions to the inner table
of the skull. This is particularly the case in frontal
forms of deformation. In such forms of deformation
an exophthalmos is produced by the pressure-in cer-
tain parts considered muy simpatico!” [sic] (44)
CONCLUSION
The anthropological record supports endocranial effects of
head deformation in situations that parallel those of the posi-
tional plagiocephaly that has followed the adoption of the
Back to Sleep campaign. However, the overwhelming preva-
lence of head shaping in ancient cultures seems to argue
against cranial shaping exerting a significant adverse effect on
cognition. Across history, cranial deformation has been much
more severe than that currently encountered by neurosur-
geons. Yet many cultures, including most of their populations
or at least their leading citizens, have practiced incredible
skull deformation, while still achieving marked cultural pro-
gression (e.g., producing architecturally complicated struc-
tures, systems of calendars, mathematics, and materials work-
manship). Such cultural progression would likely have been
precluded if cognitive deficits had been widespread among
those of high status, much less across most of their popula-
tions. Some cultures, such as the Maya, achieved high levels
of scientific and artistic sophistication despite their wide-
spread practice of extreme forms of head shaping. Even if the
archeological record reflects only a small subset of the Maya,
such as the elites, those people presumably responsible for
advancing and maintaining Maya culture, it would be logical
to assume that at least gross deleterious effects would be
noted rapidly and the practice halted. Nevertheless, some
NEUROSURGERY
IMPLICATIONS OF CRANIAL DEFORMATION PRACTICES
form of cognitive effect (e.g., a “learning disability”) cannot be
discounted entirely. However, the observations of cranial
deformation with proptosis by Ashley Montagu and J.K.
Townsend imply significant increases in intracranial pressure
in these individuals. Around-the-head, or band-type, defor-
mation procedures would seem to be more serious in not
allowing the head to expand in compensatory ways. Over
time, such procedures would cause brain injury with associ-
ated intellectual deterioration. The translation to a popula-
tion scale may be that a cognitive effect, although not obvious,
could be serious enough and culturally widespread so as to
interfere with the ability of a culture to respond to certain
challenges. The collapse of the southern Mayan culture
remains enigmatic, attributed to warfare, invasion, migration,
disease, over-farming, social class struggle, economic collapse,
religious change, and climactic alteration. It is intriguing,
however, to postulate whether or not neurological effects from
artificial head deformation contributed to the scenario of cul-
tural demise. Unfortunately, the record of severe head shaping
found in some of the most notable ancient cultures in the New
World does not lend itself to a direct demonstration of the
effects of cranial deformation on cognition. There is simply no
way to test cognition in cultures that precede us by centuries.
As Ashley Montagu stated, the mystery is likely to go on as
“unfortunately microscopic examinations [on the brains under
conditions of artificial cranial deformation] have seldom been
done.” If present, however, such a cognitive effect may have
been adapted to or contributed to the perceived world or
Weltanshauung of these peoples in an interesting and meaning-
ful, or even culturally harmful, way. Perhaps, considering the
evidence from past cultures that practiced severe skull defor-
mation may help shed perspective on our own medicocultural
practices by which we assess and treat deformational plagio-
cephaly today.
REFERENCES
1. Anton SC: Intentional cranial vault deformation and induced changes of the
cranial base and face. Am J Phys Anthropol 79:253–267, 1989.
2. Anton SC, Weinstein KJ: Artificial cranial deformation and fossil Australians
revisited. J Hum Evol 36:195–209, 1999.
3. Argenta LC, David LR, Wilson JA, Bell WO: An increase in infant cranial
deformity with supine sleeping position. J Craniofac Surg 7:5–11, 1996.
4. Balan P, Kushnerenko E, Sahlin P, Huotilainen M, Naatanen R, Hukki
J: Auditory ERPs reveal brain dysfunction in infants with plagiocephaly.
J Craniofac Surg 13:520–526, 2002.
5. Bjoerk A, Bjoerk L: Artificial deformation and cranio-facial asymmetry in
ancient Peruvians. J Dent Res 43:353–362, 1964.
6. Bradley JP, Shahinian H, Levine JP, Rowe N, Longaker MT: Growth restriction
of cranial sutures in the fetal lamb causes deformational changes, not cran-
iosynostosis. Plast Reconstr Surg 105:2416–2423, 2000.
7. Brothwell DR: Digging Up Bones. Ithaca, Cornell University Press, 1981, ed 3.
8. Burrows AM, O’Loughlin VD, Mooney MP, Smith TD, Losken HW, Siegel MI:
Endocranial vascular patterns in a familial rabbit model of coronal suture
synostosis. Cleft Palate Craniofac J 38:615–621, 2001.
9. Ceponiene R, Hukki J, Cheour M, Haapanen ML, Koskinen M, Alho K,
Naatanen R: Dysfunction of the auditory cortex persists in infants with cer-
tain cleft types. Dev Med Child Neurol 42:258–265, 2000.
VOLUME 60 | NUMBER 6 | JUNE 2007 | 1145
LEKOVIC ET AL.
10. Cheverud JM, Kohn LA, Konigsberg LW, Leigh SR: Effects of fronto-occipital
artificial cranial vault modification on the cranial base and face. Am J Phys
Anthropol 88:323–345, 1992.
11. Coe MD: Mexico: From the Olmecs to the Aztecs. London, Thames and
Hudson, 2002.
12. Cybulski JS: Skeletal Variability in British Columbia Coastal Populations: A
Descriptive and Comparative Assessment of Cranial Morphology. Ottawa,
Archaeological Survey of Canada Mercury Series No. 30, Canadian Museum
of Man, 1975.
13. David LR, Genecov DG, Camastra AA, Wilson JA, Argenta LC: Positron emis-
sion tomography studies confirm the need for early surgical intervention in
patients with single-suture craniosynostosis. J Craniofac Surg 10:38–42, 1999.
14. Davis BE, Moon RY, Sachs HC, Ottolini MC: Effects of sleep position on
infant motor development. Pediatrics 102:1135–1140, 1998.
15. Dewey C, Fleming P, Golding J: Does the supine sleeping position have any
adverse effects on the child? II. Development in the first 18 months.ALSPAC
Study Team. Pediatrics 101:E5, 1998.
16. Dingwall EJ: Artificial Cranial Deformation: A Contribution to the Study of Ethnic
Mutilations. London, John Bales, Sons & Danielson Ltd., 1931.
17. Flower HH: Fashion in Deformity, as Illustrated in the Customs of Barbarous and
Civilized Races. Humboldt Library of Popular Science Literature. New York,
Fitzgerald, 1882, vol 2.
18. Foley WJ, Kokich VG: The effects of mechanical immobilization on sutural
development in the growing rabbit. J Neurosurg 53:794–801, 1980.
19. Gerszten PC: An investigation into the practice of cranial deformation
among the pre-Columbian peoples of northern Chile. Int J Osteoarcheology
3:87–98, 1993.
20. Gerszten PC, Gerszten E: Intentional cranial deformation: A disappearing
form of self-mutilation. Neurosurgery 37:374–382, 1995.
21. Goodrich JT, Tutino M: An annotated history of craniofacial surgery and
intentional cranial deformation. Neurosurg Clin N Am 12:45–68, viii, 2001.
22. Graham JM Jr: Craniostenosis: A new approach to management. Pediatr Ann
10:27–35, 1981.
23. Graham JM Jr: Alterations in head shape as a consequence of fetal head con-
straint. Semin Perinatol 7:257–269, 1983.
24. Graham JM Jr, Badura RJ, Smith DW: Coronal craniostenosis: Fetal head con-
straint as one possible cause. Pediatrics 65:995–999, 1980.
25. Graham JM Jr, deSaxe M, Smith DW: Sagittal craniostenosis: Fetal head con-
straint as one possible cause. J Pediatr 95:747–750, 1979.
26. Graham JM Jr, Gomez M, Halberg A, Earl DL, Kreutzman JT, Cui J, Guo X:
Management of deformational plagiocephaly: Repositioning versus orthotic
therapy. J Pediatr 146:258–262, 2005.
27. Grosse LA: Essai surles deformations artificielles du crane [in French]. Paris, JB
Balliere, 1855.
28. Habal MB, Leimkuehler T, Chambers C, Scheuerle J, Guilford AM: Avoiding
the sequela associated with deformational plagiocephaly. J Craniofac Surg
14:430–437, 2003.
29. Hrdlicka A: Physiological and medical observations among the Indians of
Southwestern United States and Mexico. Washington, D.C., US Government
Printing Office, 1908.
30. Konigsberg LW, Kohn LA, Cheverud JM: Cranial deformation and nonmetric
trait variation. Am J Phys Anthropol 90:35–48, 1993.
31. Koskinen-Moffett LK, Moffett BC Jr, Graham JM Jr: Cranial synostosis and
intra-uterine compression: A developmental study of human sutures. Prog
Clin Biol Res 101:365–378, 1982.
32. Littlefield TR, Saba NM, Kelly KM: On the current incidence of deformational
plagiocephaly: An estimation based on prospective registration at a single
center. Semin Pediatr Neurol 11:301–304, 2004.
33. Lorentz KO: Cultures of physical modifications: Child bodies in ancient
Cyprus. Stanford J Archaeol 2:1–17, 2003.
34. Mason OT: Cradles of the American Aborigines. Annual Report of the Smithsonian
Institute. Washington, D.C., US Government Printing Office, 1889.
35. Miller RI, Clarren SK: Long-term developmental outcomes in patients with
deformational plagiocephaly. Pediatrics 105:E26, 2000.
36. Molfese DL, Molfese VJ: Discrimination of language skills at five years of age
using event-related potential recorded at birth. Dev Neuropsychol
13:135–156, 1997.
37. Morton SG: Crania Americana; or a Comparative View of the Skulls of Various
Aboriginal Nations of North and South America. Philadelphia, J Dodson, 1839.
1146 | VOLUME 60 | NUMBER 6 | JUNE 2007
38. Moss ML: The pathogenesis of artificial cranial deformation. Am J Phys
Anthropol 16:269–286, 1958.
39. National Science Foundation: Scientists find earliest “new world” writings in
Mexico. http://www.nsf.gov/od/lpa/news/02/pr0297.htm. Accessed 2006.
40. Neumann GK: Types of cranial deformation in the eastern United States. Am
Antiquity 7:306–310, 1942.
41. O’Loughlin VD: Effects of different kinds of cranial deformation on the inci-
dence of wormian bones. Am J Phys Anthropol 123:146–155, 2004.
42. Ortner DJ: Identification of Pathological Conditions in Human Skeletal Remains.
San Diego, Academic Press, 2003, ed 2.
43. Panchal J, Amirsheybani H, Gurwitch R, Cook V, Francel P, Neas B, Levine N:
Neurodevelopment in children with single-suture craniosynostosis and pla-
giocephaly without synostosis. Plast Reconstr Surg 108:1492–1500, 2001.
44. Preul MC: Letters: George W. Anderson to M.F. Ashley Montagu, January 17,
1958; Ashley Montagu to George W. Anderson, January 23, 1958; George W.
Anderson to Ashley Montgu, January 27, 1958. Private Collection of Mark C.
Preul, M.D., 2006.
45. Pucciarelli HM: The influence of experimental deformation on neurocranial
wormian bones in rats. Am J Phys Anthropol 47:29–38, 1974.
46. Pucciarelli HM: The influence of experimental deformation on craniofacial
development in rats. Am J Phys Anthropol 48:455–461, 1978.
47. Sommerring ST: Vom baue des menschlichen Korpers [in German]. Leipzig,
Voss, 1800.
48. Tiesler V: Head shaping and dental decoration among the ancient Maya:
Archaeological and cultural aspects. Presented at the 64th Annual Meeting of
the Society for American Archaeology, Chicago, March 24–28, 1999.
49. Torres-Rouff C: Shaping Identity: Cranial Vault Modification in the Pre-
Columbian Andes. Santa Barbara, University of California, 2003 (dissertation).
50. Turk AE, McCarthy JG, Thorne CH, Wisoff JH: The “back to sleep campaign”
and deformational plagiocephaly: Is there cause for concern? J Craniofac
Surg 7:12–18, 1996.
51. von Winning H: Process of head deformation shown by mesoamerican fig-
urines. Masterkey 42:53–58, 1968.
52. Wells C: Arificial Interference. London, Thames and Hudson, 1964.
53. White CD: Sutural effects of fronto-occipital cranial modification. Am J Phys
Anthropol 100:397–410, 1996.
54. Wilford JN: Mother Culture, or Only a Sister? New York Times, March 15, 2005.
Acknowledgments
Gregory P. Lekovic, M.D., Ph.D., received the Vesalius Prize from the History of
Neurological Surgery Section of the American Association of Neurological Surgeons
for this study, which was presented in part at the 73rd Annual Meeting of the
American Association of Neurological Surgeons in New Orleans April 16–21, 2005.
We thank Charles Merbs, Ph.D., for his photographs from the collections of
Arizona State University and the Museum of Man, Jorge Perez de Lara for pho-
tographs of Olmec and Mayan antiquities, and the Dallas Museum of Art, Dallas,
TX, for the photograph of the Olmec figurine.
COMMENTS
T he authors have performed a most interesting review of cranial defor-
mation and its practice in ancient cultures. The report was originally
sparked by a series of recent publications that suggest there is a higher
incidence of developmental delays in children with craniosynostosis
and, more importantly, in the population of children with deformational
plagiocephaly. In reviewing some of the recent work on this subject, the
increasing numbers of children with developmental issues is somewhat
alarming. Keeping that concept in mind, the authors were interested in
whether the practice of cranial deformation, intentionally performed in
most cases, caused a similar incidence of developmental delay. In a care-
ful analysis of the early literature from explorers and conquistadors, it
became clear that intentional cranial deformation apparently did not
cause a higher incidence of developmental delay. The images the authors
have attached to the paper clearly point out some of the severe cranial
deformations that were obtained with these practices. I remember a lec-
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ture by William Feindel, MD, in which he advocated that the possible
demise of the Mayans during the late classic period (circa 800–900 A.D.)
might be caused by overly severe intentional cranial deformation. He
argued that this practice, typically only allowed among the nobility,
might have led to a higher incidence of epilepsy and developmental
issues. It’s a provocative thought, but no one has an answer; hence the
speculations are most interesting to read. The only question that remains
in my mind is the recent disturbing issues being raised regarding devel-
opmental delays in children with deformational plagiocephaly. If this is
true, then we have a serious problem, because pediatric neurosurgeons
and neurologists are observing an epidemic of this disorder.
James T. Goodrich
Bronx, New York
T his fascinating article is the product of a careful review of the scien-
tific literature as well as the anthropological collections of two large
institutions to examine the evidence for any adverse consequences on
cognition associated with the practice of intentional cranial deforma-
tion. The authors focused their research on the practice in the Americas,
although intentional cranial deformation occurred at different times
by different cultures on every inhabited continent. The question stated
by the authors for this study is whether plagiocephaly resulting from
craniosynostosis causes cognitive impairment. They surmise that, given
the severity of the deformational plagiocephaly caused by intentional
cranial deformation, if the practice did not result in any cognitive
deficit, then the much “milder” cases of positional cranial molding
encountered by physicians today would be even less likely to result in
cognitive impairment.
The authors conclude from their investigation that there were likely
no adverse consequences on cognition associated with even the most
extreme forms of intentional cranial deformation as practiced in the
Americas. Otherwise, the practice would have likely not been so
widely practiced throughout human history. An important question
is, what were the origins of this mutilation that was practiced by cul-
tures widely separated by time and space?
Enrique Gerszten
Richmond, Virginia
Peter C. Gerszten
Pittsburgh, Pennsylvania
T his article contains a fascinating description of historical cranial defor-
mation along with a relevant discussion of contemporary thought on
NEUROSURGERY
IMPLICATIONS OF CRANIAL DEFORMATION PRACTICES
positional plagiocephaly. As the authors note, the incidence of this con-
dition is increasing, making current dialog regarding the topic particu-
larly relevant. Although careful to point out the lack of any direct evi-
dence relating intentional cranial deformation and cognition, the authors’
consideration of the advancement and productivity of the historical civ-
ilizations in which this practice was prevalent makes for an intriguing
argument. Considering the growing number of children who are devel-
oping plagiocephaly, along with their concerned parents, the historical
context presented here will make for interesting discussion.
Lissa C. Baird
Michael L. Levy
San Diego, California
I n recent decades, paleoanthropology has undergone impressive
advances from a merely descriptive and historical discipline to a
dynamic interpretation of the variability of the human cranium in
terms of the functional and structural relationship of its different com-
ponents. The anatomical variations induced by volumetric changes of
the brain are those that most attracted the scientists’ attention.
Consequently, the changing human cranial phenotype is presently
interpreted as an integrated functional structure rather than a sim-
ple coexistence of different and variable features. Craniosynostosis
can be regarded as a kind of disorder that interrupts the harmony of
the progressive change of the calvarium and face during human
evolution. The therapeutic efforts are indeed aimed at reestablishing
an “ideal” phenotype, namely, the perfect shape of the face and the
cranium.
Cranial molding, and in particular, positional posterior plagio-
cephaly, represents an additional puzzling phenomenon for functional
craniology, as the deformed calvarium seems to not be associated with
significant functional disturbances. There are several examples of pop-
ulations that seem to have associated artificially deformed craniums
with privilege. Although cumulative experience suggests minimal or
absent neurofunctional impact of molded craniums, the reason for such
an attitude continues to remain very intriguing. Lekovic et al. stimulate
the debate with this elegant and very exciting review that uses an orig-
inal source of information to question the possible impacts of cranial
molding on neurodevelopment.
Concezio Di Rocco
Rome, Italy
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