Historical VignetteTrepanation Procedures/Outcomes: Comparison of Prehistoric Peru with Other Ancient, Medieval, and American Civil War Cranial Surgery
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)
Differential diagnosis: trepanation
Int J Paleopathol
(2016)The prehistoric practice of trepanation
World Neurosurg
(2013)- et al.
Prehistoric skull trepanation in China
World Neurosurg
(2013) - et al.
Trepanation in ancient China
World Neurosurg
(2017) Early surgeons performing trepanation: an examination of Scythian trepanations in the Gorny Altai at Hippocratic times
World Neurosurg
(2015)- et al.
Scythian trepanations in the Gorny Altai in Hippocratic times: modern expert appraisal of ancient surgical technologies
World Neurosurg
(2014) - et al.
Trepanation to treat a head wound: a case of neurosurgery from 13th-century Tuscany
World Neurosurg
(2017) Holes in the Head: The Art and Archaeology of Trepanation in Ancient Peru
(2016)- et al.
Ancient trepanation from the perspective of modern neurosurgery
The historiography of neurosurgery: organizing themes and methodological issues
Cited by (26)
Holes in the Head. Double cranial surgery on an individual from the Chalcolithic burial site of Camino del Molino (SE Spain)
2023, International Journal of PaleopathologyDecompressive Hemicraniectomy in the Stroke Patient
2023, Critical Care Nursing Clinics of North AmericaCloser examination does not support infection as cause for enigmatic Tyrannosaurus rex mandibular pathologies
2022, Cretaceous ResearchCitation Excerpt :While similar penetrating alterations have not been reported in tens of thousands of mammals, reptiles and birds with non-traumatic diseases documented to spontaneously affect the skeleton (e.g., osteomyelitis) (Moskovitz, 1951; Stabler, 1954; Stone and Nye, 1981; Cooper and Petty, 1988; Pepler and Oettlé, 1992; Samour et al., 1995; Wilson and Carpenter, 1996; Boal et al., 1998; Cole, 1999; Real et al., 2000; Hampl et al., 2001; Simon et al., 2003; Vilela et al., 2003; Krone et al., 2005; Rothschild and Martin, 2006; Borji et al., 2011; Rataj et al., 2011; Juan-Sallés et al., 2014; Martínez-Herrero et al., 2014, 2017; Rushmore et al., 2015; Dudek et al., 2018), these pathologies share many features with bone reaction in a healing penetrating wound such as the intentionally-induced bone defect (trepanation) (Andrushko and Verano, 2008; Barbian and Sledzik, 2008; Campillo, 1994, p. 40–63; Marino and Gonzales-Portillo, 2000; Nerlich et al., 2003; Aidonis et al., 2021; Partiot et al., 2020). Trepanation (alternatively sometimes spelled trephanation and trephination), the creation of circular wounds in the cranium using metal surgical tools, is a relatively common practice in numerous different human societies (Kushner et al., 2018). This practice is well documented in Perú, where this surgical procedure was used to treat head injuries presumably inflicted during battle (Verano 2016a).
New Evidence of Prehistoric Neurosurgery in Italy: The Case of Castello Del Tartaro
2019, World NeurosurgeryCitation Excerpt :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
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.