Trepanation (primitive Neurosurgery) in the Ancient Greek world

In this article we present a summary of official (published) information on trepanation in the Ancient Greek world. The word trepanation comes from the Greek word trypanon (τρύπανον) meaning trepan, or borer. It refers to the surgical procedure of creating an opening in the skull. Trephination is a more recent word and specifically refers to an opening made by a circular saw (trephine), but both terms are used interchangeably in the literature. Trepanation is a kind of primitive Neurosurgery.

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Paleoneurosurgery represents a comparatively new, still-developing aspect of neurosurgery that comprises the identification of archaeological skull and spine finds and the study of their neurosurgical aspects. Skull trepanation of the cranial vault, one of the most intriguing paleoneurosurgical techniques, was widespread in antiquity. This neurosurgical operation (also called trephination or trephinement) involves the removal of one or more pieces of bone without causing any damage to the blood vessels, the three
membranes that envelop the brain, or the brain itself; it is a procedure that requires both skill and care from the part of the surgeon.

In trepanation, the skull is perforated via various techniques. Surgical instruments used in the Neolithic period included hand drills of flint and obsidian stone, whereas in the Bronze Age both stone and metal instruments were used. Osteoarchaeological evidence suggests four basic techniques of trepanation: 1) scraping with a rough or abrasive tool until the dura was exposed; 2) using a sharp-point stone to carve a circular piece of bone from the skull; 3) drilling multiple burred holes to create a circle and then cutting the space between the holes to allow removal of a disk of bone—a more dangerous method
and therefore probably a rare technique; and 4) making four cross cuts to remove a rectangular piece of bone.

The aim of the present paper is to present one of the most ancient cases of trepanation
on a skull excavated in Greece. The approach to this trepanation case (FOP 1/S 9; 1900 BC) has been by macroscopic observation (16), whereas this paper attempts documentation via computed tomography (CT) methods.

As for the archaeological context, Kirra is located approximately 10 km northwest Delphi. According to the archaeological evidence, this ancient city developed significant cultural activity during the Middle Bronze Age (1900e1600 B.C.), 1000 years before the golden period of Delphi Oracle. Both macroscopic examination and threedimensional CT were used in this study.

The relatively large size of this skull and also the excessive mastoid process and supraorbital arches seem identify it as belonging to a man. The cranial sutures give us an indication that the man from Kirra died at 30-35 years of age. Trepanation was performed on the right parietal bone. The healed aperture of this ancient operation has relatively small dimensions (14 × 10 mm). The actual hole has shorter dimensions (8 × 7.5 mm). The shape of the actual hole is oval or ellipsoid.

Both macroscopic and computed tomography evaluation demonstrate an intravital bone reaction at the edges of the aperture. Projected on the right surface of the brain, the trepanation is located on the level of the central groove. The small dimensions and the symmetrical shape of this hole give us an indication that it was made by a metal tool.

The skull shows normal bone healing after surgery at the margins of trepanation openings and is marked grossly by a closed diploe. There is good osteological evidence that the young man survived the operation and lived for a long time (months to years) after it.

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Conclusion We describe a skull trepanation from the Bronze Age Greece. Although there is not enough data about the cause and the goals of this operation, no one should dispute
the knowledge and the abilities of the ancient neurosurgeon who managed to design rightly and operate successfully lengthening the life of the young inhabitant of Kirra. Given the exceptional fact that, through a misty path, trepanation has survived from the Bronze Age through to modern practice, we can reasonably bear that, indeed, neurosurgeon’s profession must be one of the world’s oldest.

(Source: “Neurosurgery during the Bronze Age: a skull trepanation in 1900 BC Greece”, by Papagrigorakis MJ, Toulas P, Tsilivakos MG, Kousoulis AA, Skorda D, Orfanidis G, Synodinos PN. )

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Cranial trepanation is the oldest neurosurgical operation and its roots date back to prehistory. For many centuries, religion and mysticism were strongly linked to the cause of diseases, and trepanation was associated with superstitions such as releasing evil spirits from inside the skull. The Hippocratic treatise “On injuries of the head” was therefore a revolutionary work, as it presented a systematic approach to the management of cranial trauma, one that was devoid of spiritual elements. Unfortunately, there are only a limited number of skeletal findings that confirm that the practice of trepanation was performed as part of Hippocratic medicine. In this historical vignette, the authors present a trepanned skull that was found in Chios, Greece, as evidence of the procedure having been performed in accordance with the Hippocratic teaching. The skull bears a parietal bur hole in association with a linear fracture, and it is clear that the patient survived the procedure. In this analysis, the authors examine the application of the original Hippocratic teaching to the skull of Chios. The rationalization of trepanation was clearly a significant achievement in the evolution of neurosurgery.

The use of skull trepanation in antiquity has been well documented, and archaeological research has revealed trepanned skulls that date back to the Mesolithic era, some of them bearing evidence of healing. Prehistoric men clearly practiced the procedure.

The earliest written description of trepanation is found in the Hippocratic treatise “On injuries of the head.” The writer presents a systematic approach to head injuries and provides a detailed description of the indications, timing, and techniques of trepanation. It is likely that, following dissemination of this account, the method began to be performed for purely medical reasons.

Despite a rich literary record, there is little in the way of skeletal evidence to confirm that cranial trepanation was indeed performed by Hippocratic physicians.24 However, a trepanned skull that dates back to the second half of the second century BC was found on the Aegean island of Chios, Greece, and it constitutes one of a very few known skull trepanations that might have been performed under the influence of Hippocratic medicine. The archaeological dig was conducted in the Hellenistic necropolis of the island in 2003.

Cranial surgery in Greece predates Hippocrates by many centuries. The oldest skeletal evidence of trepanation discovered to date was in a Minoan ossuary in Crete (Early Minoan to Middle Minoan period, 2200–1720 BC). Trepanned skulls belonging to different periods have also been unearthed in Delphi (Middle Bronze Age period, 1700–1750 BC), the Peloponnese (Late Helladic period, 1400–1060 BC), Crete (8th century BC), Abdera (7th century BC), and in many other regions, indicating a wide geographic as well as a prolonged chronological distribution. Fabbri et al. presented a case of cranial trepanation that was performed at the beginning of the 5th century BC, in a Greek colony in Sicily. This procedure was evidently performed in the manner that was described a few decades later in “On injuries of the head.” The lack of relevant skeletal evidence in the geographic area of ancient Greece during and after the Hippocratic era has, however, led some authors to suggest that the practice was not popular among the physicians of that time. Another possible explanation could be that relevant archaeological material has not been studied adequately.

On the skull of Chios, the location of the bur hole immediately over the fracture in the otherwise solid parietal bone is in accordance with the Hippocratic teaching of scraping down on linear fractures. The bur hole was not made where the fracture intersects the squamosal suture because Hippocrates taught that trepanation over cranial sutures should be avoided. Whether this represents knowledge of the anatomical relationship between cranial sutures and dural sinuses is uncertain. Moreover, the scraping on the skull of Chios did not extend onto the temporal part of the fracture, probably because of a misconception that cutting the superficial temporal artery could cause contralateral spams, which were regarded as a poor prognostic factor. In the case of the Chios skull, it is not known whether there was any associated intracranial injury.

The trepanned skull found in Chios illustrates the state of development of medicine in ancient Greece and sheds some light on the practice of skull trepanation in Hippocratic medical culture from the neurosurgical perspective. Moreover, what the skull shows us validates the theory described in the treatise “On injuries of the head” and removes some of the speculations regarding the history of cranial surgery.

(Source: “The skull of Chios: trepanation in Hippocratic medicine”, by Tsermoulas G, Aidonis A, Flint G.)

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Abstract The paper deals with a new case of partial cranial trephination found in one of the necropolises of the Greek colony of Himera in Sicily. It is one of the very few cases of cranial trephination of Greek classical age. Macroscopic as well as radiological investigations prove that the operation was perimortal as no growth of new bone could be detected, SEM-EDS microanalysis of the piece revealed the traces left by the tool used during trephination. The review of ancient Greek and Latin medical and surgical texts permitted us to establish that the tool used in Himera was a (trypanon) mentioned by Hippocrates and named terebra by Latin authors.

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Himera was an important Greek colony on the northern coast of Sicily, founded in 648 B.C. and destroyed by the Carthaginians in 409 B.C. In Himera, three necropolises (Vassallo 1993, 1998, 2005) have been found: the southern necropolis ‘Cozzo Scacciapidocchi’; the western necropolis which includes ‘Piano del Tamburino’ and ‘Piana di Buonfornello’; and in the east, ‘Pestavecchia’. The Pestavecchia necropolis (Fabbri et al. in press) on the coastal plain is around 1 km long (east-west) and 90- 100 m wide (north-south). More than 2,400 tombs have been discovered in the past 15 years of excavations performed by the Directorate of Cultural Heritage of Palermo. Pestavecchia yielded the most ancient Himerian tombs founded so far, representing the first generation of Greek settlers. The antiquity of the tombs and the wealth of grave goods accompanying the skeletons render the necropolis of Himera-Pestavecchia one of the most important in Sicily and southern Italy.

Tomb n°2004 from Himera-Pestavecchia (HimPT2004), of the so called “cassa” type, found in 2004, contained one partially preserved human skeleton and five grave offerings (mainly bowls), two of which are of typical Himerian production and can be dated to between 525 and 480 B.C.. The human skeleton, according to the pubic morphology (Phenice 1969) and the high value (143.5) of the cotylosciatic index (Sauter & Privat 1955), belonged to a woman. She had just reached adult age, as proved by the erupting lower left M3, the unfused left humeral upper epiphysis, right iliac crest, and S1 and S2 vertebral bodies, the obvious traces of fusion on the occipito-sphenoid suture, and the marked billowing of the pubic symphysis (Meindl et al. 1985). An age at death of 19-20 seems the most probable for our subject. No entirely preserved long bone is present, but the length of the humerus can be estimated at 295 mm, yielding a stature estimate of about 155-160 cm, calculated using Trotter & Gleser’s (1952) “white females” formula. The postcranial skeleton is rather gracile, but it is normal with no macroscopic traces of pathology.

A circular perforation (diameter 13.2 mm) is present on the right hemifrontal bone. The margins of the hole are located 42.5 mm from the right supraorbital margin, 32.5 mm from the metopic suture, 32 mm from the coronal suture and 46 mm from the fronto-sphenoidal suture. The lesion penetrates the bone nearly perpendicularly to its surface. On both the ecto- and endocranial surfaces its margins are sharp, except some very tiny detectable chippings. The morphology of the perforation, circular with constant radius and perpendicular to the bony table, is unmatched among European trepanated skulls.

The cranium of the young woman from HimPT2004 has been trepanated during life for unknown reasons. Survival after trepanation, if any, was minimal and radiologically not detectable. It is the first Italian case of trepanation of classical Greek age and culture. The form of the trepanation is consistent with the utilisation of a cylindrical crown wheel drill, the prion or Hippocratic drill. This type of drill is mentioned in Hippocratic texts and it has been found in archeological excavations but the trepanated skull from Himera is the first direct evidence of its utilization. Moreover, the dating of the tomb (between 525 and 480 B.C.) proves that the instrument was invented before the birth of Hippocrates himself (460-355 B.C.). This find sheds new light on Greek pre-Hippocratic medicine and proves that sophisticated surgical techniques and surgical instruments already existed at least by the beginning of the 5th century B.C.

(Source: “Partial cranial trephination by means of Hippocrates’ trypanon from 5th century BC Himera”, by F. Fabbri, N. Lonoce, M. Masieri, D. Caramella, M. Valentino, S. Vassallo)

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The cult of Asclepius, as reflected through its rife healing temples, Asclepieia, remained active possibly for almost two thousand years, marking an important chapter in the global history of medicine.

Medical practice was, at the time, closely linked to religious practice which moved from the worship of local gods-therapists across Greece, to national practice under the patronage of god Asclepius (ca 13th century BC).

Possibly the most advanced and difficult surgical procedure practiced in the Asclepieia was trepanation (a word originating from the Greek word “trepani”, drill). There are strong archaeological evidence today showing that certain patients survived the seemingly barbaric operation, largely undertaken using metal tools.

In the Hippocratic Corpus, the most comprehensive knowledge base of the era, brain damage was described as an excessive imbalance of the 4 body humours. Any cranial or brain trauma was to be treated as an acute condition. Trepanation was recommended in the cases of cranial fracture (either domestic accidents or battle wounds), periosteal stripping, massive intracranial haemorrhage, apoplexy (as a cluster of acute brain conditions), epilepsy (or any continuous spasms), “acute brain anguish” (possibly stroke). The operation was performed both in adult and younger patients. A slow drilling of the cranial bones would follow a thorough examination of the whole cranium with the use of a metallic probe (Greek: µήλη), with the eventual aim of brain decompression.

Decompressive craniectomy techniques have been practiced for millennia but it is possible that they were first systematized as a neurosurgical innovation through the Ancient Greek religious cult followed in Asclepieia.

(Source: “Trepanation practices in Asclepieia: systematizing a neurosurgerical innovation”, by Gregory Tsoucalas, Antonis A. Kousoulis, Theodoros Mariolis-Sapsakos, Markos Sgantzos)

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Abstract Cranial trepanation is one of the most ancient surgical operations. This kind of ʺoperationʺ has been reported in prehistoric Greece with several specific case studies. In this paper, a significant case of trepanation, on a male skull, dated to the Late Bronze Age, is presented. Our interest was pointed firstly to the verification of the technique, secondly the description of the trepanationʹs shape and finally to the surgical procedure. A series of imaging techniques were implemented including X‐ray diffraction and CT scan imaging. The observations of the skull support our statement as to the nature of the trepanation. This specimen represents one of the earlier confirmed cases of trepanation in Greece. We also discuss when and how this technique came to Greece.

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Furthermore, it is of interest to note that the practice of trepanation remained in use from the Neolithic (Mallegni & Valasina, 1996; Weber & Wahl, 2006) until well into the European Middle Ages (Mays, 2006; Holck 2008; Rubini, 2008; Mckinley 1992; Mays, 2006; Powers, 2005).

Specifically for the Aegean region, trepanation has been discussed, to a lesser degree comparative to other regions, and primarily by researchers in the field of the history of medicine (Grmek, 1989; Arnott, 1997; Panourgias et al., 2005; Missios, 2007).

Anthropological examinations of such cases exist but are limited in number. Five cases of trepanation have been documented by Charles (1958) at Argos. Two skulls are dated to the Late Bronze Age era and the rest three are dated to the Geometric period. It is worth mentioning that these skulls have small circular holes on them possibly made with a sharp drill.

From the study of the skeletal material found in the Middle Bronze Age graves at Asine, Lerna and Mycenae (Grave Circles A, B), L. J. Angel identified five cases of trepanation, mostly performed on the parietal and frontal regions of the cranium (and occasionally on the occipital) (Angel, 1971, 1973, 1982), by using the scraping technique.

Manolis et al (1995) presented the findings on a skull from Delphi (dated to the Middle Bronze Age period, approximately 1700‐1750 BC) which displays on the right parietal bone (in the middle of the squamosal suture) a “teardrop” shaped trepanation of medium size, made also by the scraping technique. The operation was performed whilst the patient was alive; and he survived, since at the edges of the aperture were observed traces of osseous regeneration.

More recently Agelarakis (2006) and Liston (2009) have reported two trepanations dated to 7th century B.C. (Abdera) and 8th Century B.C. (Kavousi, Crete) respectively. However, there is another skull with trepanation which was unearthed from the village of Terpsithea (near the Pineios river, Thessaly), but its age is unknown, and we are waiting for the results of the radiocarbon dating. This paper presents a case study of a Late Bronze Age skull from the Agia Triada cemetery in North‐West Peloponnesus (Ilia),
which exhibits a cranial lesion that is consistent with intentional trepanation. Furthermore, we explore the introduction and early character of this behaviour in the Greek peninsula.

Results The observation of the imaging analysis of the skull supports our statement as to the intentionality of the trepanation. Both x‐ray and CT scan imaging analysis verify the characteristic bevelling and discontinuity of the bone in the area of the lesion, as well as osteogenic activity which is indicative of ante‐mortem formation and the post‐surgical survival of the individual. Bone regeneration is evident along the entire surface of the surgical lesion.

(Source: “A trephined Late Bronze Age skull from Peloponnesus, Greece”, by C. Mountrakis, S. Georgaki & S.K. Manolis)

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In the Aegean, this praxis is clearly documented already in the Middle Bronze Age—the case from Kirrha and the other ones from Lerna and Asine—although some cases from Crete might be even older. In the large corpus of human skeletal remains (the minimum number of individuals is—according to the preliminary study—in the region of 400) from the cave of Hagios Charalambos (in east-central Crete), which functioned as a secondary collective ossuary (that means the burials were originally deposited elsewhere), 3 clear cases of trepanation (one of them even as a part of a massive neurosurgical intervention) and one more possible example of an unfinished trepanation (18, 19) were identified. Consideringthe fact that this was a secondary collective burial site and the human remains were transferred to the cave in Middle Minoan IIB period (i.e., the developed phases of the Middle Bronze Age,c. 1900/1850-1800 BC), it is, unfortunately, not possible closer specify the date of the individual burials. The archaeological context, however, suggests that the chronological range for the original burials was the Final Neolithic (i.e., the final phases of Young Stone Age, c. the second half of the 4th mill. BC) to the Middle Minoan IIB phases, with most of the material from Early Minoan III to Middle Minoan I phases (c. 2300-1900 BC). It is thus probable that the trepanations from this site—which are dated to “Middle Minoan IIB period or earlier”—are older than the three Middle Bronze cases from the Greek mainland.

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There are altogether 9 clear/positive cases of trepanations known from the Bronze Age Aegean [except for the already-discussed cases, the other cases were found in Lerna, Asine and Mycenae (Argolid, Peloponnese), Achaea Klauss (Achaia, Peloponnese), Agia Triada (Ilia, Peloponnese) and 3 more uncertain (or probable) cases (Asine), Hagios Charalambos, and Archanes-Phourni in central Crete]. There are no cases of Bronze Age trepanations, however, in the skeletal material from Argos. Of the 9 clear trepanations, 7, i.e., 78%, show evident traces of at least partial healing of the edges of the trepanation hole, which indicates the patient survived the surgical intervention. Only 2 trepanations were not successful (Lerna and Mycenae), making the mortality rate 22%.

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The trepanations in the Aegean were performed at the latest from the Middle Bronze Age till the end of the Late Bronze Age. However, it is very probable that these interventions were performed already in the Early Bronze Age—which is indicated by the Hagios Charalambos cases—but Papagrigorakis et al. mention a wrong reference (without any positive evidence) in this context. The success rate is surprisingly high—78%. Two thirds of the cases were found in the Peloponnese and central Greece, the last third in Crete.

(Source: “Skull Trepanations in Bronze Age Greece: An Archaeologist’s View”, by Tomas Alusik)

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Research-Selection for NovoScriptorium: Philaretus Homerides

 

 

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