International Journal of Osteoarchaeology Int. J. Osteoarchaeol. (2008) Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/oa.1028 Cranioplasty in Ancient Peru: A Critical Review of the Evidence, and a Unique Case from the Cuzco Area J. W. VERANO a* AND V. A. ANDRUSHKO b a Department of Anthropology, Tulane University, New Orleans, LA 70118, USA b Department of Anthropology, Southern Connecticut State University, New Haven, CT O6515, USA ABSTRACT Cranioplasty is a well-known procedure in modern neurosurgery. Although some authors have claimed it was also performed by prehistoric trepanners in various parts of the world, there is little hard evidence to support this. Here we review various claims of cranioplasty in Peru, where trepanation was widely practised in Prehispanic times. We find little support for assertions that cranioplasty was common. One recently discovered burial from the Cuzco region, however, provides the first documented case of the reinsertion of a bone plug into a trepanation opening. Copyright ß 2008 John Wiley & Sons, Ltd. Key words: trepanation; cranioplasty; Peru Introduction common in certain geographical areas and time periods, citing anecdotal accounts of the use of Cranioplasty, the repair of a skull vault defect by gourd, shell, or metal plates by traditional insertion of some object (bone or non-biological trepanners of the South Pacific and Andean materials such as metal or plastic plates), is a well- South America (Ford, 1937; Hrdlicˇka, 1939; known procedure in modern neurosurgery. Rytel, 1962; Asenjo, 1963; Sanan & Haines, Motivations for the practice include protection 1997). Others are more cautious, finding surpris- of the exposed brain and cosmetic restoration of ingly few examples of attempts at repairing skull normal vault contour (Reeves, 1950; Stula, 1984; defects, even in areas where trepanation was Moreira-Gonzalez et al., 2003). In Western commonly practised (Courville, 1959). Unfortu- medicine, the earliest documented attempts at nately, anecdotal accounts and secondary sources cranioplasty date to the early to mid-16th century continue to be accepted uncritically (Carod-Artal (Sanan & Haines, 1997; Aciduman & Belen, 2007), &Va´xquez-Cabrera, 2004; Aciduman & Belen, but it was not until the 19th century that 2007), resulting in an aura of truth. substantial experimentation with human and animal subjects was done (Reeves, 1950; Courville, Trepanation and rondelles 1959). Was cranioplasty practised by ancient trepan- In the 19th century, the discovery at Neolithic ners? Some authors have claimed that it was sites in France of trepanned crania associated with rondelles (in some cases found within the cranial * Correspondence to: Department of Anthropology, Tulane Univer- sity, 7041 Freret St., New Orleans, LA 70118, USA. cavity itself) led to early debates about whether e-mail: [email protected] these bone disks had been replaced in trepan Copyright # 2008 John Wiley & Sons, Ltd. Received 22 July 2008 Accepted 1 September 2008 J. W. Verano and V. A. Andrushko holes to protect the brain following surgery difficult task. Most trepanned crania were (Broca, 1877; Lucas-Championnie`re, 1912; Ruf- collected in the late 19th and early 20th centuries fer, 1918–19). While Broca believed that one from communal tombs or burial caves where example of a trepanned cranium with an skeletal remains were commingled and disturbed associated rondelle found by Prunie`res at Loze`re by artefact collectors and other taphonomic was convincing, others disagreed. agents. These specimens exist in museums today The Crichel Down skull from Dorset (UK) as isolated crania with few or no grave asso- appears to be the only unequivocal case where a ciations and little contextual information. It is rondelle was cut from a cranium and then possible that objects such as shell or metal plates, replaced in its original position. Piggott (1940), originally associated with these skulls, were lost. who excavated and described the skeleton, Cranioplasties made from organic materials, such hypothesised that the bone disk was replaced as gourd, would probably decompose in most beforeburialandfixedinplacewithabandageor burial contexts and thus would not be detectable. some other device. The margins of the trepanation Portions of cranial vault bone, if they were showed no evidence of bony reaction, however, replaced in trepan openings, might have become indicating that the patient had not survived. separated from crania and lost. The archaeologist Julio C. Tello, who col- Cranioplasty in ancient Peru lected hundreds of trepanned skulls from high- land Peruvian burial caves in the early 20th This paper examines the specific question of century (Tello, 1913), claimed to have found whether cranioplasty was a widespread practice cranial amulets in the Huarochirı´ region of central in ancient Peru, as has been claimed by some highland Peru, which he believed to have come authors (Hrdlicˇka, 1939; Rytel, 1962; Asenjo, originally from trepanned skulls. Unfortunately, 1963; Sanan & Haines, 1997). Peru is a good test Tello never described or published these, and the case for such a review, since it is distinguished by palaeopathologist Pedro Weiss, who later inquired having the largest number of prehistoric tre- about them, reported that ‘unfortunately, they have panned skulls of any region of the world, with a been lost’ (Weiss, 1958: 561). The specific contexts time depth for the practice of over two millennia in which these ‘amulets’ were found were not (Stewart, 1958; Verano, 2003). If cranioplasty described by Weiss, but it appears that they were were a common practice, or even an occasional isolated items found in graves, and not in direct experiment, one would expect to find physical association with trepanned skulls. evidence to confirm this. Mummified bodies with trepanation openings Here we review all relevant examples of: (1) museum retaining scar tissue or remains of the scalp might specimens; (2) published accounts from the late provide the best opportunity for identifying 19th and early 20th centuries; and (3) modern cranioplasty, if it were indeed practised. Unfor- ethnographic reports, for evidence of cranioplasty tunately, relatively few mummies with trepana- in Peru. We find little evidence to support the tions exist in museum collections. The Peruvian practice – even published photographs of skulls anthropologist Sergio Quevedo, motivated by with purported cranioplasties are unconvincing. colleagues and explorers who claimed to have Finally, we present a case study of a recently seen mummies with trepan openings covered discovered cranium from the Inca site of Kanamarca with pieces of gourd, performed dissections of (department of Cuzco, Peru), with a trepanation in several well-preserved Cuzco area mummies in which the plate of bone removed during the which healed trepanations were still covered by procedure was replaced in its original location. intact tissue. In fact, his dissections did not reveal evidence of any foreign body inserted into the bony defects (Quevedo, 1943). Our examination Bony evidence of other trepanned mummies in Peruvian and US museums likewise has not uncovered evidence of Searching for convincing evidence of cranioplas- any objects covering or inserted into trepanation ties in ancient Peruvian skulls is admittedly a openings. Copyright # 2008 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. (2008) DOI: 10.1002/oa Cranioplasty in Ancient Peru Published descriptions of The anterior margin of the defect shows ragged cranioplasties in Andean edges marking the location of a perimortem trepanned crania depressed fracture, with a radiating fracture line extending inferiorly to the margin of the right orbit and extending along the orbital roof. Initial account Separation of the right coronal suture and a portion of the sagittal suture, and a radiating The earliest description of a possible cranioplasty fracture extending across the left parietal, indi- in an ancient Peruvian skull appears to be that of cate the severity of the blow to the head. W.J. McGee, who studied a collection of 19 Apparently the trepanation was done in an trepanned skulls brought to the US in 1893 by attempt to treat the head injury. Like the Manuel Antonio Mun˜iz, Surgeon General of the trepanation margins, the fracture edges show no Peruvian Army (McGee, 1894; Mun˜iz & McGee, osteoclastic or osteoblastic activity, suggesting 1897). In his description of the collection, death during or relatively soon after the McGee singled out one of the trepanned skulls trepanation procedure. as unusual, because reportedly it had been found with a plate covering a trepanned opening: ‘The specimen is of interest also in that it was Other accounts of cranioplasties the only one in which a plate is known to have been used, a silver plate having been found in Following McGee’s early report, other authors place over the aperture in the mummy [exhibit] would assert that cranioplasties had been found in case. The presence of the plate, its seat in the Peruvian trepanned skulls. In a 1939 review of skull showing long wear, and the absorption ancient skull surgery, Alesˇ Hrdlicˇka claimed that and reparative growth, all indicate that the in the case of large trepanation openings: operation was survived.’ (McGee, 1894: 3) ‘Andean primitive surgeons used various objects for ‘‘stoppers’’. In some cases these For some reason, this plate did not accompany consisted of a gourd, or perhaps a bone; in the cranium to the US, and McGee never