​The 2008 article Trepanation: The Legacy of Ancient Brain Surgery by Jim Myres contrasts the quality of life in Europe with that of Peru in the 18th century and earlier to explain the success of brain surgery in Peru while it was failing in Europe. It points out:

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"Survival of surgery is a quality-of-life issue. The citizens of pre-Columbian Peru had a substantially higher quality-of-life than their counterparts in Medieval and Renaissance Europe. Examination of Peruvian skulls, by today’s physicians, reveals that these cranial surgeries rarely became infected, and most survived. Even more impressive are the skulls exhibiting successful cranio-plasties (plates inserted into the trephination holes) made of silver and gold, which were placed with such skill that the bone healed around them.

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In contrast, during the 18th century, trephination of the cranium in Europe reached a nearly 100% fatality rate. Comparing the two cultures may give a clue to why the Peruvian patient’s quality-of-life was better and therefore, he/she was more likely to survive.

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The Inca Empire, which we are interested in, was by far the largest pre-Columbian state, extending from Peru to Chile including western and central South America.....Historically, the Incas came late on the scene.... Quality of life was improving because of wise and benevolent rulers....Before Francisco Pizarro’s conquest of the Inca’s, their empire was equivalent in area to France, Belgium, Holland, Italy, and Switzerland combined.... At its height, the Inca empire had an estimated 12 million people in much of what is now Peru and Ecuador and large parts of Chile, Bolivia, and Argentina.

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At the beginning of the Renaissance (circa 1500 AD), there were about 73 million people living in Europe.... With the fall of the Roman Empire, social structure and public works infrastructure collapsed as barbarian hordes overran Europe. As Europe emerged from the Dark Ages, life was not good even in the best of times for the average person.....

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Cities in Europe and Peru are not related in structure or function. In Europe, people lived in walled towns for protection. In Peru, the detribalized population was united, cities were cultural and religious centers, people lived in surrounding countryside.

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The wall around a town in Europe was its first line of defense. Therefore, the land within was very valuable, and not an inch of could be wasted. The twisting streets were extremely narrow and were not paved. Doors opened directly onto streets which were filthy, urine and solid waste were simply dumped out windows. Sunlight rarely reached the ground level, because the second story of each building always extended out over the first story, and the third story extended over the second, nearly meeting the building on the other side of the street.

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The walled town was not typical of Europe though. Between 80 and 90 percent of the population lived in villages of fewer than a hundred people. These villages were fifteen or twenty miles apart surrounded by endless forest. Unless a person was a noble or priest his/her mental geography limited their world to what they knew. If war took a man even a short distance from his nameless village, the chances of his returning were slight, and finding his way back alone was virtually impossible. Each hamlet was inbred, isolated, unaware of the world beyond the most familiar local landmark.

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Cities in Peru did not have the cramped population and unsanitary conditions of Europe. Nor did they have the pollution-producing industries emerging in Europe. These people were engaged the cooperative efforts of agriculture, mining, herding, and fishing. They had a rural lifestyle in small villages over the high plateaus and coastal lowlands. Their cities appeared to be cultural centers where people would travel to, they lived in the outlying country side. Because even the remote mountain villages were tied to the rest of the empire with an intricate road system of approximately 20,000 km for rapid messenger service to communicate across the empire, the pre-Columbian people had a much broader mental geography.

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In Europe at the end of the Dark Ages, agriculture and transportation of foodstuffs were inefficient, the population was never fed adequately from year to year. Famines, Black Death, and recurring pandemics repeatedly thinned the population of Europe at least once a generation after 1347.

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The Peruvians demonstrated knowledge of the contagion mechanisms of typhus (which would be understood in Europe only at the beginning of the twentieth century). They fought it with isolation measures and recognized the role of body lice in its spread. It is also evident that they understood the means by which malaria, endemic on the Peruvian coast, was spread. Houses were routinely built in the high and sandy part of the valleys, outside of the access radius of the mosquito vectors. Tuberculosis, whose cause and spread depends essentially on poor social conditions was not endemic in their culture. Europe was not so lucky.

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There are numerous reports in historical chronicles that refer to the pharmacological wealth of South America that was used by the pre-Columbian cultures. Many of these drugs could help the patient survive trepadation. The most obvious would be drugs that could be used for anesthesia. This could have been accomplished with drugs known to be used by the Incas such as, coca, datura, or yuca.

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It is known that alcoholic beverages such as chicha, made of fermented corn, was given to patients, causing a relaxed or sedated state. The next most obvious drug choice would seem to be an antiseptic to prevent infection, such as, Peru balsam, tannin, saponins, and cinnamic acid. These were available and used for embalming the dead and may have been used in surgery. It would be prudent to have a good drug to control bleeding. This could have been done with herbal extracts of Indean ratania root, pumachuca shrub, and preparations high in tannic acid.

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Beyond surgery, a drug used then as well as today to control Malaria is quinine. It is well known that they used the bark of the cincona tree as a source of quinine to treat malaria. The tragedy of the pre-Columbian historical period is the lack of written records this would have provided remarkable insights into early surgeons and their medical practices."

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