IELTS Academic Reading Practice Test 388

Of all the operations that human beings have devised, the removal of a piece of bone from the skull is the oldest for which there is direct physical evidence. Known as trepanation, from a Greek word for a borer, it was performed thousands of years before the invention of writing, and skulls bearing its characteristic openings have been recovered from sites on every inhabited continent. What makes these skulls so striking is not the holes themselves but their rims. In many specimens the bone around the opening has grown smooth and rounded, a change that occurs only when a patient survives an operation for months or years.

One of the earliest known examples was found at Ensisheim, in Alsace, in eastern France, and is around seven thousand years old. The opening was produced not by drilling but by scraping away bone a little at a time with a sharpened stone — a slow and painful process that must have taken a considerable period. Some Neolithic skulls carry the marks of more than one operation, and a few show several separate openings, which suggests that a patient might submit to the procedure repeatedly. In the Andes, where the practice continued for more than two thousand years, surgeons later used obsidian blades and, eventually, bronze tools and a bow drill.

The smooth rims of many skulls are the reason archaeologists are confident that trepanation was carried out on living people rather than performed on the dead. They also allow the survival rate to be estimated, because bone that has begun to heal proves that the patient lived for at least some weeks afterwards. A study of trepanned skulls from Peru, published in 2018, concluded that survival improved markedly over the centuries. In the earliest period examined, fewer than half of the patients appear to have recovered, whereas by the time of the Inca empire the proportion had risen to around four in five.

Written sources show that the operation was well established in the classical world. A treatise in the Hippocratic corpus, probably composed in the fifth or fourth century BC, gives detailed instructions for treating head injuries, advising the surgeon when to cut away bone and warning against opening the skull directly over one of the seams, or sutures, that run across it. The author notes that these seams can easily be mistaken for fractures, and that a surgeon who confuses the two will do harm. Roman physicians continued the practice with a cylindrical saw, the ancestor of the instrument later called a trephine, and it remained a standard tool for centuries.

Why the operation was performed is harder to establish. Battle wounds and blows to the head were certainly among the reasons, and a fractured skull with blood accumulating beneath it was, in principle, a sensible thing to relieve. Historical accounts also link trepanation with epilepsy, persistent headaches and mental disturbance. Some holes may have had no therapeutic purpose at all: discs of bone cut from human skulls, some pierced so that they could be worn, have been found at Neolithic sites, and a few scholars argue that these were made from the skulls of the dead for use as amulets.

Nineteenth-century science took a long time to accept the evidence. When trepanned skulls from Peru reached Europe, some anatomists assumed that the openings had been made after death, perhaps to obtain a piece of bone for a ritual object. The French anatomist Paul Broca, who examined such a skull in the 1860s, was at first unsure, but the healed edges of later specimens convinced him that the operation had been performed on the living. His reports helped to establish trepanation as a subject of serious study.

The practice did not disappear with the ancient world. It survived in Europe through the medieval period and into the eighteenth century, and in parts of Melanesia it was still being carried out in the twentieth, sometimes with implements made from shell or bone. Such persistence is remarkable given the absence of anaesthesia, of any understanding of infection and of the instruments that make modern surgery possible.

That patients survived at all can partly be explained by the technique. Scraping, unlike drilling, can be stopped as soon as the inner surface of the skull is reached, and there is evidence that many practitioners deliberately left the membrane beneath the bone intact, protecting the brain from direct injury. The wounds were small, the bleeding limited, and the scalp heals quickly. Even so, infection must have killed many, and the skulls that archaeologists recover are only those of people who lived long enough for bone to heal — a reminder that the evidence is biased towards success.

Trepanation has not vanished; it has merely changed its name. Every time a surgeon performs a craniotomy — the removal of part of the skull to reach a blood clot or a tumour — the principle is the same, though the equipment and the reasons could hardly be more different. What the ancient skulls demonstrate is not primitive superstition but a willingness to open the body in order to save it, and a surprisingly long record of patients who lived to tell the tale, or at least to grow new bone around the hole.

Few parts of the human body alarm new parents as much as the soft spot on the top of a baby's head. It pulses, it dips, and it appears to offer no protection at all to the brain beneath. In fact the gaps in a newborn's skull are not a design fault but a set of features that make birth and early development possible. Understanding what they are, and what they are not, removes much of the anxiety that surrounds them.

The vault of the skull is not a single bone but a set of plates. In a newborn the frontal bone, which forms the forehead, is still in two halves, and it meets the two parietal bones, which form the sides and roof, and the occipital bone at the back and base. Below the parietal bones, above the ears, lie the temporal bones. Between the plates run narrow fibrous joints called sutures. Where several sutures meet, the gap widens into a membrane-covered space known as a fontanelle. A baby is born with six of these, but only two can normally be felt through the skin.

The first and most obvious job of these gaps is to let the head change shape during birth. The plates of the vault can slide slightly over one another, so that the head can be squeezed through the birth canal; obstetricians call this moulding. A baby born vaginally may accordingly have a head that looks long or slightly lopsided for a few days, a shape that usually corrects itself within a week or so. Babies delivered by caesarean section, who do not pass through the canal, generally have rounder heads.

The second job is to leave room for the brain. A newborn's brain weighs only about 350 grams, roughly a quarter of the adult figure, but it grows faster in the first year than at any later time, and by the first birthday it has roughly tripled in weight. Head circumference, a routine measurement at baby clinics, rises from around 35 centimetres at birth to about 46 or 47 at twelve months. A skull that had already fused could not accommodate such expansion, so the sutures stay open and the plates continue to grow at their edges.

The fontanelles close at very different times. The posterior fontanelle, a small triangular gap at the back of the head, is usually closed by about two or three months. The anterior fontanelle, the diamond-shaped one on top, is the last to go and typically closes between nine and eighteen months, though the range of normal is wide and partly depends on inheritance. The sutures themselves remain for far longer: the metopic suture, which runs down the middle of the forehead, usually closes within the first year, while others do not become rigid until adult life.

Because the anterior fontanelle lies directly beneath the skin, it is also useful to clinicians. A fontanelle that looks sunken is one of the signs doctors look for when they suspect that a baby is dehydrated, while one that feels tense or bulges may, in some circumstances, point to raised pressure inside the skull. Neither sign means much on its own. The same gap serves a further purpose in hospital, because sound waves pass easily through it: cranial ultrasound, widely used to image the brains of newborn babies, takes advantage of this natural window and involves no exposure to radiation.

Sometimes a suture closes far too early. The condition, craniosynostosis, affects perhaps one baby in two thousand, and it alters the shape of the head in a way that depends on which joint is affected. Early fusion of the sagittal suture, which runs from front to back over the top of the head, produces a long, narrow skull, whereas fusion of one of the coronal sutures, which separate the frontal bone from the parietal bones, flattens the forehead on that side. If several sutures close, the growing brain may be placed under pressure. Surgery, usually in the first year of life, reopens the affected joint or reshapes the vault.

Far more common is a flat area on the back or side of the head caused not by bone but by position. Since the 1990s, when parents in many countries were advised to put babies to sleep on their backs to reduce the risk of cot death, positional plagiocephaly has become much more frequent. It does not affect the brain, and it usually improves as the baby learns to sit and to turn over. Clinicians commonly suggest varying the position of the head during waking hours and allowing supervised time lying on the front.

Much remains uncertain. Why one fontanelle closes at eight months and another at twenty is not understood in detail, and the timing varies between populations, which makes it hard to say what is typical. A fontanelle that stays open unusually long is occasionally the first clue to a thyroid problem or to a disorder of bone formation, but in most children it means nothing at all. Researchers now use three-dimensional scans to measure how the plates move as they grow, in the hope of predicting which infants will need surgery and which will do perfectly well without it.

Few decisions in medicine are as personal as where a baby should be born, and few attract as much argument. In the United Kingdom, fewer than three in a hundred births take place at home; in the Netherlands, where home birth has long been part of ordinary maternity care, the figure has historically been far higher. Supporters describe home birth as a safe option that avoids unnecessary interference; critics describe it as a gamble taken with two lives. The argument, in my view, has generated more heat than light, largely because it has been conducted as though the answer must be the same for every woman.

The most substantial evidence comes from a study of planned place of birth in England, published in 2011, which followed about 64,000 women at low risk of complications. For those having a second or later baby, a planned home birth was associated with outcomes for the baby as good as those in an obstetric unit, and with considerably fewer interventions: fewer epidurals, fewer forceps deliveries and fewer caesarean sections. For women having a first baby the picture was different. Serious problems for the baby were slightly more common at home, at roughly nine cases per thousand births compared with five in an obstetric unit, and close to half of first-time mothers were transferred to hospital during labour.

These differences are not surprising once the nature of a first labour is considered. Labour is on average longer, the tissues have not been stretched by a previous birth, and difficulties such as a baby that fails to rotate, or a perineum that tears badly, are more likely. Shoulder dystocia, in which the baby's shoulder catches behind the mother's pelvis, is unpredictable and requires swift, practised hands. A woman having her second baby is in most respects a different clinical proposition from one having her first, and it is a weakness of the debate that the two are so often lumped together.

The advantages of home birth extend beyond the clinical. Women who give birth at home frequently describe a greater sense of control, more privacy and the presence of whoever they choose, and continuity with a midwife they already know is easier to arrange. There is also a financial argument: a home birth costs the health service considerably less than a hospital delivery, chiefly because it is less likely to end in an operating theatre. Many women who have experienced both settings describe the difference as one of atmosphere rather than medicine. These benefits are real, but they are mostly about the experience of birth rather than its safety, and the two should not be confused.

The strongest objection to home birth is a matter of time and distance. Most labours proceed without drama, but the emergencies that do occur — a haemorrhage after delivery, a baby who does not breathe, a shoulder that will not release — can become dangerous within minutes. A home birth therefore depends on a system: two midwives present, an ambulance that can be dispatched at once, and a hospital near enough for a caesarean section to be performed without delay. Where any of these is missing, the balance shifts. For a family living an hour from the nearest obstetric unit, home birth is a considerably riskier undertaking than the averages suggest.

How should the arithmetic be weighed? The difference found in the English study amounts to a handful of additional cases per thousand first births. In absolute terms it is small; in a service delivering several thousand babies a year it is not negligible. Parents are entitled to know the size of the risk rather than being told only that it exists, and they are entitled to weigh it against the things that make birth at home attractive to them. Some will decide that the additional risk to their baby outweighs everything else; others will not. A policy that removes the choice treats adults as incapable of judgement.

There is, finally, a question of equity. Home birth is chosen disproportionately by older, better-educated and better-off women, and money spent expanding a service used mainly by them is money not spent elsewhere. In practice, of course, resources are finite and choices have to be made. Yet the same evidence suggests that continuity of care from a known midwife, which is much of what makes home birth attractive, benefits precisely the women whose outcomes are worst in conventional systems. The lesson is not that home birth should be restricted but that the model of care it represents has value beyond the group that usually asks for it.

My conclusion is that home birth should be enabled rather than encouraged. For a healthy woman expecting a second or later baby, with a midwife she knows and a hospital within reasonable reach, it is a defensible choice, and the system should be funded to make it safe. It should not be promoted as the better way to give birth, nor offered where rapid transfer is impossible. First-time mothers should be told plainly that they are more likely to be transferred, and should not be made to feel that requesting hospital is a failure. Encouragement is the wrong verb; informed permission is the right one.