Elsevier

World Neurosurgery

Volume 114, June 2018, Pages 245-251
World Neurosurgery

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Trepanation Procedures/Outcomes: Comparison of Prehistoric Peru with Other Ancient, Medieval, and American Civil War Cranial Surgery

Some preliminary data given in this article were presented as a poster at the American Academy of Neurology 69th Annual Meeting, April 24, 2017, in Boston, Massachusetts.
https://doi.org/10.1016/j.wneu.2018.03.143Get rights and content

Highlights

  • More prehistoric trepanned crania have been found in Peru than anywhere worldwide.

  • Trauma was likely the main reason trepanation was developed in prehistoric Peru.

  • Advances in trepanation techniques over time led to gains in long-term survival.

  • Crania with as many as 7 successful trepanations were found at Inca sites.

  • Trepanation survival rates in ancient Peru are astonishing considering the many risks.

More prehistoric trepanned crania have been found in Peru than any other location worldwide. We examine trepanation practices and outcomes in Peru over nearly 2000 years from 400 BC to provide a perspective on the procedure with comparison with procedures/outcomes of other ancient, medieval, and American Civil War cranial surgery. Data on trepanation demographics, techniques, and survival rates were collected through the scientific analysis of more than 800 trepanned crania discovered in Peru, through field studies and the courtesy of museums and private collections in the United States and Peru, over nearly 3 decades. Data on procedures and outcomes of cranial surgery ancient, medieval, and during 19th-century through the American Civil war were obtained via a literature review. Successful trepanations from prehistoric times through the American Civil War likely involved shallow surgeries that did not pierce the dura mater. Although there are regional and temporal variations in ancient Peru, overall long-term survival rates for the study series were about 40% in the earliest period (400–200 BC), with improvement to a high of 91% in samples from AD 1000–1400, to an average of 75%–83% during the Inca Period (AD 1400s–1500). In comparison, the average cranial surgery mortality rate during the American Civil war was 46%–56%, and short- and long-term survival rates are unknown. The contrast in outcomes highlights the astonishing success of ancient cranial surgery in Peru in the treatment of living patients.

Introduction

Trepanation, or trephination, the scraping, cutting, or drilling of an opening into the cranium, was practiced in various parts of the world in prehistoric times, dating back 5000 years ago in Europe and to around 2500 years ago in the New World.1 Interestingly, more prehistoric trepanned crania have been found in Peru than any other location in the world.1 And even more interesting, the survival rates for the ancient procedure in Peru rival those for trepanation done during other ancient and medieval times and through the American Civil War in the 19th century, which is impressive, considering the many potential risks of cranial surgery, including direct or indirect perioperative complications such as infection and blood loss.2

Treatment of head trauma was the main reason for the evolution of cranial surgery in ancient times through the start of the modern surgical era in the 19th century. Similarly, there is an association of trepanation in prehistoric Peru with evidence of cranial trauma, making it plausible that head injury was probably the main reason that this procedure was developed. However, just as modern neurosurgery is performed for many reasons other than brain injury, prehistoric trepanation was done on crania that have no clear evidence of trauma, suggesting that the procedure also was performed for other reasons.

Neurosurgery evolved into a distinct profession by the end of World War I,3 and since then, neurosurgical research developments have continued to hone the understanding of brain anatomy, physiology, and pathology while improving outcomes through better surgical tools, techniques, pharmacology, and perioperative management. Likewise, in Peru, from 400 before Christ [BC] through the time of the Inca Empire (circa [ca.] anno Domini [AD] 1400–1500), advances in trepanation techniques led to improvements in long-term survival. This article will compare the evolution of trepanation procedures and outcomes in prehistoric Peru with other cranial surgery in ancient times through the time of the American Civil War to provide a perspective on the development and outcomes of these practices while underscoring the remarkable success of the ancient surgery in Peru.

Section snippets

Ancient Trepanation in Peru

Data on trepanation survival rates, types of injury, techniques, and demographic information including age and sex were collected through the scientific analysis of more than 800 trepanned crania and artifacts discovered in coastal regions and the Andean Highlands of Peru, dating from ca. 400 BC through the time of the Inca (ca. AD 1400–1500). Data were acquired from the analysis of the trepanned crania and artifacts through the courtesy of museums and private collections in the United States

Ancient Trepanation in Peru

There were regional differences within Peru, but overall long-term survival rates for the series described in this study were nearly 40% in the earliest examples (400–200 BC) (n = 59), with improvement to a high of 91% (range 53%–91%) in samples dating between AD 1000–1400 (n = 430) to an average of 75%–83% during the Inca Period (AD 1400–1500, n = 160) (Table 1). Crania having multiple trepanations discovered at Inca burial sites had an average long-term survival rate of 79.5% (Figures 4 and 5

Discussion

There are striking similarities in the evolution of trepanation in ancient Peru with that of other ancient civilizations. Evidence shows that the surgical techniques from all the civilizations and time periods were initially the same but were refined through trial and error. Written texts beginning from the time of Hippocrates document the gradual refinement of trepanation tools and procedures in Western medicine to the time of the Middle Ages and through the Renaissance. There are no written

Acknowledgments

The authors thank the following museums for permission to study and photograph the crania illustrated in this article: the Peruvian National Museum of Anthropology, Archaeology, and History (Figures 1, 4, and 6); the National Museum of Natural History, Smithsonian Institution (Figures 2 and 3); and the Museo Inka, Cuzco (Figure 5).

References (20)

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    Therefore, it is reasonable to hypothesize that the cause of death of this woman was because of a traumatic event or pathologic condition which cannot be observed on the skeletal remains, either because of the bad condition of preservation or because of the nature of the pathology itself. The cause of death may also be represented by a bad outcome of the surgical treatment because direct injury to the brain may occur during trepanation processes44; hemorrhage or severe and fast infection processes could have also been likely consequences of ancient trepanation because of the absence of aseptic conditions during the surgery.45 However, in most cases, it is impossible to establish with certainty the reason for trepanation observed on skeletal remains.12

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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