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Greek archaeologists discover evidence of a skilled surgeon who practiced centuries before Hippocrates
Sometime before 600 B.C., a surgeon in the settlement of Abdera on the north coast of the Aegean faced a difficult case. Standing back from his patient, a young woman in her late twenties lying on the table before him, he examined the wound cautiously. Normal practice required that the healer ask how an injury occurred, but here it was clear from the broken flesh and hair matted with blood. A stone or lead missile, hurled from a sling by one of the native Thracians intent on the colony’s destruction, had bit her on the back of the head. Stepping closer, a grave expression on his face, the surgeon gently explored the wound by ham and with a bronze probe. As he feared, the impact was at a point where the bones came together, joining in a suture — the weakest point of the skull.
TODAY, MOST MEDICAL STUDENTS take a solemn vow, repeating the Hippocratic Oath, named for Hippocrates, the ancient Greek physician we call the “Father of Medicine.” Although we know little about him — he has been described as the “most famous but least known Greek physician” — in his own day, Hippocrates (ca. 460-370 B.C.) was spoken of with respect by Plato and Aristotle. He was born at the island of Kos, near Ionia (the eastern coast of the Aegean Sea), and after practicing medicine throughout Greece, he devoted considerable time to teaching students.
None of the surviving late fifth- and early fourth-century B.C. Greek medical treatises — numbering about 70 and collectively known as the Hippocratic corpus — can be securely ascribed to the great physician himself. They could have been compiled by his students, who conceivably added to their master’s notes, handbooks, and lecture materials. Perhaps in part from a library on Kos, the texts — gathered together in Alexandria at a later date — reflect the rich legacy of the Ionian school of medicine.
Some of the works are instructional, such as About the Physician and In the Surgery. Others, such as Fractures and On Head Wounds, appear to have been written as practical handbooks. Of these, the Oxford Classical Dictionary notes that, “The directions for bandaging and for diagnosis and treatment of dislocations and fractures, especially of depressed fractures of the skull, are very impressive.” And it describes On Head Wounds “as a practical work by a highly skilled craftsman, and every sentence suggests experience.” Indeed, it was still in use as a medical text in Europe more than two millennia after it was written.
But new evidence, on which the story of the wounded young woman at the head of this article is based, will rewrite our history of the development of ancient medical practice. The patient was among those sent north by Clazomenae, a Greek city in Ionia, to establish a colony at Abdera around 654 B.C. She was successfully treated — a difficult operation performed by a master surgeon saved her — and lived for another 20 years. Her remains, which were excavated at Abdera by Eudokia Skarlatidou of the Greek Archaeological Service and which I have had the privilege to study, provide incontrovertible evidence that two centuries before Hippocrates drew breath, surgical practices described in the treatise On Head Wounds were already in use.
According to the historian Herodotus, the Clazomeneans at Abdera were “driven out by the Thracians” who perhaps conducted a war of attrition, contesting the colonists’ access to land for agriculture and timber or plundering and destroying their crops. Yet the archaeological record indicates that the Clazomenean settlers persisted for at least eight decades, and excavations have revealed many traces of their colony, including its 13-foot-thick fortification walls and cemeteries. In one burial ground was the grave with the well-preserved skeleton of the woman who had survived the wound and subsequent surgery.
From her bones, I could determine that apart from some dental pathologies and arthritis of the spine and limbs, she had been relatively healthy and quite physically active before she died of an unknown cause The healed wound itself is dramatic: a hole about the size of a quarter (14.8 by 9.2 mm) on the back right side of her skull is surrounded by a larger oval area (66.4 by 19.9 mm) where the surgeon scraped the bone with a rasp, leaving faintly discernible marks that radiate outward from the opening.
When the young woman was hit, the stone or lead missile crushed the soft tissues of her scalp and caused a serious depressed fracture, possibly with the projectile embedded in the bone. Sharp edges on fissure fractures extending from the wound endangered the dura mater (the fibrous membrane enveloping the brain). Surgery was needed to remove bone splinters and possibly the lodged missile, eliminate fissures, evaluate the condition of the dura mater if exposed, and apply “healing drugs.”
To judge by procedures set out in On Head Wounds, the surgeon first evaluated the injury without touching the patient, then by touching and subsequently by using a probe to better diagnose the type, extent, and severity of the trauma. He asked about the injury and the patient’s physiological responses to it. Then he cut and opened up the soft tissues surrounding the wound for better visual inspection and preparation for surgical intervention before dressing the wound with a paste of fine barley wheat boiled with vinegar. The next day, he further cleaned and dried the soft tissues around the wound and made a final diagnosis of the bone injury And he might have spread black ink on the cleaned bone; it would seep into and reveal any hairline fissures that might not be visible otherwise.
On Head Wounds sets forth diagnostic procedures for identifying and treating a range of cranial injuries caused by different weapons. In most cases, a wound on the back of the head — “where the bone is thicker and oozing puss will take longer to reach the brain” — was less likely to be fatal than one in the front. But, as in the case of the woman from Abdera, “When a suture shows at the exposed bone area of the wound — of a wound anywhere on the head — the resistance of the bone to the traumatic impact is very weak should the weapon get wedged in the suture.” So, according to the Hippocratic text, the case was a serious one. It was made more so because of the nature of the weapon, a missile from a sling, because, “Of those weapons that strike the head and wound close to the cranial bone and the cranium itself, that one that will fall from a highest level rather than from a trajectory parallel to the ground, and being at the same time the hardest, bluntest, and heaviest…will crack and compress the cranial bone.”
For compressed head fractures, On Head Wounds recommends trepanation, removal of a disk of bone from the skull using a drill with a serrated circular bit. This would eliminate the danger of bone splinters and radiating fracture fissures. It would also permit the removal of bone fragments that had been crushed inward, allowing the brain to swell from the contusion without pressing against loose bone fragments with sharp edges that might puncture the dura mater. But there was one cranial area where a scraping approach was strongly recommended instead of trepanation: “It is necessary, if the wound is at the sutures and the weapon penetrated and lodged into the bone, to pay attention for recognizing the kind of injury sustained by the bone. Because…he who received the weapon at the sutures will suffer far greater impact at the cranial bone than the one who did not receive it at the sutures. And most of those require trepanation, but you must not trepan the sutures themselves…you are required to scrape the surface of the cranial bone with a rasp in depth and length, according to the position of the wound, and then cross-wise to be able to see the hidden breakages and crushes…because scraping exposes the harm well, even if those injuries…were not otherwise revealed.”
Faced with a compressed fracture with radiating fissure fractures and fearing damage to the dura mater, the surgeon scraped the bone in length, width, and depth, removing fragments and eliminating the fissures through scraping and not trepanation. He then would have tended to any adjacent injured tissues.
While the reconstruction of the patient’s treatment is in part conjecture, based on the Hippocratic text itself, the size and shape of the surgical intervention and use of the rasp rather than trepanation is certain from traces on the bone itself. So the surgical procedure matches perfectly what was recommended two centuries later in On Head Wounds for this type of injury in this location.
ANCIENT GREEK SOURCES OFFER little aid in tracing the development of medicine before Hippocrates. It is not surprising that medical historian Guido Majno wrote in The Healing Hand that “the beginnings of Greek medicine, which should fill a library, are mostly blank pages.” Medical writings from before the Hippocratic corpus have not survived. Moreover, we only know of one real Greek physician before Hippocrates. The historian Herodotus notes that some time after 522 B.C., a Democedes successfully treated the Persian king Darius I for a sprained ankle after Egyptian doctors had failed. But that is still a century after the unknown physician of Abdera performed his masterful surgery.
If we look to earlier times, Homer, before 700 B.C., describes more than 140 combat injuries in the Iliad and, in a few cases, tells how they were treated — the arrow or spear extracted, ointment applied to reduce the pain and stop the bleeding, and the wounds bound. But in all the Greek army there are only two trained healers, Machaon and Podalirios, both sons of the legendary hero-physician Aesclepius, son of the god Apollo. The healers were highly valued, and when Machaon is wounded, he is rushed off the battlefield in a chariot because, says Homer, “the physician who knows how to extract arrowheads and with herbal ointments to cure the wounds” is worth the lives of many men.
But medicine has an element of the supernatural in Homer. When Machaon and Podalirios are unavailable, it falls to Achilles’ comrade Patroclus to treat a wounded warrior. He does so using a method he learned from Achilles. Who taught both Aesclepius and Achilles? According to Homer it was Chiron, the wisest of all the centaurs. And in the Odyssey, when the young prince Odysseus is injured by a boar, a charm is recited over the wound to staunch the blood.
Medicine in the Iliad, composed just a century before the Clazomenean physician at Abdera, is rather simplistic. Clearly, significant advances in medical thought took place during the eighth and early seventh centuries B.C. Perhaps the sociopolitical changes that occurred with the emergence of city-states favored the rapid evolution of medical practice. While one cannot argue that the Ionian Greeks developed sophisticated medical practices entirely in isolation, there is no strong evidence that they drew on an outside source in making the jump from simple battlefield first aid or reciting a charm over a wound to performing the sophisticated skull surgery exhibited on the young woman from Abdera.
We do not know exactly how the Clazomeneans chose the colonists who sailed to Abdera. Were they an elite group, the less wealthy who were willing to risk the venture, or the politically and socially disfavored? We do know, however, that among them there was a masterful surgeon, Hippocrates’ predecessor, who was among the earliest of the Ionian school of medical practitioners.
