International Journal of Caring Sciences 2012 September - December Vol 5 Issue 3 239

SPECIAL PAPER

Cases of Trephination in Ancient Greek Skulls

Theodoros Pitsios, PhD

Associate Professor of Physical Anthropology, Anthropological Museum, Medical School, University
of Athens Greece

Vasiliki Ζafiri, PhD

Dentist, Dental Anthropologist, Anthropological Museum, Medical Scool, University of Athens
Greece

Correspondence: Ζafiri Vasiliki, dentist, dental anthropologist. Elaion 32, N. Kifisia 1454. Athens,
Greece. vzafiri @med.uoa.gr

Abstract
Background: Trephination, or trepanning, is considered to be one of the most ancient surgical operations
with an especially extensive geographical incidence, both in the New World and in the Old. In Europe,
more than 200 finds of trephination have been found, from Scandinavia to the Balkans. The technique of
trephination or trepanning covers overall the last 10,000 years and exhibits great versatility and adjustability
in the knowledge, technical means, therapeutic needs, prejudices and social standards of each period and of
each population group. Hippocrates was the one to classify for the first time the kinds of cranial fractures
and define the conditions and circumstances for carrying out a trepanning.
Aim: The present research aims to investigate the Greek cranial trephinations on sculls from the collection of the
Anthropological Museum of the Medical School of Athens that come from archaeological excavations.
Method: Skulls were examined by macroscopic observation with reflective light. Furthermore, radiographic
representation of the skulls was used.
Results: The anthropological researches and the studies of anthropological skeleton remains that came out
during archaeological excavations from different eras and areas have given information about the medical
practices in the very important geographic area of Greece and in particular, we referred to cases of Greek
trephinations.
Key words: trephination, craniotomy, ancient skulls, Hippocrates.

Introduction
Africa and Asia (Ksettry et al. 2007). During
Trephination, or trepanning, is considered to be
this period, the percentage of survival of the
one of the most ancient surgical operations with
persons who had sustained a successful
an especially extensive geographical incidence,
trephination operation exceeds 40-70% (Kuehl
both in the New World and in the Old
1988).
(Lisowski 1967, Brothwell 1972, Spanopoulou
During the Copper era, the trephination finds
1937). Especially in Europe, more than 200
exhibit an important reduction, in relation to
finds of trephination have been found, from
those of the Neolithic period. A fact attributed,
Scandinavia to the Balkans.
on the one hand, to the custom of burning the
As far as the time span in the appearance of
dead, as a result of which the relevant
trephination is concerned, the European finds
indications on the skeletal finds of that period
dated back to the Upper Palaeolithic and
were often destroyed. And, on the other hand, to
Mesolithic period are considered dubious.
the use of metal weapons which allowed a
However, during the Neolithic period, the
greater ability to strike vulnerable areas of the
practice of trephination appears particularly
body, such as the neck and its vital blood
frequent and extensive (Lisowski 1967),
vessels.
including Europe, North and South America,

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International Journal of Caring Sciences 2012 September - December Vol 5 Issue 3 240

While, in the same period, the use of protective Clower, Stanley (2001). The next important
head covers of warriors assured a greater verification of the dangerous surgical opening
protection to the already strong bones of the of the skull with primitive means, came from a
cerebral skull, preventing the sustaining of collection of skulls in Peru with openings,
cranial injury (Breitinger 1938). In any case, impressive in size and in the frequency of
however, the discovery of relevant finds survival of the operated Peruvians (Ksettry et
suggests the continuation of the practice of al. 2007).
trephination also in the following prehistorical However, in the beginning of the 2nd century,
and historical periods, until the Medieval times. professor Elliot Smith who thoroughly
In the middle Ages, the classical method of examined, in Cairo, 15,000 Egyptian skulls,
trephination implemented was the one described was not able to ascertain not even one case of
by Celsus in his work De Medicina (25-35 a.D.) trephination for therapeutic or other purposes
(Celsus, 1971). In neighbouring geographical (Ksettry et al. 2007).
areas, such as south-west Yugoslavia and north The technique of trephination or trepanning
Albania, evidence has been found of covers overall, in the greater duration of its
implementation of trephination to man, but also implementation, the last 10,000 years and
to pets for a very long time, which extends until exhibits great versatility and adjustability in the
the 19th cent. (Boev 1959). knowledge, technical means, therapeutic needs,
In certain areas of the world, the practice of prejudices and social standards of each period
trephination was maintained until our time. and of each population group.
Thus, in Kenya, cases of living persons were Definitely, in the farther prehistoric period, the
reported, who had undergone more than one implementation of trephination must have been
operation of skull opening, in conditions with stone tools, mainly of silicate stones which
equivalent to those of prehistoric times dispose of excellent hardness and form edges
(Margetts 1967, Lisowski 1967, Brothwell with an excellent cutting ability. Much more,
1972). and since the Neolithic period and especially in
During the 18th and 19th century, trephination the wider geographical area of the Aegean,
operations had been rejected as a therapeutic volcanic tools must have been used, which
surgical method, due to the high mortality that disposed of even greater abilities to shape and
reached 100% at that time. This belief was to serve many uses (as blades, drills, spear-
overturned thanks to the progress of heads, knives, sharpeners, etc.).
microbiology and the use of antiseptic The techniques of carrying out trephination
substances, as well as to the discovery of with stone tools was with the method of
ancient skulls which had sustained trepannings gradually scraping, first the outer plate, then the
and maintained clear indications of healing of diploe, and finally the inner plate of the cranial
the craniotomy and survival of the person bone. Or with the gradual opening of a circular
operated. canal up to the full incision and removal of
In Greece the practice of trephination for cranial fragments, avoiding injuring the brain,
therapeutic purposes is considered granted at as well as with the gradual opening of straight
least since the 5th cent. b.C. based on relevant canals which created a square or polygon,
reports in the writings of Hippocrates, which instead of the circular or elliptic form of the
reveal that the operation must have been quite cranial incision.
frequent in our geographical area (Krug 1984, In the next prehistorical and historical periods,
Lisowski 1967). However, apart from the the carrying out of trephination was done with
literary or historical sources, very few verified metal tools, either by opening holes of a small
trephination finds are known from the discovery diameter in a circular form, which were then
of relevant palaeoanthropological finds brought connected by cutting the intermediary bone
to light by archaeological excavations in bridges (Steinbock 1976, Lisowski 1967), and
Greece. with the use of a metal drill with a cylindrical
The first researcher who ascertained the end, which allowed the removal of a disc-
existence of ancient trephinations was the shaped section of the cranial bone. This method
famous doctor and anthropologist Paul Broca, was established by Celsus (Celsus Cornelius), a
in a collection of prehistoric skeletons from famous Roman doctor of the 1st cent. a.D.,
central France, dated at 4000-5000 years thanks to his classical work “De Medicina”, and

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International Journal of Caring Sciences 2012 September - December Vol 5 Issue 3 241

met with wide implementation for many pressure to the brain. Finally, in his
centuries. In any case, of the different kinds of “Epidemics”, two more cases of trephination for
trephination implementation, the most frequent therapeutic purposes are mentioned: that of a
was the case of circular opening (Brothwell young man with a head injury from horse hoof,
1972 Celsus, 1971). and of another hit with a stone (Krug 1984).
Despite the relevant bibliographical references, The operation involved the removal of the soft
it is considered doubtful whether the use of tissues and revealing of the cranial bone to an
natural anaesthetic substances was wide, i.e. of extent greater than that of the wound, so as to
alcohol, coka leaves, opiate substances and be able to spot with precision the damages in
mandrake, during the painful surgical operation the bone. For this purpose, a black thick
of trephination (Ksettry et al. 2007). substance could be used, which infiltrated in the
Hippocrates (460-370 b.C.), often called the fissured fractures of the cranial vault, thus
father of Medicine, exceeding the metaphysical helping to spot and remove bone fragments
beliefs of his predecessors, was able to establish (Krug 1984).
the medical science in the objective observation
and logical processing of the data. He was the Aim
one to classify for the first time the kinds of The aim of this study is the investigation of the
cranial fractures and define the conditions and Greek cranial trephinations at the
circumstances for carrying out a trepanning Anthropological Museum of the Medical
(Ksettry et al. 2007). School of Athens that come from
The classification of cranial fractures by archaeological excavations. In addition, we
Hippocrates included five categories based on attempt to shed new light on patients, diseases,
the alterations of the cranial bones, due to the and therapeutic interventions of the remote past
wound: on the very important geographic Greek Area.
• Fissured fracture which is always
accompanied by a brain hematoma Method
• Hematoma of the bone, without a fracture The examination of the skulls took place at the
• Depressed trauma of the outer plate, laboratories of the Anthropological Museum of
without any damage to the inner plate the Medical School of the University of Athens.
• Dinted trauma of the outer plate and The method of examination was macroscopic
fracture of the inner plate by opening the observation with reflective light. Furthermore,
skull radiographic representation of the skulls was
• Indirect fractures as a secondary used.
consequence of direct cranial-cerebral
Material
injuries (countercoup injuries
(Hippocrates1988,1994). The case of a Byzantine skull of Avdira
The excavation of the extensive Byzantine
For the interpretation of cranial operations, graveyard in Avdira, the burials of which are
various causes have been suggested, which refer dated between the 9th and the 11th cent. a.D.,
either to therapeutic purposes to treat injuries, took place during three excavation periods from
especially cranial fractures, epilepsy, and other 1979 up to 1981 (Sarla - Pentazou 1981). In the
conditions, or to treat mental disorders, framework of the archaeological excavations of
superstitions and “evil spirits”, or even to serve the site, on-site works of observation, assembly
ritual purposes (Brothwell 1972, Spanopoulou and maintenance of the anthropological material
1937). According to Stewart (1958), the most of the graveyard took place by a crew of the
frequent reason for carrying out a trephination Anthropological museum of the University of
must have been the effort to relieve the brain Athens.
from endocranial pressure, because of cranial After the completion of the programmed
fractures. excavation works, and during the sorting of
In Hippocrates’ paper “On Head Injuries”, the osteological material from excavations of
opening of the skull is mentioned in the cases of previous years, a small wooden case was
fractures and of cranial bone fragmentation with spotted in a site storeroom, which contained,
the purpose of removing bone fragments which among motley objects, a number of bone finds
penetrated the endocranial space, exerting which were initially considered to be useless

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International Journal of Caring Sciences 2012 September - December Vol 5 Issue 3 242

remains of an older work. Later, a more careful operation and the inability of survival of the
observation showed that most of the bone finds person.
were cranial fragments and indeed that they However, except from the circular opening Α at
came from the same human skull of a young the upper right part of the occipital bone, the
person (ΞΑΞ1/Σ29). examination of the skull also gave interesting
Specifically, the two parietal bones of the skull, data on the conditions of death of the young
the occipital bone, parts of the two temporal person (Fig. 2).
bones, as well as part of the left sphenoid, have Thus, in the left section of the occipital bone
been preserved. Along with the above, the first and at a distance of 25mm from the left end of
cervical vertebra and four teeth, two canine, one the lambdoid suture, the presence of a second
premolar and one molar, have been found and and non-completed opening Β of the skull was
are likely to belong to the same person. Based found, which could be owed to an incomplete
on the shaping of the bones of the cerebral attempt of a second trephination operation to
skull and the lack of synostosis of the cranial the same skull as, in the periphery of the bone,
sutures, the biological age of the person has fragments of bone tissue in a position of
been determined at approximately 22±5. As for penetration in the interior of the cerebral skull
the person’s sex, based on the limited have been preserved. Opening B, of which 2/3
diagnostic characters preserved, it could with of the round craniotomy is preserved, has a
relative certainty be attributed to a young man. diameter of 20 mm and a morphology same as
However, the most interesting feature of this that of the initial opening Α.
particular skull constituted the presence of a
circular opening (Fig. 1) at the upper right
section of the occipital bone, with a vertical
diameter of 24mm and a cross-diameter of
21mm, which was considered to be a clear case
of trephination. That is, a deliberate and ante
mortem operation in the aim of removing part
of the flat bones of the skull for the treatment of
a serious craniocerebral injury of the young
person. An operation known and documented
by an important number of relevant finds from
all over the world, but also from its
implementation on domestic animals which
exhibited mostly ambulatory disorders due to fig-2 Avdiron
encephalopathy /brain disease (Pitsios 1984).
In addition, at the back third of the saggital
suture and 3cm higher than the lambda, a
depressed trauma C has been found which has
caused damage to the outer bone plate and a
12x12mm/cm opening to the parietal bones. At
that spot, fragments of the outer bone plate of
the skull have infiltrated, after an external strike
to the interior of the cranial cavity, suggesting a
fatal injury, as in the case of opening B.
In the interior surface of the cranial vault, at the
spot of the injury, a part of the interior bone
plate along with spongy substance has broken
fig-1 Avdiron off at a surface four times as much (25x23cm)
as that of the exterior plate (Fig. 2), a
In this particular case, the clear and irregular phenomenon characteristic of the structure and
incision of the circular opening showed that it mechanical behaviour of the flat cranial bones
had been carried out with a hand-operated metal in cases of skull injuries (Heliakis 1963).
cutting tool. Whereas the absence of organic Finally, at the right part of the occipital bone of
operations of bone healing, in the periphery of the person and lower than opening Α, a
the circular incision, suggested the failure of the

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International Journal of Caring Sciences 2012 September - December Vol 5 Issue 3 243

depressed trauma D with a circular shaping was “operated bone” had been presented by the
found which only caused damage to the outer Secretary of the Archaeological Society of
bone plate of the occipital, which was not Athens, Mr. Stefanos Koumanoudis, as a rare
accompanied by an opening of the cranial bone, “part of a human frontal bone found a few
equivalent to that of injuries A, B and C. This months ago in a tomb in Attiki. We have not
injury is likely to have been the first and the been able to detect more accurate information”,
less painful sustained by the young Avdirite. as indicatively mentioned in the Pandora
Whereas the next two, harder hits at the back of journal.
the skull, as well as the last one at the top of the Specifically, this cranial find is made up of only
person's head must have fatally caused his a large part of the frontal bone and a small
death. fragment of the left temporal one, while it is
In any case, the total absence of healing also accompanied by four teeth, probably of the
indications in the young Avdirite’s multiple same person (Fig. 3),. These are a premolar and
craniocerebral injuries shows their temporal and two molars of the lower jaw, as well as two
causal correlation with the person’s death, more premolars.
which, most possibly, was the result of a violent Examining the parts of the cranial sutures
event and multiple injury of the person which preserved and the morphological characters of
could not be faced by the double trephination the part of the frontal and temporal bone, we are
operation. led to the conclusion that they belonged to an
The exceptionally favourable conditions of adult person, possibly male. In addition, if we
excavation and preservation of the human assume that the teeth belong to the same person
skeletal material in the sandy deposits of the (Fig. 6),, which is quite likely, then the person’s
Byzantine graveyard of Avdira, contributed to biological age of death, according to
the best possible use of the important human Brothwell’s method of biological age
skeletal material, to the study of the physical determination, could be between 25 and 35
condition and health of the population, as well years.
as to the thorough recording of the burial
customs of that period. We therefore thank once
again all the associates of the Komotini
Archaeological Museum for the warm
hospitality and for facilitating the
anthropological work with all available means it
had at its disposal.

The case of a multiple trephination of a skull

in Attiki
In September 2001, during works of
classification and maintenance of older
collections of the Anthropological museum of fig-3 Attikis
the University of Athens, which had been
assembled with personal actions of Klonos
Stefanos, founder and first Director of the
museum from 1886 to 1915, a rare and
impressive case of multiple trephination of an
ancient skull was spotted.
This skull, on the basis of the data collected,
comes from an ancient tomb of Attiki and it
must originally have been delivered to the
Archaeological Society (under find no. ∆.Υ. 65)
by an experienced seller of antiquities, around
1871. According to a scientific publication of
the 16th of February 1871, in the Pandora
journal, by doctor P. Kallivoursis, it is
fig-6 Attikis
mentioned, among other things, that this ancient

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International Journal of Caring Sciences 2012 September - December Vol 5 Issue 3 244

Yet the main interest of the find lies in the Thus, it is obvious that these pathological
presence of five perfect circular trepannings, of factors acted osteolytically in that particular
a diameter of 1 cm, opened in the right frontal area of the cranial bone, then causing a process
area of the skull, obviously with a mechanical of dissolution of the bone tissue, the
hand-operated drill(Fig. 4),. consequence of which was the observed porous
It appears, therefore, that, on the Attiki skull corrosion of the outer and of the inner bone
with the multiple trephinations, the above plate of the frontal bone. The carrying out of
process of opening of Celsus’ method was multiple trephinations in the same area of the
implemented, which helps us date the cranial cranial bone obviously aimed at opening the
find as later than the 1st cent. a.D. ailing area and removing possible inflammatory
The spatial closeness of cranial openings in the elements to relieve the patient.
same area of the frontal bone seems to be owed
to the spatially specific pathological symptoms Conclusions and Discussion
of the person and to the vain effort to relieve The anthropological researches and the studies
him, since the absence of indications of healing of anthropological skeleton remains that came
activity of the bone tissue in the areas of the out during archaeological excavations from
craniotomies shows that these were done at the different eras and areas have given information
same time and without the expected result of about the medical practices in the very
survival of the person. important geographic area of Greece. In
particular, we referred to four cases of Greek
trephinations. In 1971, Angel mentioned the
case of skull 33 of the Middle Copper era from
Lerna, which bore in the frontal area an
irregular and rough opening of the bone with a
doubtful interpretation as to its aetiology.
In 1973, the same writer described a case of a
very likely, although incomplete, trephination in
the frontal bone of skull 51 Myc which
belonged to a man of about 28 and came from
the royal tombs of Mycenae. The morphology
and the dimensions of the cranial opening
(30x27mm) resemble those of the skull from
fig-4 Attikis Avdira, which we examine. The craniotomy had
been done with an especially sharp cutting
More specifically, the macroscopic observation instrument. According to Angel, the cause of
of the bone of the cranial husk in the area of the the operation must have been the treatment of a
trephinations and specifically between the right skull injury and fracture. That is, this is a case
frontal area and the coronal suture, shows an similar to that of skull ΧΑΧ1/S29, exhibited at
osteoporotic corrosion which must be owed to the Anthropological Museum of the University
inflammatory workings of the endocranial area of Athens.
from pathological causes. This centered In the year 1982, Angel described two more
osteoporotic working was also found with an X- cases of opening in skulls 49 As and 107 As of
ray (Fig. 5). the Middle Copper era from Assini, which were
characterised by an unusual shaping of the
opening of the skull and a doubtful aetiology.
A serious and objective difficulty to diagnose
trephination in palaeoanthropological finds
constitutes the possibility of openings to the
skull, which may be due to either pathological
reasons and injuries during the person’s live, or
to organic and inorganic factors during the time
the bones were in the ground or to mechanical
damage, before or during the excavation of the
fig-5 Attikis

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International Journal of Caring Sciences 2012 September - December Vol 5 Issue 3 245

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Krug A.(1984),Medizin in der Antike.Munchen
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