A Cut Above the Rest: Trepanation Among the Post-Imperial Chanka of Ancient Peru

Danielle S. Kurin, Department of Anthropology, Vanderbilt University

Introduction
Ancient cranial surgery, called trepanation, is thought to have been practiced by groups in the pre-Colombian Andes in order to alleviate intracranial pressure caused by traumatic physical or psychosomatic injury (See Verano 2003). This paper reports on the bioarchaeological evidence for pre-, peri-, and postmortem trepanations among different skeletal sub-populations affiliated with the Chanka society (AD 1000-1400) of highland Andahuaylas, Peru. Following the collapse of the Wari Empire around AD 1000, the Chanka society emerged as a formidable presence in the south-central Andes. Human skeletal remains were recovered from burial contexts at four sites in Andahuaylas: Turpo (cranial MNI= 28), Cachi (cranial MNI =172), Ranracancha (cranial MNI=, 40), and Pucullu (cranial MNI=31). Skulls from Qasiachi burial cave (cranial MNI=24), currently stored in the Natividad Community Museum, were also examined. At Turpo, a Wari era (AD 600-1000) site, crania were recovered from a circular cist tomb. The other four sites date to the post-imperial Chanka Period (AD 1000-1400). Chanka populations interred their dead collectively in small caves, known as machays. The largest site in this study, Cachi, was a defensive settlement built near an important salt mine, and is associated with the upper moiety of Chanka society, while the village of Ranracancha was a lower moiety community. Pucullu may have be an enclave community of ethnic Kechwa people who were eventually assimilated into lower moiety Chanka society. The provenience for the Natividad Museum sample is less secure, but is likely associated with the upper moiety Chanka. In the lab, human crania were examined to see how different trepanning techniques may have impacted survivability among distinct sub-population groups. Following standards established by Verano (2003) and Andrushko (2007) (See also Andrushko and Verano 2008), each trepanned individual (n=32) was assessed for the following data: provenience, cultural association, age-at-death, sex, cranial vault modification, trepanation method, location, size, degree of healing, and evidence of traumatic injury. In several crania, trepanation apertures were associated with attempted trepanations (which did not reach the endocranium) and possibly errant bore holes. These contemporaneous actions were recorded as a single trepanation event. Finally, to provide a reference for comparison within the general population, individuals (over 5 years old) lacking trepanation (N=271) were also examined.
Trepanation in Andahuaylas
anterior anterior anterior

Trepanation Among the Chanka Methods

Temporal and Geographic Distributions

The presence of trepanation between imperial Wari and post-imperial Chanka eras approaches significance (Fishers exact, p = 0.0545), and suggests that in Andahuaylas, trepanations were uncommon until after the collapse of the Wari empire. While knowledge of trepanation may in fact have great antiquity in the region, it does not appear in the bioarchaeological record until after AD 1000. This relatively late appearance (See Verano 2003) may coincide with larger socio-political transformations occurring the south-central Andes and related to Wari socio-political fragmentation. Trepanation could have emerged in Chanka society as a result of both novel interactions with practitioners from other regions, as well as by trial-and-error experimentation motivated by a need to cope with high levels of violence, which characterize the era. In terms of geographic distribution, there were no significant differences in trepanation frequencies, methods, or survival rates between Chanka Period sites. This suggests that people from the region likely shared the same sort of general technical knowledge on the tools and methods involved in cranial surgery. Moreover, given that trepanation patterns are so similar between sites, the social and/or bio-physical factors that motivated individuals to remove a portion of the cranial vault may have been widespread throughout Andahuaylas.
Andahuaylas Province, Apurimac Department, Peru

1330S Pucullu Ranracancha Natividad Cachi Turpo

Cachi

Circular Grooving

Legend
Chanka Site (AD 1000 -1400)

1340S
Wari Site (AD 600-1000)
N

River Provincial Boundary

0 km 30 km 60 km

Cachi

Scraping

7330W

730W

Trepanation Events Cachi

Boring/Drilling Scraping

Circular Grooving Other

left

right

Boring/ Drilling

posterior Right Side posterior Midline right Anterior left left Posterior right Left Side posterior

Scraping

Circular Grooving

Boring/ Drilling

Trepanation and Trauma

Cachi Ranracancha Natividad Pucullu

Demography
Standards (Buikstra and Ubelaker 1994) were used to determine the sex and age-at-death of trepanned crania. The general population (n= 213) is uniformly split between males and females, but males underwent trepanation at a significantly higher rate, compared to females (Fishers exact, p<0.0001). Importantly, patterns in cranial fractures (a motive for trepanation) are similar between men and women. That equally-injured men and women are being treated differently with respect to surgical intervention, suggests that trepanation may not have been practiced to cope with just anyones injuries, but rather reserved for a certain gendered sector of society. Moreover, in contrast to other published studies from the south-central Andes (Andrushko 2007; Tung personal communication), and as a result of Chanka mortuary practices, juveniles are underrepresented in both the trepanned sample, and within the general population.
Sex Distribution in Andahuaylas
N= 213 sexed adults

Age-at-Death of Trepanned individuals and General Population

Only Peri-mortem Trepanation All Trepanations General Population

Males N=116 (54.5%)

Females N=97 (45.5%)

Age-at-death data indicates that individuals were trepanned in early and middle adulthood. Perimortem trepanations (which occur around the time of death) are only present in young and middle adults. Furthermore, the age-atdeath of trepanned adults tend to be younger than the age-of-death of the general population.
Cachi Natividad

Trepanation and Trauma

Traumatic cranial injuries can cause intracranial hemorrhaging, and releasing this pressure is often posited as a motivation for trepanation. Yet, this association is hard to confirm directly, because trepanation apertures may obliterate signs of fracture. In the Andes, trepanations may have also been employed to alleviate the symptoms of epileptic seizures (called sonqonany in Quechua) or, according to local informants, susto (traumatic fear). However, these assertions are difficult to confirm in the bioarchaeological record. In many cases, radiating fracture lines (evidence of blunt force trauma) were associated with trepanation apertures. In this study, trauma and trepanation are positively correlated in the Natividad Museum sample (Fishers exact, p=0.0207). However, the presence of trepanation is not significantly correlated with the presence of cranial fractures at the other sites. Even so, the distributional pattern of cranial vault fractures is generally similar to the locational patterning of trepanations. For instance,10/13 (69.9%) individuals had a trepanation located on the same side of the skull as a fracture (though not necessarily the same region). More specifically, individuals with trepanation have a significantly more fractures on the right posterior, while individuals without trepanation have significantly more injuries on the left posterior (Fishers exact, p=0.0381). This pattern is difficult to explain. Cranial injuries are often the result of violence, and the location of fractures informs on the position of a victim at the moment of impact (Walker 2001). In this instance, it is possible that individuals who became trepanation patients were engaged in different sorts of violent activities then the general population. Finally, while trepanations are significantly directed to the left posterior of the cranium (Fishers exact, p=0.0186), cranial fractures are more evenly distributed throughout the vault. This pattern may suggest that practitioners are not necessarily concerned with trepanning at the point of physical impact, but rather intervening on a predetermined region of the vault.
Trepanations and Cranial Trauma Trepanations and All Cranial Trauma in the Andahuaylas Sample (MNI=258) Scraping Circular Grooving Boring/ Drilling

Trepanation by Sex
N= 28 sexed adults Females N=3 (10.7%) Males N=25 (89.3%)

Experimentation
The Chanka may have attempted peri- and post-mortem trepanations as a form of experimentation. Sequences of bore holes drilled to various depths, and cut marks on endocranial vault fragments, suggest attempts by the practitioners to refine surgical techniques or better understand cranial anatomy.
Natividad Natividad Cachi

Fishers exact, p < 0.0001

Dimensions and Distribution

Certain cranial vault regions were selected for trepanation over others. Overall, trepanations tended towards the left side of the skull. Despite risks to the patient, 10 (23.3%) trepanations impacted sutures, while 16 trepanations (37.2%) impacted either facial or temporal musculature. The nuchal muscles were completely avoided. In three cases (7%) trepanations impacted the frontal sinus cavities. Trepanation Shapes Distribution of Trepanation by Cranial Region These patterns suggest either a limited N=43 N=40 understanding of cranial anatomy, or reflect a sense of urgency such that the trepanation was N=6 carried out regardless of the risks of soft tissue 14% damage. Trepanations also vary by shape. Sixteen (37.2%) trepanations were oval, 21 (48.8%) circular, 6 (14%) are polygonal (square, triangular, and cuadri-circular).
N=21 48.8%

Antemortem Trauma Perimortem Trauma

Cranial region

N=16 37.2%

Boring/drilling method with over 70 perforations of various depths. Bone polishing on the ectocranial surface and color discontinuity between the surface and drilled areas suggest post-mortem manipulation. This cranium also has a healing trepanation on the right parietal.
Circular Grooving
Natividad

Boring/ drilling method with over 60 perforations of various depths. This cranium also has a healing (scraped) trepanation on the left parietal (not shown).

Employing a linear cutting method, the square-shaped incision was made on the endocranial surface of an adult parietal bone. The ectocranial surface was not perforated.

Trepanation and Ethnicity

Post-imperial Chanka society was composed of nested moieties of ethnic groups called ayllus, whose members claimed decent from a common ancestor and maintained corporate landholdings. Cranial vault modification was likely used by the Chanka to conspicuously demarcate members of the same ethnic ayllu. In this study, modified and unmodified individuals were compared in order to determine if prominently denoting ethnic membership resulted in differences in trepanation patterns. Importantly, modified individuals are undergoing trepanation at a significantly higher rate than unmodified individuals (p=0.0069). This pattern follows trends in cranial fractures; Chanka individuals with modification were victims of both lethal and sub-lethal trauma at a significantly higher frequency than their unmodified neighbors (antemortem trauma: 2=11.826; p<0.001; peri-mortem trauma: 2 =7.984, p<0.01). Within the trepanned sub-sample however, modified crania have only a slightly higher survival rate, and there are no significant differences in trepanation methods, sizes, or locations. Geographic origin does not appear to impact surgical intervention either. Strontium isotope analysis performed by Ellen Lofaro (U Florida) on a sub-sample (n=24) of the Andahuaylas collection, indicates that two individuals with trepanations --both young adult males--were born in non-local regions. These results suggest that trepanation may indeed have a violent etiology, but the practice itself was not limited to select ethnic or residential-kin groups.

Trepanations and Cranial Vault Modification

Trepanation Methods
Four methods of trepanation (See Verano 2003) are present in Andahuaylas: scraping (n=24, 55.8%) circular grooving (n=9, 20.9%), boring/drilling (n=9, 20.9%), and linear cutting (n=2.4%). Of 43 trepanation events, 13 (30.2%) have no healing, 6 have short-term healing (14%), and 26 (60.4%) show signs of longterm healing. While the overall survival rate in Andahuaylas is 69.8%, certain trepanation methods proved more successful than others. Scraping is significantly more successful than both circular grooving (Fishers exact, p=0.0031) and boring/drilling (Fishers exact, p<0.0001). Although drilling was the most unsuccessful method only 24 out of 223 total bore holes (10.7%) show signs of healing5/7 (71.4%) of individuals with bore holes also have healing scraped trepanations. This pattern suggests that the boring/drilling method may have been intentionally practiced (peri- or even post-mortem) on individuals who had already survived previous surgical intervention. Trepanation sizes (the area of vault that was impacted by the surgical tool) ranged by method. There are no significant differences between the sizes of scraped or grooved trepanations within or between sites. Nor is there a significant association between trepanation size and degree of healing. However, the size of the drill bit used to make bore holes differs between sites. At Cachi, bore holes have an average diameter of 3.76 mm (sd= .626). In contrast, bore holes at Pucullu have an average diameter of 5.86 mm (sd =.714). These patterns suggest that different standardized toolkits may have been employed by practitioners at different sites.

Peri-Operative Practices
Cachi

Unmodified Crania

Scraping

Modified Crania
Scraping Circular Grooving Boring/ Drilling

Boring/ Drilling

This mummified adult male has a healing trepanation (scraping) on the left parietal boss (not shown). There is also a perforation on the frontal bone (boring/drilling). An unknown darkcolored substance is also present near the trepanation.

This adult male cranium has a healing trepanation (scraping) centered on left parietal, which crosses the coronal suture. The metal plaque (a copper-silver alloy) was found next to the cranium and may be an example of cranioplasty.

Trepanation Among the Chanka

This study characterized trepanation among the Chanka of Andahuaylas, Peru. Trepanation could have emerged in Chanka society as a result of both novel interactions with practitioners from other regions, as well as by trial-and-error experimentation following the collapse of the Wari empire ca. AD 1000. Standardization in trepanation techniques suggest that practitioners throughout Andahuaylas shared a common understanding of how to perform cranial surgery, but likely employed distinct standard toolkits. Given that trepanation patterns are similar between sites, the social and/or biophysical factors that motivated individuals to remove a portion of the cranial vault may have been present throughout the region. Overall, trepanations tended towards the left side of the skull, and generally coincide with distributional patterns in cranial fractures. However, practitioners may have directed trepanations on predetermined region of the vault, and not on acute loci of physical impact. These results further suggest that trepanation may indeed have a violent etiology. Although the practice itself was not limited to select ethnic or kin groups, trepanation may have been reserved for a certain male-gendered sector of society. Finally, while trepanation by scrapping was overwhelmingly successful, the boring/drilling method may have been intentionally practiced on peri- or post-mortem individuals as a means of better understanding cranial anatomy and improving techniques. In sum, results suggest distinct (though not intractable), culturally-informed understandings of how to heal an unwell body in the ancient past.

References Cited
Acknowledgments
This research was supported by a Fulbright-Hays Doctoral Dissertation Research Aboard Fellowship, award # P022A090074. Special thanks to Ellen Lofaro, Enmanuel Gomez Choque, and the entire Proyecto Bioarqueologico Andahuaylas crew.
80th Annual Meeting of the American Association of Physical anthropologists April 13-16. 2011 Minneapolis, MN
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