LEGACIES
Preconquest Peruvian Neurosurgeons: A Study of Inca and
Pre-Columbian Trephination and the Art of Medicine in
Ancient Peru
Raul Marino, Jr., M.D., Marco Gonzales-Portillo, M.D.
Department of Neurosurgery (RM), University of São Paulo Medical School,
São Paulo, Brazil, and Department of Neurosurgery (MGP),
Lima Institute of Neurosciences, Lima, Peru
TREPHINATION AND CRANIOTOMY performed by abrasion, scraping, crosscut sawing, and drilling are the oldest
known surgical techniques used by primitive peoples. As a result of archaeological findings, the human skull is the
most frequently studied part of the excavated body, leading to the creation of a new aspect of anthropology known
as “cultural osteology.” Found in ancient tombs, the human remains, mummies, skeletons, and their belongings,
including war instruments, pottery, clothing, jewels, and surgical instruments, constitute the richest source of insight
into the lives and pragmatic activities of ancient cultures. This study summarizes thousands of years of preColumbian history and medical evolution, specifically in the early and primitive practice of trephination, as
precursors of neurosurgery. Comparative osteology studies have demonstrated that using primitive stone or metal
instruments, the sirkaks (Inca surgeons) achieved an average survival rate of 50 to 70% of their craniectomy patients,
with little incidence of infection or other complications. Despite their rudimentary knowledge of disease and
pathology, a considerable knowledge of anatomy and natural medicine provided them with hemostatic agents,
antiseptics, and other medical drugs, such as quinine for fever and malaria, as well as gold, silver, and other products
to perform cranioplasties. Living in a world of continuous hand-to-hand combat, they also developed aggressive and
defensive weapons that necessitated refinement of surgical techniques to save soldiers from battle wounds to their
poorly protected crania. (Neurosurgery 47:940–950, 2000)
Key words: Inca, Peru, Pre-Columbian neurosurgery, Trephination
It has often been said that the two oldest living professions are
prostitution and neurosurgery. I would assume that the ancient warrior realized very early on that it was easiest to
annihilate, or at least slow down, his opponent with a blow to
the head. Therefore, the concept of head injury remains as
ancient as the powers of solicitation of the opposite sex.
(James T. Goodrich [12])
I
t is quite an experience for a neurosurgeon to examine
some of the 15,000 skulls and sitting mummies that have
been preserved and recovered from pre-Columbian Andean civilizations and are stored in the National Museum of
Anthropology and Archaeology in Peru. Other surprises are
reserved for those who visit the Gold Museum (Museo del
Oro), also in Lima, with its incredible collection of jewels,
pre-Columbian weapons, and metal instruments used in neurosurgical procedures by ancient Andean civilizations. These
940
include T-shaped tumis, obsidian lances for trephination, scalpels, bone elevators, retractors, forceps, chisels and needles,
bandages, and several other instruments. They are crafted of
gold, silver, copper, or alloys of these metals; gold, silver,
coconut, calabash, maté, or gourd plates used for cranioplasties also may be found. A meticulous examination of these
operated skulls and cranioplasties demonstrates clear signs of
healing and recovery in 70% of them, which forces us to pay
tribute to these ancestors of our specialty and to their ability.
Thousands of years ago, they demonstrated a keen knowledge of anatomy, preserving the sagittal sinuses in their approaches, treating traumatic wounds and cranial fractures,
and implanting prosthetic material with a minimum of infection or osteomyelitis (22), considering the means at their disposal. It is astonishing to reflect on the enormous achievements of pre-Inca “neurosurgery” and realize that our
Paleolithic ancestors, such as Sinanthropus or Homo erectus
pekinensis, probably perforated the cranium only to extract
and eat the human brain (5)!
Neurosurgery, Vol. 47, No. 4, October 2000
The Art of Medicine in Ancient Peru
HISTORICAL BACKGROUND
The Andean area, where Peru is located, has one of the
roughest and most difficult terrains on earth. Thousands of
years of effort were required by the first Peruvian inhabitants
to tame the Andean Cordillera. The Andean culture comprised the territories of Ecuador, Peru, Bolivia, and parts of
Chile and Argentina; the area is divided by altitude and
climate into three regions: the coast, the Sierra, and the Amazon jungle (Fig. 1). Archaeologists have dated the first evidence of humans in the Andes to the time after the last glacial
period (the Wisconsin period), approximately 10,000 BC (17,
18). Archaeologists have gradually uncovered a Peruvian pre-
FIGURE 1. Map showing the territory of the Inca and
Andean cultures. This comprised the present Ecuador, Peru,
Bolı́via, and part of Chile and Argentina, divided here into
three main regions: the coast, the Sierra, and the Amazon
jungle.
Columbian history of astonishing and highly advanced societies that, despite formidable geographic difficulties and frequent natural disasters, prevailed over these awesome odds
until a few centuries ago. During the Hispanic colonization
period, war and disease caused the extinction of this culture.
The first discovery of Stone Age instruments of ancient
Peru was made in 1948 by Rafael Larco Hoyle and Junius
Bird, in Cupinisque, north of Trujillo, where the Paijanense
culture developed; the “puntas of Paiján“ were used to spear
big fish. Through carbon-14 testing, the skeletons found in the
tombs have been demonstrated to be 8250 years old. They are
located from Chiclayo to the area north of Ic᝺ á (17, 18).
Other archaeological studies on the coastal desert, from
Lambayeque to south of Paracas, have revealed a true “American Egypt” regarding the important findings of ancient
tombs and their historical contents. These artifacts often are
discovered after they have been looted by gangs of huaqueros,
or grave robbers, stimulated by intense demand from the
international antiquities market.
The Incas’ Tahuantinsuyo Empire was in place when the
Spaniards arrived. Hundreds of years previously, the Peruvian land had been overrun by primitive peoples who were
constantly at war with each other and were among a succession of civilized cultures dating back as far as 2000 BC. The
most accomplished among them were the Chavin-Sechin (900
to 200 BC), the Huari-Tiahuanaco (750 BC to AD 1000), and
the Moche-Chimú culture (200 BC to AD 1400) (17, 18).
One of the greatest achievements of these latter cultures
was their artistic genius. They crafted exquisite ornaments in
gold, silver, and precious stones, as well as pottery during
several stylistic periods, most notably in the Moche culture,
with stunningly lifelike portrait vases and a variety of everyday scenes created through naturalistic ceramics. Their art
tells us more than is known about earlier cultures; these
“visual aids” compensate for the lack of a written language
and reveal their daily native life, including their erotic life.
Their mummies, incredible textiles, military weapons, surgical instruments, and architecture, united by the incoming Inca
Empire, earned these territories around the Imperial City of
Cuzco the epithet “umbilicus of the Universe” just before the
Spanish conquest. This area was equivalent to France, Belgium, Holland, Luxembourg, Italy, and Switzerland combined, measuring approximately 980,000 km2.
In 1490, the Chimú kingdom was defeated by the Inca
dynasty, led by the great warrior Túpac Yupanqui, the son
and heir of the Inca ruler Pachacutec Inca Yupanqui.
Pachacutec was considered a sort of Andean Alexander the
Great. He and his son Topa managed to subjugate all their
rivals from Ecuador to Chile. However, their empire fell less
than 100 years later to the rapacious warriors of Spain, after
Francisco Pizarro arrived in Tumbes with 179 conquistadors.
Like the Aztecs in Mexico, the Incas came late on the
historical scene of Peru, and even their legends do not predate
AD 1200. Like the European civilization, the Incas recounted
Neurosurgery, Vol. 47, No. 4, October 2000
941
942
Marino and Gonzales-Portillo
their history in terms of the reign of their kings. The first was
Manco Capac, considered to be the founder of the Inca Empire, in AD 1200, followed by Sinchi Roca, Lloque Yupanqui,
Mayta Capac, Capac Yupanqui, Inca Roca, Yahuar Huacac,
Viracocha Inca (the famous white god), Pachacutec Inca
Yupanqui (1438–1471), Tupac Inca Yupanqui (1471–1493),
Huayna Capac (1493–1525), Huázcar (1525–1532), and his
brother Atahualpa (1532–1533). Atahualpa was executed by
Pizarro in Cajamarca; he was strangled with a tourniquet,
died at the stake, and was then quartered after the Incas had
prepaid with gold objects filling many rooms to ransom and
rescue him! Pizarro had planned to burn him alive, but
Atahualpa claimed that fire would destroy his soul and
Pizarro agreed to a different type of execution. Today, studying their history, we are forced to ask ourselves who were the
true savages at the time. Atahualpa was the “cement” that
assured the cohesion of the Inca Empire. This cement was
dissolved after his death, and the lack of leadership led to the
rapid decline and disappearance of the Incas for (17, 18).
Our only means of studying these ancient, extinct Inca and
pre-Incaic civilizations is through the art and instruments
found in archaeological sites. These findings provide a visual
record: their mummies, ceramic vessels, clothes, metal instruments for medical and war purposes, jewels, and statues
depict the life of the people who manufactured them. We
found that more trephinations were performed in ancient
Peru than in the rest of the ancient world combined, apparently for the treatment of trauma, disease, epilepsy, and headache, as well as for rituals, among other purposes (1). Archaeological skulls exhibit evidence of recovery, a low infection
rate, and good results that could be compared with those of
modern times, considering the conditions under which they
were performed! Some of the ceramics, called huacos, depict
medical achievements such as a surgeon working on a patient’s cranium with instruments (Fig. 2). Such procedures
have been documented in the literature (the best studies are in
Spanish) (3, 13, 19).
MEDICAL KNOWLEDGE OF THE TIME
Examination of several skulls reveals extensive craniectomies, which preserved the trajectory of the dural sinuses and
left behind protective bone bridges, thus demonstrating anatomic knowledge of these regions (4, 9, 10, 13, 16, 22) (Fig. 3).
The surgeon’s experience in inducing hemorrhages in these
areas probably was transmitted to his assistants. Weiss (27)
suggests the existence of centers and schools for teaching and
training in Paracas and Cuzco, where archaeologists have
found ruins resembling hospitals.
During the Inca period and in previous eras, the vast
Tahuantinsuyo Empire reached a high level of culture under
the paternal government of the monarchs. The culture was
based on agricultural (agrario) socialism, admirably organized, which could be observed in all aspects of their social
life. Because of wise sanitary precepts and protective measures for the people, the Tahuantinsuyo Empire detribalized
into a large population.
FIGURE 2. The famous Morales-Macedo huaco, a reconstituted ceramic representation of a sitting surgeon operating
on a patient whose head is held between the surgeon’s
thighs; he works on the scalp with a tumi instrument. A,
detail of the original ceramic. B, artist’s rendering of the
ceramic piece. (This art object was found in the Casma cemetery, on the coast of Peru near Callejón de Huaylas. It was
made public in 1916 by Dr. Carlos Morales-Macedo [19].)
Without populous cities or pollution-producing industries,
the people were engaged in agriculture, mining, military service, herding, and fishing. They endured a rustic rural life in
small villages over the altiplanos (high plateaus) and coastal
valleys, where they led a healthy existence in the open air and
sunlight. Relative prosperity owing to the magnificent political organization of the state meant that tuberculosis, whose
cause and diffusion depend essentially on poor social conditions, was not endemic in their populations (7, 8, 17, 18).
Nursing during infancy was imposed by inflexible natural
law; therefore, infantile mortality caused by gastrointestinal
illnesses was avoided. Tuberculosis and enteritis have always
been the most powerful causes of demographic loss in some
populations (17, 18).
Through empirical intuition, the aborigines knew the contagion mechanisms of exanthematous typhus (which could be
demonstrated in central Europe only at the beginning of this
century). They fought it with isolation measures and recognized the role of insects in its propagation; in the tribes where
an epidemic occurred, a penalty was imposed, represented by
a tax with reeds containing swarms of lice (Pediculus capitis and
P. vestimenti). It is also evident that they understood the means
by which malaria, endemic on the Peruvian coast, was spread.
Houses were systematically built in the high and sandy part of
the valleys, outside the cultural centers and outside of the access
radius of the vector insects (7–9, 13, 17, 18).
Numerous reports in historical chronicles refer to the pharmacological wealth of the Incas, stating that la Mamma Viracocha (mother earth), one of their goddesses, (Mamacocha was
the sea) would show them the plants with healing powers and
those that were poisonous. They had large and selected herbolarios; they knew diseases quite well and the means to cure
them with the use of herbs (9, 13, 17, 18). It is well known that
Neurosurgery, Vol. 47, No. 4, October 2000
The Art of Medicine in Ancient Peru
943
Intentional deformations of the head
Intentional deformation of the head, widely practiced when
the Spaniards arrived, was banned in 1752. The main purpose
of deformation was to establish differences and characteristics
among different tribes and nations, chiefly among the nobility. The methods used were the cuna and the llautu. Some
specimens of the former were found in Chilca on the coast,
dating from 3800 BC, and were associated with suprainion
trephination. The llautu involved tying ropes, padded cushions, and leather straps around the heads of young people,
which over time produced plagiocephalic crania or other
deformations (9) (Fig. 4).
Head trophy and head shrinking
FIGURE 3. A and B, two scraping or abrasion craniectomies
over the occipital region, showing extensive openings. The
trajectory of the dural sinuses is preserved, leaving protective
bone bridges and demonstrating some anatomic knowledge
of those regions.
they were the first to use the cortex of cinchona bark, which
contains quinine, to fight malaria. This knowledge was revealed to the world when the life of the Viceroy Luis Jeronimo
de Cabrera y Bobadilla, fourth count of Chinchón, was saved
(9, 13). Their high achievements in agriculture, mining, industry, art, irrigation, architecture, ceramics and pottery, and
elegant textile fashions, which are now preserved in museums
after being buried for centuries, amaze observers and artists
who contemplate them.
The Incas thus were not, as some may assert, a barbarous
and brutish people, lacking a government and without social
organization, immersed in profound ignorance and unable to
develop industries, arts, or elementary rules of social life. On
the contrary, a careful historical-sociological analysis demonstrates a cultured and creative people, wise and refined, with
esthetic tendencies and an appreciation of the highest manifestations of the spirit. They had the capacity to learn medical
and surgical arts and to achieve advanced methods and techniques corresponding to their elevated cultural hierarchy,
which also was reflected in various aspects of their social life.
The pre-Inca Nazca and Paracas were true headhunting
cultures. They demonstrated their ferocity in war through the
munduruco and tsan-tsan: emptying the contents of the skull
through the occipital bone, then shrinking and drying the
skulls for trophies. They hung these trophies on their belts, as
did the Amazon Jı́varos (9).
It is surprising that the Spaniards were not able to capture
the highly advanced medical and surgical capabilities of the
conquered aborigines. These practices abruptly and definitively collapsed at the moment of conquest, which virtually
destroyed all aspects of the old civilization found in Peru.
Cities of great historical importance, such as Machu-Picchu,
Huayna-Picchu, and Wiñay-Huayna, were jealously hidden
from the view of the conquistadors, and their ruins were not
found until 1913 and 1941, respectively (7, 8, 17, 18). This
phenomenon was probably produced by a violent clash between the two opposing civilizations. The conquistadors imposed their creed, habits, and principles and inhibited the
dominated community. Keeping secrets was the only means
of defense and a silent form of protest (7, 8, 17, 18).
THE WEAPONS
Weapons in antiquity were either offensive or defensive.
We traveled to Lima specifically to observe these items in
museums, to study their effect on cranial trauma, and to view
the protection Peruvians used for self-defense.
FIGURE 4. Typical plagiocephalic deformation of the head,
obtained by tying straps around the head of a young person.
Neurosurgery, Vol. 47, No. 4, October 2000
944
Marino and Gonzales-Portillo
Among offensive weapons (Fig. 5), we found the classic
bow and arrow; the spear or lance; the cerbatana (blow pipe);
the honda or maraca (slingshot to throw stones); the estolica,
tiradera, or cumana (dart thrower); the lanza or spear, named
chuqui, turcuna, or pica, for different sizes; the boleadora or ayllu
(two or three round stones attached to a rope); the clava, maza,
or huactana (a heavy, 90-cm-long club of wood or stone); the
porra, which was responsible for most of the cranial trauma (a
long wooden handle with a heavy, sometimes stellate, stone
in the extremity, which was called macana or huicapa); the
hacha, chictana, or champi (a combination of porra and axe); the
chingana (a large double-edged dagger); the tuccina (a sword);
and the tumi (a semilunar knife, also used, in smaller sizes, for
scalp incisions by the tribal surgeons) (7–9, 13).
The defensive equipment (Fig. 6) was precarious and unsafe, because it was made of fragile material such as wood,
cane, bamboo, or thin metal. The escudos (shields) were crafted
of wood lined with leather. The corazas (breastplates) were
worn by the nobility and were made of bronze, silver, or gold;
their shine dazzled the Spaniards. The escampiles, aucanas, or
cushma were breastplates made of wood or cotton to protect
against enemy arrows (9). Large tumis also were used to
behead or decapitate enemies or in religious and traumaturgic
ceremonies. In the Museo del Oro, a gold statue with a ferocious facial expression holds a tumi in one hand and a decollated head in the other (Fig. 7).
HEAD PROTECTION
Examination of the cascos (helmets) was one of the main
purposes of this study. Cascos were worn to protect the head;
crafted of wood or thin metal, they were called umachina and
ñauhichina, respectively. Some were made of interwoven thin
cane and were very light. Feathers, plumes, and other ornaments and emblems were attached to the front. Ribbons of
different colors hung from the back. The helmets were quite
FIGURE 6. Artist’s rendering of an Inca warrior wearing sandals, uniform, escudo (shield), the coraza (breastplate), and a
protective helmet to prevent head trauma, with a clava in his
right hand.
fragile, which may explain the prodigious development of
surgical treatment for craniocerebral trauma to correct the
effect of heavy weapons, chiefly the porra, on the warriors’
poorly protected crania (9) (Figs. 8-10). Sometimes, heavy
cotton turbans were used by the soldiers, which also provided
little protection against blows to the head.
CRANIAL TREPHINATION
FIGURE 5. Pre-Columbian weapons. 1 and 5, the hacha,
chictana, or champi; 2–4, 8, 9, 13, and 14, the porra and its
stones, macana or huicapa; 6, the clava, maza, or huactana;
7, the lanza, chuqui, turcuna, or pica; 10 and 15, the honda
or maraca (slingshot with stone); 11 and 12, the boleadora
or ayllu.
The suggested reasons for trephination surgery in ancient
Peru are numerous. Operations apparently were performed
for trauma, fractures, diseases of the cranium, scalp and cranial infections, epilepsy, headaches, mental disease, and some
traumaturgic rituals (1, 4, 9, 13, 15, 16, 22) (Fig. 11). The main
trephination techniques evident in archaeological skulls are
associated with excavations in the territories of the Paracas,
Nazca, Huari, and Ic᝺ á cultures. They were less popular in the
more recent Inca culture and were apparently interdicted in
the Inca empire long before the Hispanic conquest (1, 4, 9, 13).
Examination of the operated skulls reveals samples of several techniques, including circular cutting, scraping, crosscut
sawing, and drilling (1, 2, 4, 6, 10, 13–16, 20, 22, 24–26) (Fig.
12). The Paracas culture primarily used the circular cutting
technique. The first evidence of the crosscut technique is in
the Nazca culture, which followed that of the Paracas in the
Neurosurgery, Vol. 47, No. 4, October 2000
The Art of Medicine in Ancient Peru
945
FIGURE 9. Ceramic piece (huaco) depicting a warrior using
his maza or clava against the cranium of his opponent.
FIGURE 7. Warrior with a large tumi (one of the main neurosurgical instruments), used as a weapon to decapitate an
enemy, and holding the head in his left hand. He has a ferocious facial expression (gold statue, Mochica culture; Museo
del Oro, Lima).
FIGURE 8. Artist’s rendering of battle showing the war
weapons in use (Juán Bravo).
area around Lake Titicaca. This mountain culture eventually
developed into the Huari culture, and around AD 800 their
warriors overran the coast and northern mountains and
formed an empire; these skulls exhibit only the crosscut and
drilling techniques (AD 800 to 1200). The Ic᝺ á culture (AD 1200
to 1450) followed the dissolution of the Huari Empire and
used only the circular and scraping techniques. Examination
of these skulls reveals that surgical wounds rarely became
FIGURE 10. Skull showing
two circular cutting
craniotomies, probably a
correction of a depressed
cranial fracture caused by a
stone porra weapon.
infected, and some skulls indicate survival (Fig. 13). In contrast, during the 18th century, trephination of the cranium in
Europe reached nearly 100% fatality and was discontinued
(1).
Some authors think that antiseptics were used in these
primal Peruvian cultures, namely the well-known Peru balsam, tannin, saponins, and cinnamic acid, which also was
used for embalming the dead. Studies on Peruvian trephination began in 1865, when Squier (23) showed Paul Broca a
skull from a tomb of Yucay that had a frontal square craniectomy. After examining it, Broca concluded that it was an
intentional trepanation (5).
Lastres and Cabieses (16) made an important study of healing and survival after these primitive trephinations and advanced some interesting observations: 1) no sign of biological
reaction of the cranial vault means that death was almost
Neurosurgery, Vol. 47, No. 4, October 2000
946
Marino and Gonzales-Portillo
FIGURE 11. Artist’s panel at the entrance of the Lima Institute of Neurosciences, representing a skull trephination
scene of the pre-Inca period (Juán Bravo). Surgical instruments and bandages are shown at lower left, accompanied
by potions, cautery, and coca leaves. Right, standing with a
tumi in his right hand and a bowl of chicha in the left is Dr.
Gonzales-Portillo, the neurosurgeon founder of the Institute.
His son Marco, one of our ex-residents and the co-author of
this article, performs the trephination with the help of his
two brothers (a neurosurgeon and a neurologist). Left, the
standing priestess is their sister, a neuropediatrician. All of
the faces correspond exactly to those of the family members.
The scene, although reconstructed by a modern artist,
exactly depicts the performance of these ceremonies in
ancient times.
FIGURE 12. Operated skulls exhibiting several techniques:
A, multiple circular cutting; B, large scraping craniectomy; C,
two circular sawing techniques. The anterior craniectomy
shows a gold cranioplasty with perfect healing (Museo del
Oro, Lima); D, frontal drilling technique.
FIGURE 13. Skull
showing two frontal
craniectomies. The
larger is an osteoplastic
bone flap, which was
replaced after the
craniotomy and firmly
attached to it,
suggesting prolonged
survival of the
operated patient. The
original head of hair is
present after centuries
of burial (Museo del
Oro, Lima).
immediate; 2) a discrete ring of superficial osteoporosis
around the wound appears 1 to 4 weeks postoperatively; 3)
destruction of necrotic bone occurs around the edge of the
wound, owing to osteolysis with separation of irregular fragments and sequestrum formation; these tend to fall off and be
lost during the preparation and cleaning of a skull for examination in the museum; and 4) the edge of the wound reaches
an equilibrium and calcium is deposited. New bone forms
radial striations, and eventually the edge consolidates (Fig.
14). These last two processes do not occur until a number of
months have elapsed (1, 4, 16).
SURGICAL INSTRUMENTS
From the study of mummies with scars over their scalps
(Fig. 15), it is evident that incisions were performed in a linear
fashion (4, 11, 13, 15, 16). Instruments found archaeologically
include chisels made of copper, silver, gold, or champi (the
Inca bronze) (Fig. 16). Obsidian knives, made of a silex sharpedged volcanic crystal called escapelos or pedernales, were used
for incisions and cutting bone (Fig. 17). They would disintegrate if used in a drilling fashion. The famous tumi, a metal
instrument with a crescent blade and a short central T-shaped
handle (Figs. 18 and 19), which today is the symbol of Peru,
was used to open the scalp (but never the bone, as might be
expected). Some researchers have used tumis on cadaver
skulls with success (13, 21). Bone elevators, dura protectors,
forceps, suturing needles, cotton bandages, and hemostatic
wool tourniquets for the head also have been found. Some of
this equipment has been used by present-day Peruvian neurosurgeons for demonstration of Inca-period interventions
(13, 21). Cranioplasties using gold or silver may be observed
at the Museo del Oro (Fig. 20). Other materials, such as maté,
gourd, coconut, and calabash, have been reported to be failures (1, 5, 9, 13, 22), because some cases of osteomyelitis were
found (1, 4, 13, 16, 27).
Neurosurgery, Vol. 47, No. 4, October 2000
The Art of Medicine in Ancient Peru
947
FIGURE 15. A typical
sitting mummy buried
with personal gold
belongings (Nazca
culture, c. AD 100 to
900; Museo del Oro,
Lima).
FIGURE 14. A and B, large frontoparietal craniectomy showing signs of bone regeneration.
Little is known regarding anesthesia, which probably was
based on herbal preparations containing coca, datura, or yuca.
Alcoholic beverages such as chicha, made of fermented corn,
was given to patients in large amounts, causing a soporific
effect (9). Hemostasis was obtained with herbal extracts of
Andean ratania root, pumachuca shrub, and preparations rich
in tannic acid (9, 13, 22). Thermal needles, metal cautery, and
boiling oil also were used. Metal suture needles have been
found with cotton threads at burial sites (9, 13). Scalp margins
were sometimes joined by tying the patient’s hair across both
sides of the incision (22). Curettes made of cachalot (sperm
whale) teeth have been discovered, and cotton dressings and
gauze-like material have been found around operated skulls
(9) (Fig. 21).
There were two kinds of tribal doctors: the churihampicamayoc, who treated the nobility, and the more popular sirkak
FIGURE 16. The Inca bronze instruments (champi) used in
craniotomies: a bone elevator, crescent tumis, dissectors, and
needles.
or sangrador (the bleeder), who treated the common people
and performed craniectomies during war and peace. In 1944
and 1953, two separate teams of modern neurosurgeons attempted to revive ancient Peruvian neurosurgery, using only
museum archaeological surgical instruments. They used the
instruments initially in cadavers and then tested their effectiveness in human patients (13, 21). As these interventions
were considered historically important, we summarize them
here as interesting and unusual case reports.
ILLUSTRATIVE CASES
Patient 1
On September 9, 1944, in the Hospital Mixto de Belén, in Cuzco, the
seat of the old Inca Empire, two daring neurosurgeons performed the
first neurosurgical operation using old archaeological instruments
Neurosurgery, Vol. 47, No. 4, October 2000
948
Marino and Gonzales-Portillo
FIGURE 19.
Ceremonial gold tumi,
decorated with
precious turquoise
stones (Chimu culture,
c. AD 1000 to 1600;
Museo del Oro, Lima).
FIGURE 17. Arrow-shaped stones from obsidian knives made
of a silex sharp-edged volcanic crystal.
FIGURE 18. Artist’s
rendering of a famous
gold surgical tumi. At
the top of its handle is
a surgery scene,
showing the sirkak or
sangrador performing
a craniotomy, while
the patient is held fast
by the surgeon’s
assistant.
provided by the Museum and Archaeological Institute of Cuzco. The
surgeons were Dr. Sérgio A. Quevedo, who was also the Chairman of
Anthropology at the Museum, and Manuel Callo. They found a patient
suited for the procedure, a 22-year-old woman who had experienced
cranioencephalic trauma after a tree fell on her head, resulting in a
depressed cranial fracture, Jacksonian epilepsy, and dysphasia. She was
prepared, and the scalp was cleaned with antiseptics.
A circular compression was placed around the head to
achieve hemostasis, with wool tourniquets applied in the same
manner formerly used by the sirkak or Indian surgeons. The
incision was performed using an archaeological tumi, which
also served as a periosteal elevator. The bone was opened with
an obsidian silex chisel, and the dura was protected with an
Incaic dura protector. A 6-cm by 3-cm oval craniectomy was
performed, and the scalp flap was retracted with another Inca
instrument. A cranioplasty was performed using plastic material, and the wound was closed with a special champi needle,
after sulfa crystals were left underneath, because no other
antibiotics were available. The patient was perfectly well after
a 1-hour procedure and had a good recovery.
FIGURE 20. Amazing
skull showing the
impressive result of a
frontal cranioplasty
performed with gold
plate, followed by
perfect healing
around the bone. A
smaller crosscut open
craniectomy is
observed over the left
parietal region (Museo
del Oro, Lima).
However, the patient developed a bronchopulmonary complication after the 7th postoperative day and died. The nurses
reported later that she had removed ice chips from the pack
that had been placed on the scalp to prevent swelling. The
patient had sucked them at night, pretending they were ice
cream, and she developed a pulmonary complication and infection (21, p 51).
Patient 2
The following account was reported by Drs. Francisco Graña and
Estebán D. Rocca (Fig. 22):
On July 1, 1953, we decided to carry out our first trephination
in a cadaver, over the frontal region; using a tumi with a radius of
3 cm for the scalp incision, followed by a cranial trephination
using an obsidian silex knife and other instruments borrowed
from the National Museum of Anthropology and Archaeology.
We have demonstrated that the typical obsidian cannot be used in
Neurosurgery, Vol. 47, No. 4, October 2000
The Art of Medicine in Ancient Peru
FIGURE 21. Cotton and wool dressings and bandages found
around operated skulls (National Museum of Anthropology
and Archaeology, Lima).
949
and bronze elevators. A bone plaque was thus obtained, including the compact external layer and spongy layer, leaving the
internal layer intact (13, p 266).
A second intervention on a cadaver was carried out on July 6, 1953, in
an attempt to imitate the craniotomies found in the Museum. An oval
craniectomy was performed in August, this time exposing the dura,
with the same instruments.
On September 10, 1953, we prepared a patient who had
experienced cranioencephalic trauma followed by right hemiplegia and aphasia, and in whom a subdural hematoma was
diagnosed. He was given the usual preoperative medication,
followed by general anesthesia with intubation. The operative
technique included sterilization of the pre-Incaic instruments
and placement of a rubber tourniquet over the external occipital protuberance and glabela, similar to the ones used in the
pre-Columbian era, which were made of wool, thus obtaining
compression of the pericranial vessels. The operative field was
delimited, and the scalp incision was performed with a tumi
held by its handle, using the right hand, reaching the periosteum with a single coup, elevating the periosteal sheath with
the same instrument and leaving the bone surface exposed. A
round craniectomy was then performed, using a chisel-like
tumi, introduced step by step, gently hammering it in. A bluish
meninge was thus exposed, showing a bloody collection underneath. It was incised with the same tool, and the hematoma
was drained. The next steps of the operation and total aspiration of the hematoma were terminated using regular neurosurgical instruments. The use of the pre-Columbian instruments was thus demonstrated.
We call attention to the use of the tourniquet in preColumbian fashion, which has allowed a perfect hemostasis
during the whole procedure. The use of the tumi for the scalp
incision had a surprising result, and the chisel-tumi combination was also perfect for the craniectomy (13, p 266).
The original text contains several photographs and x-rays illustrating
the procedure. Figure 22 shows the scalp incision. The postoperative
period and follow-up of the patient are not reported in the article.
ACKNOWLEDGMENTS
We thank Juán Bravo, José Falcetti, and Rodrigo R. Tonan,
whose artwork illustrates this article. We also thank the
Museo del Oro and the National Museum of Anthropology
and Archaeology in Lima, Peru, for allowing us to study their
precious specimens.
Received, November 5, 1999.
Accepted, May 12, 2000.
Reprint requests: Raul Marino, Jr., M.D., Department of Neurosurgery, Universidade de São Paulo, Rua Maestro Cardim 808/814,
01323-007 São Paulo, Brazil. Email: [email protected]
FIGURE 22. Postoperative photograph of Patient 2 (A), who
was operated on July 1, 1953, by F. Graña and E.D. Rocca
using only archaeological surgical instruments. Trephination
was performed for removal of a subdural hematoma. B, the
incision was performed using a pre-Incaic tumi (13).
circular movements like a drill—it will disintegrate; it has to be
used in sawing movements, until the external surface of the bone
is penetrated. A rectangular craniotomy was obtained after the
diploë was traversed. The opening was completed using chisels
REFERENCES
1. Allison MJ: Treatment of head wounds in pre-Columbian and
colonial Peru. M C V Q 12:74–79, 1976.
2. Alvarado R: Trepanaciones pre-colombinas. Arch Boliv Med
5:55–56, 1997.
3. Asenjo A: Trephining among the American peoples: Inca trephination, in Asenjo A (ed): Neurosurgical Techniques. Springfield,
Charles C Thomas, 1963, pp 20–26.
4. Cabieses F: Dioses y Enfermedades. Lima, Arte Graff, 1974, vol II, pp
201–280.
Neurosurgery, Vol. 47, No. 4, October 2000
950
Marino and Gonzales-Portillo
5. Campillo D: Neurosurgical pathology in prehistory. Acta Neurochir (Wien) 70:275–290, 1984.
6. Courville CB, Abbott MD: Cranial injuries of the pre-Columbian
Incas. Bull Los Angeles Neurol Soc 7:107–130, 1942.
7. Busto del Duthurburu JA: Perú Incaico. Lima, Libreria Studium,
1978, ed 3, vol 1.
8. Busto del Duthurburu JA: Perú Incaico. Lima, Libreria Studium,
1982, ed 4, vol 2.
9. Escardo FA: História de la Cirurgia en el Perú. Lima, Editorial
Monterrico S.A., 1992, pp 53–57.
10. Froeschner EH: Two examples of ancient skull surgery. J Neurosurg 76:550–552, 1992.
11. Gerszten PC, Gerszten E, Allison MJ: Diseases of the skull in preColumbian South American mummies. Neurosurgery 42:1145–1152,
1998.
12. Goodrich JT: Stone age skull surgery in Mecklenburg-Vorpommern: A systematic study. Neurosurgery 45:151, 1999 (comment).
13. Graña F, Rocca EB, Graña LR: Las Trepanaciones Craneanas en el
Perú en la Época Pré-Hispánica. Lima, Inprenta Santa Maria, 1954.
14. Hrdlicka A: Trepanation among pre-historic people, especially in
America. Ciba Symp 1:170–177, 1939.
15. Jorgensen JB: Trepanation as a therapeutic measure in ancient
(pre-Inka) Peru. Acta Neurochir (Wien) 93:3–5, 1988.
16. Lastres JB, Cabieses F: Trepanación del Cráneo en el Antiguo Peru.
Lima, Universidade Nacional de Cuzco, 1960.
17. Montalberti RC, McBride MLP: Historia del Peru. Lima, Tercer
Milenio S/A, 1997, vol 1.
18. Montalberti RC, McBride MLP: Historia del Peru. Lima, Tercer
Milenio S/A, 1997, vol 2.
19. Morales-Macedo C: Trepanation of the cranium and its representation in pottery of Peru. Science 43:869–875, 1916.
20. O’Connor DC, Walker AE: Prologue: Prehistoric and primitive
trepanation, in Walker AE (ed): A History of Neurological Surgery.
Baltimore, Williams & Wilkins, 1951, pp 1–7.
21. Quevedo SA: Un caso de trepanación craneana en vivo, realizado
con instrumentos pre-colombinos del Museo Arqueologico. Rev
Museo Instit Arqueol 22:1–73, 1970.
22. Rifkinson-Mann S: Cranial surgery in ancient Peru. Neurosurgery
23:411–416, 1988.
23. Squier EG: Peru: Incidents of Travel and Exploration in the Land of the
Incas. London, Macmillan, 1877.
24. Stewart TD: Stone age skull surgery: A general review with
emphasis on the new world. Ann Rep Smithsonian Instit 107:
469–591, 1957.
25. Tello PE: La trepanación de cráneo en la antigua civilización
Hazca. Lima, Facultad de Medicina, 1937 (thesis).
26. Trelles JO, Fernandez Enriquez VE: Sobre las trepanaciones
craneanas en el antiguo Peru. Rev Neuropsiquiatr 13:359–424, 1950.
27. Weiss P: Osteologia Cultural: Practicas Cefálicas. Lima, Universidade
Nacional de San Marcos Press, 1958.
COMMENTS
After 100 years of incredible technological advances in
neurosurgery, it is interesting to look back at pre-Columbian
cultures such as the Incas. Their simple but ingenious instruments and techniques are a testament to their apparent accomplishments. Ignored by the Spanish conquerors of the 15th century, these techniques until recently were neglected and
relegated to museums. This article represents an important effort
by the authors to recover these valuable historical findings. In
the attempt, however, they have become emotionally involved,
and objective evaluation of the facts is occasionally jeopardized.
In some instances, the emphasis on historical and cultural aspects sacrifices the contribution to neurosurgical knowledge. The
case reports documenting the use of historical instruments in
operations on live patients are an interesting addition to the
article. However, these experiments may have gone beyond
acceptable ethical limits for the profession.
Paulo A. de Mello
Brasilia, Brazil
Articles concerning the practice of neurosurgery in preColumbian Peru always make for fascinating reading. This
article adds interesting historical vignettes and excellent pictorial
material. The article covers a multitude of aspects on the art of
medicine practiced by these ancient cultures. In the authors’
attempt to provide a summary of all aspects of pre-Columbian
neurosurgical knowledge, some of the subsections are treated
superficially. This article stimulates interested readers to pursue
and expand their knowledge of this inspiring subject.
Peter C. Gerszten
Pittsburgh, Pennsylvania
Enrique Gerszten
Pathologist
Richmond, Virginia
One cannot but be amazed at our early “neurosurgical”
colleagues who not only managed to perform trephinations
with great skill but also managed to keep the majority of
patients alive. When one looks at the survival data of 17th
century European surgeons, for example, and compares them
with results achieved by the Inca surgeons, the latter seem to
have the better outcome! I have always had difficulty understanding how a patient could consent to having a hole drilled
in his or her head, with minimal anesthesia and in total body
restraints, and survive the ordeal. Yet survive they did, and as
the authors point out, there are many examples of healed
trephinations among the museum collections of Peru. Even
more impressive are the skulls exhibiting successful cranioplasties made of silver and gold, which were placed with such
skill that the bone healed around them. The tragedy of this
early Peruvian period is the lack of written material and
documented oral history; these would have provided remarkable insights into these early surgeons and their techniques.
Nonetheless, a review of their work, the style of trephination,
and the use of the tumis reveals some remarkable early neurosurgical interventions. All of this was accomplished with
remarkably good outcomes considering the lack of anesthesia
and aseptic technique.
James T. Goodrich
Bronx, New York
This historical article is of interest primarily because of the
extraordinary illustrations provided. There is much of interest,
and the authors have expanded our knowledge concerning a
number of aspects of neurosurgical history in South America.
Neurosurgery, Vol. 47, No. 4, October 2000
Edward R. Laws, Jr.
Charlottesville, Virginia