Discovery of the First Hippocratic Cranial Trepanation from the Greek colony of Himera, Sicily (6th-5th century B.C.)

Pier Francesco Fabbri1, Gino Fornaciari2, Davide Caramella3, Giada Accomando4, and Stefano Vassallo5
(Email: pf.fabbri@ateneo.unile.it)
(1Department of Cultural Heritage, University of Lecce, Italy. 2Department of Oncology, Transplants
and Advanced Technologies in Medicine, Division of Paleopathology, University of Pisa, Italy; 3Department
of Oncology, Transplants and Advanced Technologies in Medicine, Division of Diagnostic and
Interventional Radiology, University of Pisa, Italy; 4Archaeologist, Palermo, Italy; 5Directorate of Cultural
Heritage, Italy)

Introduction
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) (Figure 1). 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.

Materials and Methods
Tomb n°2004 from Himera-Pestavecchia (HimPT2004), of the so called “cassa” type (Figure 2), 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. (Figure 3). 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.
Ectocranial sutures are unfused and the metopic suture is still visible. The beginning of fusion is detectable on the endocranial aspect of the sagittal suture at its anterior and posterior ends. The lambdoid suture shows multiple wormian bones (4-5 large and many smaller ones on each branch, partially obscured by concretions). In lateral view the upper occipital squama forms a distinct bun and a modest ‘step’ is present as the cranial profile reaches lambda. The cranium shows very attenuated features, in accordance with the diagnosed female sex. Cranial measurements of HimPT2004 have been compared to those of European populations (Howells 1973) (Graph 1): the frontal bone of HimPT2004 is unusually large, XFB (maximum frontal breadth) approaches the m+2sd of European values, and the very short FRC (nasion-bregma chord) is close to the m-2sd of European values.

Graph 1. Selected measurements of HimPT2004 cranium compared to the m+/-2sd ranges of three European populations (Howells 1973).

A circular perforation (diameter 13.2 mm) is present on the right hemifrontal bone (Figure 4). 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.

Discussion
The hole in the right hemifrontal bone is clearly the result of a cranial peri-mortem trepanation. The observation of the outer and the inner compact bony layers, and of the intermediate diploe, and the sharp margins of the hole itself show that the patient did not survive the operation or the survival time was extremely short. This interpretation is confirmed by radiological analysis (Figure 5). Therefore we can not exclude that the trepanation has been performed post-mortem, for unknown reasons, but it would be unusual with respect to the principles and the practice of Greek medical science.
Cranial trepanation has been known in Italy since Neolithic times (Germanà and Fornaciari 1992). In the majority of cases cranial trepanation was performed in consequence of cranial trauma, haemorrhage or removal of bone fragments, or as treatment of vascular pathologies that produce an increase in intracranial pressure. The earliest Greek mention of the practice of cranial trepanation dates back to 5th-4th century B.C. and can be found in the Corpus Hippocraticum (Vegetti 1965), ascribed to Hippocrates (460-355 B.C.); it was usually performed in case of fractures and cranial traumas (Kuehlewein 1902).
Archeological cases of cranial trepanation of classical age are rare and no specimens from Greek culture had been found so far, neither in Italy nor elsewhere (Fornaciari 2004). In Italy only three trepanated crania are dated to the 5th–3rd centuries B.C., two from Pontecagnano and one from Poggiardo (Fornaciari 2004), but they were been found in necropolises used by indigenous non-Greek populations.
Two more trepanated skulls are of Roman imperial age (1st-3rd century A.D.) (Capasso and Capelli 1995; Scattarella et al. 1996). The cranium HimPT2004 from Himera is the first case (and the oldest) discovered in a truly Greek cultural context.
As in HimPT2004, the majority of trepanations are perfomed in the fronto-parietal region. Macroscopic and radiological observation of the cranium shows no trace of pathology nor trauma, except for the trepanation hole itself. The only peculiarities of the specimen are the relatively early beginning of fusion of the sagittal suture, and the large number of wormian bones in the lambdoid suture, features which are correlated according to White (1996), and the very short and wide frontal bone. Premature fusion of the sagittal suture, or sagittal synostosis, takes place during infancy and is the most common form of craniosynostosis, recorded in 56-58% of cases (Pensler et al. 1996). It produces a scaphocephalic cranium with prominent frontal bossing. It is usually not associated with cognitive deficiencies or elevated intracranial pressure and its surgical treatment is at present performed mainly for cosmetic and psychological reasons. In the cranium HimPT2004, aged 19-20 years, the sagittal synostosis is just beginning, the form is not scaphocephalic, the cephalic index (79.27) is nearly brachicephalic, and the frontal squama is short and broad, not long and narrow as in crania with true sagittal synostosis. We can rule out that the relatively early beginning of fusion of the sagittal suture and the short, broad frontal squama have any relation to the observed trepanation. Facchini et al. (2003) have published a trepanated cranium from Canosa that is similar, albeit more recent (6th-7th century A.D.), to our specimen (a young adult female, lacking in pathological or traumatic signs, with absence of new bone formation). The form of the Canosa perforation is different: oval in shape, and larger on the outer table (14 x 13 mm) and smaller on the inner table (13 x 11 mm).
The morphology of the lesion observed on the HimPT2004 cranium, perpendicular to the bony surface with sharp margins, an even diameter, and without traces of scraping, allows us to think that it was performed by a cylindrical crown wheel drill. Such an instrument, named a prion, is indeed cited but not described in detail by Hippocrates. A specimen of prion, also named the Hippocratic drill, has been found in the tomb of the “surgeon” from Bingen (Germany) dated to Roman times (1st-2nd century A.D.) (Keunzl 1982).

Conclusions
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.
This knowledge was later improved and formalized by Hippocrates, but not entirely discovered by him.

Figure 1. The island of Sicily, showing Himera on the northern coast. 10 Paleopathology Newsletter Figure 2. (Right) Tomb No. 2004 from the eastern (Pestavecchia) necropolis of Himera showing the skeleton and some of the associated grave goods. Figure 3. One of the bowls of Himerian production, dated to between 525 and 480 B.C., found in the tomb No. 2004. Figure 5. (Left) Radiograph of the trepanned skull, antero-superior view. Figure 4. (Above) Detail of the trepanation orifice, superior view.

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DEPARTMENT OF ERRATA
Steven N. Byers’ first name was misspelled as “Stephen” in the Annotated Bibliography section in the September 2006 issue of the Paleopathology Newsletter.