To date, no estimates of the long-term effect of cranial vault fractures on the risk of dying have been generated from historical or prehistoric skeletons. Excess mortality provides a perspective on the efficacy of modern treatment, as well as the human cost of cranial injuries largely related to interpersonal violence in past populations. Three medieval to early modern Danish skeletal samples are used to estimate the effect of selective mortality on males with cranial vault injuries who survived long enough for bones to heal. The risk of dying for these men was 6.2 times higher than it was for their uninjured counterparts, estimated through a simulation study based on skeletal observations. That is about twice the increased risk of dying experienced by modern people with traumatic brain injuries. The mortality data indicate the initial trauma was probably often accompanied by brain injury. Although the latter cannot be directly observed in skeletal remains, it can be inferred through the relative risks of dying. The ability to identify the effects of selective mortality in this skeletal sample indicates it must be taken into account in paleopathological research. The problem is analogous to extrapolating from death register data to modern communities, so epidemiological studies based on mortality data have the same inherent possibility of biases as analyses of ancient skeletons.selective mortality | cranial trauma survival | violence | premodern Denmark T he aftereffects of head trauma are a major concern in modern medicine (1). However, for historical and prehistoric populations, there are no quantitative assessments of the longterm effects of such injuries, with the risk of dying estimated from skeletal samples being the most obvious way of doing so. Skeletons serve as a measure of the extent to which modern treatment and subsequent care have improved the outlook for survivors of trauma severe enough to fracture the cranial vault. Much of the cranial trauma in the distant past resulted from interpersonal violence, so these fractures provide a unique perspective on the human cost of conflicts that occur within communities up to the outright warfare that takes place between societies (2, 3).The effect of selective mortality acting on people who experienced differential exposure or susceptibility to life-threatening diseases or trauma was brought to the attention of paleopathologists a quarter century ago (4). Debates continue over whether it is of any real significance when characterizing the health of past populations (5-16), although it has been shown that various conditions had an effect on mortality (17-23). That is largely because what comes to the paleopathologist's attention often indicates survival well beyond the original traumatic or disease episode, including cranial vault trauma with its potentially debilitating neurological consequences (24,25).Through a simulation study, healed cranial vault fractures are used to show that selective mortality has a measurable effect in archaeological skeletal samp...