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International Journal of Paleopathology 8 (2015) 29–35

Contents lists available at ScienceDirect

International Journal of Paleopathology

j ourna l ho mepage: www.elsev ier .com/ locate / i jpp

ase Study

ibial surgery in ancient Peru

. Marla Toyne ∗

niversity of Central Florida, Orlando, FL, USA

r t i c l e i n f o

rticle history:eceived 27 February 2014eceived in revised form1 September 2014ccepted 11 September 2014

eywords:

a b s t r a c t

This case study describes a unique anthropogenic modification of two individual skeletons excavatedfrom the pre-Columbian site of Kuelap, Chachapoyas-Amazonas, in the northeastern highlands of Peru.While numerous examples of cranial trepanations using an adjacent drilling technique have been recov-ered from this site and region, this is the first example of such a surgical technique on a post-cranialelement. Skeletal remains demonstrate that ancient Andeans were skilled and successful with manysurgical treatments. Ethnohistoric documents suggest the Chachapoya shamans were known for their

ioarchaeologyibiarepanationraumaealinghachapoya

healing. In these cases, however, there is no evidence of long-term healing. This innovative medical pro-cedure appears to have been an attempt at therapeutic intervention intended to treat an osteomyeliticinfection of the distal tibial metaphysis.

© 2014 Elsevier Inc. All rights reserved.

outh America

. Introduction

Evidence of ancient surgery has been found on skeletal remainsrom various Andean cemeteries, and trepanation of the craniumas one of the most common types identified (Hrdlicka, 1939;occa, 1953; Verano, 2003; Weiss, 1953, 1961). Various surgicalethods have been identified with surprisingly high success rates

or such a potentially dangerous intervention. This paper presentswo cases from the Chachapoyas region of Peru, in which a com-

only used trepanation technique was applied to the leg (tibia),ltimately unsuccessfully, thus representing the first cases of such

medical practice identified in non-cranial remains. These cases ofurgical innovation demonstrate that this application of a known,ut invasive, treatment to another area of the body may reflecthe practitioner’s goal of providing care regardless of the risk ofnknown outcomes (Tilley and Oxenham, 2011).

.1. Andean skeletal pathology

In the Central Andean region of Peru, pre-Hispanic societies

emonstrate a long history of significant achievements in social,echnological and architectural innovations. They constructed largeities, developed elaborate artistic designs, established diverse

∗ Present address: University of Central Florida, Howard Phillips Hall Room 309,rlando, FL 32826-1361, USA. Tel.: +1 407 823 1927; fax: +1 407 832 3498.

E-mail address: j.marla.toyne@ucf.edu

ttp://dx.doi.org/10.1016/j.ijpp.2014.09.002879-9817/© 2014 Elsevier Inc. All rights reserved.

agricultural products, and built empires across a large regionknown for ecological extremes (Moseley, 2001; Rowe, 1946)(Fig. 1). The dry, desert coasts and high rugged Andean mountainchains of the area were major physical obstacles; however, thesechallenges were not overcome without leaving their mark on thelives, and the bones, of these ancient peoples.

Skeletal trauma is the most common type of lesion reportedfrom numerous sites, commonly identified as cranio-facial injuriesconsistent with interpersonal violence (Andrushko and Torres,2011; Tung, 2007) and post-cranial fractures that suggest individ-uals were subjected to various environmental and occupationalhazards (Standen and Arriaza, 2000b; Standen et al., 2010). Fewstudies have attempted to assess trauma frequency or patterns ata regional level to explore the overall impact these would havehad on lifestyle and survival (but see Arkush and Tung, 2013).Often focusing on the prevalence of healed antemortem frac-tures, previous trauma studies suggest that even with complex andmultiple-element fractures, as well as comminuted fractures anddislocations, these individuals were being treated in a way thatprevented death due to exsanguination or infection (Dettwyler,1991). Other individuals exhibited osteological lesions consistentwith surviving with advanced stages of a variety of chronic andinfectious diseases (Allison, 1984; Allison et al., 1981; Friedrichet al., 2010; Klaus, 2014; Phillips and Verano, 2011; Standen and

Arriaza, 2000a; Verano, 1997a,b). While this does not necessarilyconfirm that there were healing specialists among these indigenouspeoples, it suggests that some medical knowledge was availableand care given when possible.

30 J.M. Toyne / International Journal of Paleopathology 8 (2015) 29–35

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Fig. 1. Map showing the geographic location of the Chachapoya re

.2. Ethnohistoric descriptions and archaeological evidence ofurgery

Early written documents provide some information about pre-ispanic medical practices, though perhaps from a biased Europeanerspective. Nonetheless, these reports describe the considerablekill of indigenous healers and curanderos as specialists dealingith significant injuries, disease, and complex medical treatments

ased upon extensive knowledge of local plants and their medic-nal properties (Cabieses Molina, 1993; Cobo, 1990 [1653]; Rowe,946). There is some suggestion that Cusco, as the center of the

nca Empire, was also the center of medical achievements, evenosting a medical school (Cabieses Molina, 2007; Lastres, 1951).urthermore, the earlier Chachapoya people (A.D. 800–1470) inhe northern highlands were reported to be proficient herb doc-ors and “sorcerers” with great healing skills (Arriaga, 1968 [1621];alancha, 1972 [1638]; Schjellerup, 1997).

Several archaeological examples of surgery1 have beenescribed by Verano et al. (2000) and Verano and Andrushko2010) with specific examples of bone healing after substantialnjury, amputation, or surgical intervention. The individuals fromhe coastal site of Huacas de Moche with lower leg amputations

howing evidence of healing clearly reflect drastic procedures,lthough whether they were therapeutic or punitive interven-ions remains unclear (Verano et al., 2000). More generalized

1 Surgery here is defined as specific invasive medical procedure used to providelleviation of physical suffering, wherein the intent is to provide care for the indi-idual patient.

n Peru with major archaeological sites including Kuelap (circled).

descriptions of cranial surgery from Hrdlicka’s early Twentieth Cen-tury skull collection (Tyson and Dyer Alcauskas, 1980) and otherPeruvian cranial examples described by Weiss (1961) and Rocca(1953) include trepanations and possible cauterizations. One canassume that these complex and presumably dangerous treatmentscould not have been successful without some knowledge of theintricacies of human anatomy and physiological processes as wellas in the prevention of infection.

1.3. Trepanation techniques

Trepanation (or trephination, the modern method of drillingholes into bone) is, by definition, cranial vault surgery involvingthe removal of a section of vault bone. It has long been of interestto those studying peoples of the ancient Andes (Hrdlicka, 1939;Jorgensen, 1988; Moodie, 1919; Rifkinson-Mann, 1988; Trelles,1962). Collections of trepanned crania abound in museums due tothe fascination with these remarkable surgical procedures; many,unfortunately, have poor contextual information. The practice hasa long history in the Andes and work by Verano (2003) exploreshow widespread it was, as well as the various methods used in dif-ferent regions. Generally, four bone removal techniques have beenidentified, including scraping, incising (circular grooving), drilling,and cross-hatching (Fig. 2), using either stone or metal implements(Lisowski, 1967). There appear to be regional patterns in preferred

methods; notably, most trepanations in the Chachapoyas regionemploy a drilling or boring method (Nystrom, 2007; Toyne, 2014),while scraping and circular grooving predominate in the southernAndean highlands (Andrushko and Verano, 2008; Kurin, 2013).

J.M. Toyne / International Journal of Paleopathology 8 (2015) 29–35 31

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ig. 2. Illustration of different trepanation methods used on crania in Peru. (1)craping, (2) circular grooving, (3) boring, and (4) linear grooving or cross-hatching.

ource: Lisowski (1967).

. Materials and methods

.1. Archaeological context

The Chachapoya culture is defined geographically by the dis-ribution of similar cultural and architectural remains over a500 km2 area that lies between the Maranon and Huayallagaivers on the eastern Andean cordillera. Kuelap is a monumentaltonewall complex situated in the center of this region and dates topproximately A.D. 800–1535 at the height of its occupation. Recentxcavations demonstrate this powerful monumental city was likelyoth a political and religious center in the region (Narváez Vargas,987, 1996, 2009, 2013).

Variability in mortuary treatment and contexts recently exca-ated at Kuelap suggest the site was occupied by a large populationossibly including distinct social or ethnic groups (Ruiz Estrada,009). The first mortuary context of interest (ENT30) for this casetudy was discovered within a large retaining wall, Muralla Oeste,f the central Pueblo Alto sector of the site. This particular wall withncorporated niche burials was constructed during the mid-Latentermediate Period expansion of the site (∼A.D. 1300) (Narváezersonal Communication). Upon removing the outer stonewalluring modern consolidation efforts, the remains of at least 73 indi-iduals of both sexes and a range of ages were discovered within the

ll (Table 1) (Toyne, 2011a). These were distributed in several lay-rs and large alcoves, mostly as collections of intermingled bonesFig. 3). Most were incomplete and highly fragmentary, but severalere sufficiently complete to suggest some articulated bodies were

able 1ex and age determinations of skeletal remains from Muralla Oeste, Kuelap.

Sex estimation # Age category #

Male 23 Infant (0–2 yr) 6Possible male 1 Child (3–11 yr) 17Female 21 Adolescent (12–19 yr) 3Possible female 3 Young adult (20–34 yr) 27Indeterminate 25 Middle adult (35–49 yr) 18

Older adult (50 yr plus) 2

Total 73 Total 73

Fig. 3. Photograph of skeletal remains of ENT30 in situ articulated in a tightly flexedposition during excavation.

Source: Edwin Blas.

deposited, likely in a tightly flexed, seated position, consistent withother mummified remains found in larger collective mausoleumtombs at the site and in the region (Guillén, 2002; Kauffmann-Doigand Ligabue, 2003; Ruiz Estrada, 2009). The second (ENT6) indi-vidual reported here had been interred in a small pit in the floora house structure at the southern end of the site near the TemploMayor. Again, this burial’s chronology dates to the Late Intermedi-ate Period. These burials do not deviate in any way from traditionalmortuary practices documented at the site (Ruiz Estrada, 2009).

Skeletal analysis followed methods recommended by Buikstraand Ubelaker (1994). Pathological conditions were observedmacroscopically using a hand lens (10x) and recorded in pho-tographs and illustrations. Radiographs of ENT30 were taken ofthe dry bone at the Hospital Regional “Virgen de Fatima” inChachapoyas, Peru, under the supervision of Dr. Jose Chuquival.

3. Results

3.1. K-PAS MO – VIII T’ ENT30

This partially complete skeleton (∼75%) (ENT30) was located inone of the upper excavation levels and represents a young adultmale, aged approximately 30–34 yr at death. Missing skeletal ele-ments included the upper left limb, sacrum, and both hands andfeet. Although most of the skeleton was articulated in situ, theabsent skeletal elements suggest this was a secondary interment

of a previously desiccated corpse with minor postmortem tapho-nomic breakage. The skeleton had been interred supine, with thelower limbs tightly flexed to the chest, deposited in close asso-ciation with the partial skeletal remains of at least five other

32 J.M. Toyne / International Journal of Paleopathology 8 (2015) 29–35

Fig. 4. Photograph of the anterior aspect of the right distal tibial and fibular meta-ptm

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hyses demonstrating both lateral fracture and medial drill modification of theibia. Detail in insert identifies two fine cut marks longitudinally along the medial

alleolus.

ndividuals, including two children, an adolescent, and two adultemales (Fig. 3). There was no clear organization to the placementr orientation of these individuals; rather, they seemed to haveeen piled fairly tightly together as part of a contemporaneousepositional event.

The skeletal remains of ENT30 do not display any osteologi-al evidence of pathological conditions except for moderate dentalear and antemortem tooth loss of one mandibular molar.

.1.1. Description of modified areaENT30 presents a series of holes drilled near the distal end of

he right medial tibia just superior to the malleolus (Figs. 4 and 5a).his perforation of the cortical bone is not a destructive pathologicalesion, nor the result of postmortem damage, but of anthropogenicrigin. It has an irregularly-shaped aperture with a scalloped edgehere the small individual bore holes were placed adjacent to one

nother and overlapping to varying degrees. There appears to be minimum of nine holes creating a roughly rhombus shape, mea-uring approximately 18 by 18 mm (Fig. 6). The clearest drill holesn the superior part of the aperture are approximately 3–4 mm in

ig. 5. (A) Photograph of the medial aspect of tibial metaphysis demonstrating theonjoined drill holes perforating the cortical bone and the exposed trabecular within.lso note the longitudinal fracture extending both proximally and distally from

he aperture. (B) Photograph of the lateral view of the metaphysis demonstratinghe perimortem fracturing of the cortical surface that may have resulted from aerforation from the other side.

Fig. 6. Close up photograph of the drill holes on the medial aspect of the tibia demon-strating the irregular striations in the wall of small circular perforations consistentwith scraping with a stone tool.

diameter. The other semi-circular drill holes appear to have beenmade by a similarly sized instrument, although their proportionsare obscured by overlap. The contiguous placement of the individ-ual drill holes allowed a small central section of bone (plug) to beremoved. This surgical drilling occurred perimortem since there isno clear evidence of bone remodeling consistent with short-termhealing.

Anatomically, the holes are in a location with no direct tendi-nous or ligamentous attachments, but in close proximity to themalleolar tuberosity where the flexor retinaculum attaches. Only athin layer of skin and connective tissue would have covered thebone. The posterior (flexors) and anterior (extensors) muscularcompartments and their associated tendons would have passed toeither side of the site and would not have been impacted.

The edges of the drill holes demonstrate clear evidence ofirregular scraping consistent with a flaked edge stone tool, ratherthan a smooth, straight-edged metal tool (Fig. 6). While no stonetool drills were recovered from Kuelap, several obsidian bladeshave been (Narváez Vargas, 2009; Toyne, 2011b). There is alsoevidence of two short, parallel perimortem cut marks located onthe medial malleolus just inferior to the drilled aperture (Detail inFig. 4). The cuts run longitudinally to the shaft and likely repre-sent the incision of the superficial soft tissue in order to exposethe bony area underneath prior to drilling. However, there are nocut marks on the bone superior to the drilled area to indicate theapproximate length of the incision. These incisions are very fine,narrow cuts perpendicular to the bone surface and under micro-scopic examination present wide and irregular margins consistentwith sharp lithic blade (Walker and Long, 1977).

There is a continuous longitudinal fracture of the distal shaft thatextends from approximately 41.9 mm proximal to the superior-most drill hole to 10.9 mm distal. This fracture was visible on theX-ray and appears to involve both endosteal and sub-periosteal cor-tices. The location of this fracture is not consistent with clinicalreports of stress fractures (shin splints) commonly identified in theanterior tibia (shin) of athletes (Daffner and Pavlov, 1992; Devas,1958). Additionally, on the lateral aspect, just superior to the artic-ulation of the distal tibio-fibular joint, a fragment of bone is also lost(Fig. 5b). The area of bone missing is approximately 9.0 by 33.6 mmbut is beveled outward from a smaller aperture in the center. Thisperimortem fracturing is consistent with a thin layer of the lateralcortical surface splintered or spalled away (Knüsel, 2005; Ubelaker

and Adams, 1995). Trabecular bone loss between this fracture andthe drill hole location on the medial aspect creates a direct butnarrow connection between the two areas of bone modification,suggesting that during the trepanation, the implement used to drill

J.M. Toyne / International Journal of Paleopathology 8 (2015) 29–35 33

Fig. 7. Radiographic image of the medio-lateral view of the distal tibia of ENT30.Note the scalloped outline of the drilled-out portion of the cortical bone and alsothe radiolucent area just superior to the articular surface within the metaphysiscp

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Fig. 8. Photograph of the medial aspect of the right tibia of KSTIN – IW ENT6, withtwo perimortem drill holes along the midshaft (arrow and inset). The inset providesa close-up view of the perforation where striations can be seen along the internally

onsistent with a reduction in the density of trabecular bone, most likely due to theresence of an osteomyelitic abscess (circled).

ay have penetrated the medullary cavity with enough force toerforate and avulse a fragment of the lateral cortex. Unfortunately,he archaeologists did not recover the bone fragment.

Radiographic imaging of the tibia revealed an area of reducedpacity just inferior to the aperture suggesting a reduction in tra-ecular bone density just proximal to the distal epiphysis (Fig. 7).his was likely the result of an acute localized intraosseous infec-ion and abscess of the metaphysis, most likely of hematogenousrigin (Dr. Steven Fricks Personal Communication).

.2. KSTIN – VW ENT6

A second individual from Kuelap, an adolescent male, mod-rately well preserved, although incomplete, also presents twondividual drill holes along the midshaft of the medial right tibiaFig. 8). These drill holes also demonstrate modification consistentith an irregularly edged stone tool, and these isolated perfo-

ations, measuring approximately 5 mm in diameter, penetratedhrough the entire cortical thickness. The first hole is approxi-

ately 120 mm from the proximal epiphysis (unfused). The second,nfortunately, was damaged postmortem but is similar in size andppears roughly 62 mm from the first along the medial shaft sur-ace. There is no evidence of bone remodeling in either, but againhere is a longitudinal perimortem fracture that crosses the firstrill hole. This second case is similar to the first in that the drillingccurred on the medial surface of the tibia and also appears associ-ted with a perimortem linear fracture. These individual boreholesay have served a similar function in treating an intraosseous con-

ition. X-rays are not available for these remains. Histopathologicalnalysis of the affected area would be ideal to test this hypothesisurther in both cases at Kuelap.

beveled edges.

4. Discussion

4.1. Location and anatomy

The drill holes on the medial aspect of the distal tibia of ENT30are located just superior to the ankle-joint complex but are notassociated with specific overlying tissue structures. In order toexpose the underlying bone, skin was the only major tissue to be cutand separated, and the longitudinal cuts suggest that the incisionfollowed the center of the bone shaft.

The location and orientation of the ENT30 fracturing is notconsistent with an accidental fracture of the ankle joint. Clinicalliterature reports that injury-related fractures of the distal tibialarticular plateau most commonly occur in relation to adduction orexorotation of the ankle joint resulting in fracturing of the medialmalleolus (Salter Harris type IV) or horizontally along the epiphy-seal line, commonly called triplanar fractures (Johner and Wruhs,1983; Joveniaux et al., 2010). These more complex “pilon” anklefractures can be complicated by fibular fractures as well.

Stress fractures can also be ruled out since linear longitudi-nal fractures are more frequently located along the anterior tibialmid-shaft as fatigue fractures common to specific athletic activities(Daffner and Pavlov, 1992). Several possible healed stress fractureshave been identified in this population but none in a similar medio-distal location as this lesion (Toyne, 2011a).

The linear fracture in both cases appears to have the resultedfrom direct force applied to the area. For ENT30, the splitting ofthe bone may have occurred as the result of an antemortem pene-trating traumatic injury to the area above the ankle. Alternatively,the fracture may have occurred during surgery when the drill wasapplied to the dense metaphyseal cortical bone or when the centralportion of the bone (plug) was removed using an implement, suchas a chisel (Lisowski, 1967). The fracture of ENT6 appears to con-firm that substantial pressure was applied during drilling, similarlyresulting in radiating fractures at the drill site.

The distal tibia is a unique location for the application of a knowntrepanation technique in the Andes. The association of trepana-tion with cranial fractures is fairly common (Verano, 2003), andperhaps this represents the application of a known surgical tech-nique in a new location. The placement of adjacent drill holes toremove a larger circular plug of bone is a common trepanation tech-nique used in the Chachapoyas region, including those observed in

15 adult crania at Kuelap (Toyne, 2014). The distribution of thesetrepanations is restricted to the cranial vault but infrequently asso-ciated with other pathological lesions or fractures. Therefore the

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pplication of this technique to the tibia was likely due to a specificocalized need.

.2. Intervention and interpretation

In the case of ENT30, the tibia presents no evidence of are-existing active bone lesion evident on the surface, but the per-

mortem longitudinal fracture introduces the possibility of twonterpretations. The first option is that the individual suffered airect penetrating injury to the lower medial leg, which caused aadiating linear fracture on the medial surface and the fragmen-ation of the lateral surface of bone after complete perforation ofhe distal end of the bone shaft. This would suggest a narrow sharpbject penetrated the bone at high velocity or high force, such as arojectile stone-tipped arrow or lance. The observed radiographichanges in trabecular bone density consistent with a large abscessre thus the result of a secondary infection. The surgery may haveunctioned to remove the penetrating object, or to treat the sub-equent infection. However, since the surgery has subsequentlybscured any evidence on the surface of the bone, this interpre-ation cannot be conclusively supported.

Alternatively, the intraosseous abscess may have been the ini-iating factor for surgery. Hematogenic origin for this type of

etaphyseal infection is possible without direct inoculation, butt is impossible to determine the exact source of the infectionMcGuire, 1989). The osteomyelitis would have most likely pro-uced associated localized pain and thus prompted treatment tohis specific area. The method of drilling a single bore hole inrder to create a drainage point (bone trephination decompres-ion) in abscessed or necrotic bone is known in modern surgicalractice for cranial and some dental cases (Bellut et al., 2012; Finnend Klämfeldt, 1981; Komiya et al., 1993; Zumofen et al., 2009).n anonymous European 19th-century report described drilling arainage canal in the ilium of an individual suffering from a coldbscess in the lower lumbar region (Anonymous, 1881). Since ENT6nly has drill holes that are not contiguous to create a larger aper-ure, perhaps they were single perforations for individual drainage.he force applied to drill through the dense cortical bone likelyesulted in the longitudinal fractures.

Additionally, worth mentioning but an unlikely explanation,ould be that this procedure was post-mortem “practice” on freshuman bone in order to learn the drilling method of trepanation.his seems unlikely since all trepanations take place on the cra-ium, so it seems more likely that the practitioner would choose toxperiment with a cranium rather than a long bone. Furthermore,oth individuals were interred almost complete and articulated,

ndicating that the tibia was not removed and modified as an iso-ated skeletal element.

Finally, drilling into skeletal remains to create and removemulets or pendants from living individuals, or trophies fromeceased individuals are also possible explanations. Examples fromarious world cultures exist to demonstrate this practice (Oakleyt al., 1959). This is also a less likely explanation since this operationas clearly perimortem and the area drilled was adjacent to a local-

zed infected area (ENT30). Thus, this surgery was likely performedor medical purposes.

.3. Consideration of care

This specific osteological modification demonstrates the inten-ional application of an invasive surgical technique in an effort to

itigate a condition affecting the individual (Dettwyler, 1991). Fol-

owing the recent development of the bioarchaeology of care (Tilleynd Oxenham, 2011), which explores the identification and impactf medical treatments to alleviate suffering and facilitate contin-ed survival in past populations, this case is clearly an example of

aleopathology 8 (2015) 29–35

providing care. The specific location of the drill holes demonstratesthat there had been localized discomfort, and this was not an oper-ation that could have been accomplished by the individual alone.The surgeon understood that by drilling into the affected area theycould perhaps relieve the symptoms. If treatment had not beenattempted, the infection could have eventually spread and led tothe death of the individual. As is stands, neither individual survivedlong after the drilling, but clearly there was evidence to suggest thatsuch a procedure was necessary and that the practitioner believedit might work. Since the trepanation technique of boring holes hasonly been observed on the cranial vault (with a significant successat Kuelap of 78% (Toyne, 2014)), this extension of the method in anovel location suggests that the practitioner was exploring how touse a known method of surgery to treat two separate individuals.It is unclear who else may have been involved in this process, orif other types of medical treatments were employed, such as localanesthesia or medicines to prevent infection.

Although these individuals were treated, the operations wereultimately unsuccessful, and both died soon after. The collectivesecondary burial context of ENT30 within the wall does not distin-guish him in any way from other community members and thushis condition, treatment and/or death do not appear to be reflectedin differential burial treatment. While ENT6 also demonstratesperimortem drill holes along their tibial midshaft, this clearly inef-fective intervention did not become a common practice at the siteor elsewhere in the region.

5. Conclusion

This report of two individuals with surgically drilled tibiae fromthe eastern slopes of Peru are unique cases for the Central Andes,but perhaps reflect a local tradition or inventive application of aknown surgical approach for previously unrecognized therapeuticpurposes. Although cranial trepanations have been identified fromarchaeological contexts throughout the world (Erdal and Erdal,2011; Liston and Preston Day, 2009), this is the first reported appli-cation of a post-cranial element being drilled in an attempt to treata localized injury or infection of the leg. The surgery described here,though unsuccessful, demonstrates a similar technical skill to othertrepanned crania recovered from the site of Kuelap and region.Evidence from this case suggests that while medical practices inancient Peru may be considered technologically simple by modernstandards, they do appear to have been innovative at times.

Acknowledgements

This research would not have been possible without the Kue-lap Archaeological Project – directed by Alfredo Narváez Vargas –and the hard work of all the team archaeologists and workers. ElvisMondragon facilitated the X-raying of the bone under the supervi-sion of Dr. José Chiquival, radiologist at the Hospital Regional Fatimade Chachapoyas and his assistant Pedro Pulce. Special thanks to Lic.Manuel Malaver and Director Jose Santos Trauco of the DirecciónRegional de Cultura-Amazonas for facilitating access to materi-als stored at the museum and providing museum workspace forongoing research of the Kuelap skeletal collection. Diagnostic brain-storming with the UCF College of Medicine Anatomy Departmentand the following medical professionals was enlightening: Dr. A.Payer, Dr. Frick, Dr. Michael Keil, Dr. Valdivia, Dr. A. Tirado, andDr. L. Robinson. Finally, thanks to Natalia Guzman Requena, Elvis

Mondragon, Arturo Ruiz Estrada, John Verano, and Keith Cinami foradditional ideas and support. Editorial suggestions of the anony-mous reviewers and editors were much appreciated. All errors aresolely mine.

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