Bioarchaeology International Copyright © 2021 University of Florida Press DOI: 10.5744/bi.2021.1010 Volume 5, Numbers 1–2: 1–20 Two (Missing) Left Feet: Caring for Foot Amputees in Late Pre-Hispanic Túcume, Lambayeque Peru Megann Phillips,a Vanessa Cruz,a Erin K. Martin,a Dylan R. Smith,a Bernarda Delgado Elias,b José Manuel Escudero Villalta,b and J. Marla Toynea* aDepartment of Anthropology, University of Central Florida, Orlando, FL 32816, USA bMuseo de Sitio de Túcume, Lima, Peru *Correspondence to: J. Marla Toyne, Department of Anthropology, University of Central Florida, 4000 Central Florida Blvd., Howard Phillips Hall Rm. 309, Orlando, FL 32816, USA e-mail: J.Marla.Toyne@ucf.edu ABSTRACT Understanding pre-Hispanic Andean medical practices through skeletal evidence of surgery has been the focus of a number of bioarchaeological investigations in recent years. Amputation is an especially interesting topic of research due to the variety of social contexts in which it might have occurred. Interpretations for amputation found on the north coast of Peru have included therapeutic intervention, punitive measures, and ritualistic dismemberment. Here, we present two new cases of successful left foot amputation in young adult females exca- vated from Huaca Las Balsas (Late Intermediate Period, A.D. 1100–1470) and Huaca Las Abejas (Late Horizon, A.D. 1470–1535) at the ancient religious and administrative center of Túcume. Chronologically, they are the latest cases of pre-Hispanic amputation published to date. Contextual evidence supports a therapeutic motiva- tion for the procedure, as individualized burial treatment and placement within a cemetery group of social elites is not consistent with punitive or ritualistic action. Modification of the malleoli, extensive bone prolifera- tion covering the talar articulations, and asymmetrical cortical bone thickness of the tibiae and fibulae (revealed radiographically) suggest the return of some functional mobility using the affected limb after healing. This long-term recovery is evidence of access to quality medical care and accommodation of functional impair- ment within the amputees’ communities. The presented research uses the bioarchaeology of care approach to explore the lived experiences of these amputees and their social identities, making an important contribution to the anthropology of disability across cultures and time periods. Keywords: amputation; ancient medical practice; bioarchaeology of care; disability; skeletal trauma; surgery Comprender las prácticas médicas andinas prehispánicas a través de evidencia esquelética de cirugía ha sido el foco de una serie de investigaciones bioarqueológicas en los últimos años. La amputación es un tema de investi- gación especialmente interesante debido a la variedad de contextos sociales en los que podría haber ocurrido. Las interpretaciones para la amputación que se encuentran en la costa norte del Perú han incluido la inter- vención terapéutica, las medidas punitivas y el desmembramiento ritual. Aquí, presentamos dos nuevos casos de amputación exitosa del pie izquierdo en hembras adultas jóvenes excavadas desde Huaca Las Balsas (Período Intermedio Tardío, A.D. 1100–1470) y Huaca Las Abejas (Horizonte Tardío, D.C. 1470–1535) en el antiguo centro religioso y administrativo de Túcume. Cronológicamente, son los últimos casos de amputación prehispánica publicados hasta la fecha. La evidencia contextual apoya una motivación terapéutica para el procedimiento, ya que el tratamiento y la colocación individualizados del entierro dentro de un grupo cementerio de élites sociales Received 30 June 2020; Revised 5 October 2020; Accepted 30 October 2020 Caring for Foot Amputees in Late Pre-Hispanic Túcume2 Limb amputation is one of the oldest known surgi- cal procedures (Markatos et  al. 2019; Sachs et  al. 1999), documented by both historical and archaeo- logical record. It is defined as the intentional re- moval of a limb, either partially or completely (Marcovitch 2009:28). The earliest possible evidence of this practice dates to the Neandertals buried in Shanidar Cave, Iraq, over 40,000 years ago (Stewart 1977), and archaeological evidence of both success- ful and unsuccessful ancient amputations has been found globally. Examples exist in England (Mays 1996), Portugal (Fernandes et  al. 2017), France (Buquet-Marcon et al. 2007), Bulgaria (Zäuner et al. 2013), South Africa (Van der Merwe et al. 2010), and Egypt (Dupras et al. 2010; Nerlich et al. 2000). More- over, amputation remains as medically relevant to- day as it was in the past. Although surgical practices have evolved significantly, with advances in anes- thetic, imaging, and operative technologies, the re- moval of an appendage is a life-altering procedure that continues to be used in the treatment of trauma (Ahmad et  al. 2019; Barla et  al. 2017; Moini et  al. 2009), circulatory and neuropathic issues (Nanwani et  al. 2019), localized infections (Boffeli 2015), and other conditions (Zhao et al. 2020). This article expands current understandings of the history and social implications of amputation by pre- senting two new cases from Túcume, Peru, dated to the Late Intermediate Period (A.D. 1100–1470) and Late Horizon (A.D. 1470–1532). These cases evidence a regional continuity of surgical practices that endured for hundreds of years between the Moche culture (A.D. 100–700) and the Inca empire (A.D. 1470–1532). Additionally, utilization of the bioarchaeology of care approach (Tilley 2015; Tilley and Cameron 2014) allows these cases to be framed as reflections of community care practices and lived experiences of amputees in north coastal Peru. The bioarchaeology of care is essential to understanding the nuances of chronic functional impairment in the past—an im- portant contribution to modern disability studies. Although functional impairment, healthcare, and disability are separate concepts that should not be con- flated, they are often intertwined. This analysis of am- putation at Túcume explores the possibility that the survival of Andean amputees in the distant past was aided by community members and urban infrastruc- ture. However, it simultaneously acknowledges the po- sition of amputees as agentive community members that might or might not have actually been considered disabled. In contrast to previously discovered cases of pre-Hispanic amputation in the region, skeletal and mortuary evidence from Túcume suggests that ampu- tation occurred as a form of medical intervention, and accommodation of resulting physical limitations fell within contemporary cultural norms. Bioarchaeology of Care The bioarchaeology of care (Tilley 2015; Tilley and Cameron 2014) is an emerging interpretive frame- work in bioarchaeology that emphasizes the role of community in the lives of impaired or disabled indi- viduals. This can involve the provision of medical care for acute or chronic ailments, general task assistance, and emotional support offered to a person with a lim- iting condition either directly (often by kin) or indi- rectly within an accommodating sociopolitical structure. The identities of impaired or disabled indi- viduals are highly dependent on cultural context and are situationally malleable, and not all functionally no es consistente con la acción punitiva o ritualista. La modificación de los maléolos, la extensa proliferación ósea que cubre las articulaciones talares y el grosor óseo cortical asimétrico de las tibias y los peronés (revelados radiográficamente) sugieren el regreso de cierta movilidad funcional utilizando la extremidad afectada después de la curación. Esta recuperación a largo plazo es evidencia del acceso a atención médica de calidad y aloja- miento de deterioro funcional dentro de las comunidades de amputados. La investigación presentada utiliza la “bioarqueología de la caridad” para explorar las experiencias vividas de estos amputados y sus identidades so- ciales, haciendo una contribución importante a la antropología de la discapacidad a través de las culturas y períodos de tiempo. Two huacas, both alike in dignity, (In fair Túcume, where we lay our scene), From ancient ground break new amputees, Where literal dirt made our hands unclean. —Modified for contextual purposes from Shakespeare (1597:1) Caring for Foot Amputees in Late Pre-Hispanic Túcume 3 impaired people identify as disabled or require signif- icant structural accommodation to complete essential tasks (Byrnes and Muller 2017; Kasnitz and Shuttle- worth 2001; Reid-Cunningham 2009). However, sur- vival and quality of life of a person with impaired functional abilities often rely on interpersonal and structural accommodation. This includes healthcare access, which is often dependent on socioeconomic status (Becker and Newsom 2003; Kristiansson et al. 2009; Walters and Suhrcke 2005), and cultural per- ceptions of impairment (Rösing 1999). The bioarchaeology of care has become an invalu- able framework to guide paleopathological analysis because of its ability to integrate social theory related to identity and compassion (Tilley 2015; Tilley and Schrenk 2017). Due to the intangibility of emotions such as compassion (Dettwyler 1991), some bioar- chaeologists shy away from the more ephemeral as- pects of the approach. However, regardless of emotional consideration, the bioarchaeology of care has proven its utility in a wide variety of social con- texts that range from hunter-gatherer groups (Tilley and Oxenham 2011; Tilley 2015) to recent historical institutions (Tremblay Critcher 2017; Wesp 2017). Previous examples of the bioarchaeology of care in Peru include publications that address trepanation (Jolly and Kurin 2017), crippling Thoracic Outlet Syndrome (Palma Málaga and Makowski 2019), and chronic post-injury osteomyelitis (Sutherland 2019) as conditions that affected individuals and their care- takers in late pre-Inca cultures of central and south-central parts of the country. Amputation in Pre-Hispanic Peru The history of the bioarchaeology of care in Peru is currently limited, considering the relatively Table 1. Presently Published Examples of Pedal Amputation from Pre-Hispanic North Coast Peru. Site Time Period and Culture Individual Age and Sex Side Suggested Motivation Túcume1 Late Horizon, H. Las Abejas, unit XA, Ent. 1 Young adult female Left Medical/therapeutic amputation Chimú-Inca Túcume1 Late Intermediate H. Las Balsas, unit IB, Ent. 1 Young adult female Left Medical/therapeutic amputation Period, Lambayeque Castillo de Huarmey2 Middle Horizon, Imperial tomb, Individual XY Young adult male Left Ritual amputation Wari Castillo de Huarmey2 Middle Horizon, Imperial tomb, Individual XX Middle adult female Left Ritual amputation Wari El Brujo3 Early Intermediate West Sector, Tomb 4 Middle adult male Both Intentional amputation Period, Moche El Brujo3 Early Intermediate Huaca Cao, BRU M98-4 Adult male Left Intentional amputation Period, Moche Mocollope3 Early Intermediate MOC98-1 Young adult female Right Intentional amputation Period, Moche Mocollope4 Early Intermediate — Unknown adult Both Punitive amputation Period, Moche Huacas de Moche5 Early Intermediate Plataforma Uhle, Tomb 48 Young adult male Left Not considered Period, Moche 1Present study 2Więckowski (2016) 3Verano et al. (2000) 4Vélez López (1913) 5Chauchat et al. (2009) Caring for Foot Amputees in Late Pre-Hispanic Túcume4 Figure 1. Map of north coast of Peru showing locations of sites mentioned in the text. Map created by Toyne. Caring for Foot Amputees in Late Pre-Hispanic Túcume 5 recent definition of this theoretical paradigm, and there is much room for expansion. This article seeks to continue the regional application of the bioarchae- ology of care with the analysis of amputees from Pe- ru’s north coast. The cases presented provide an important extension of previous discussions of pre-Hispanic Peruvian amputation practices by pro- viding fresh evidence for surgical practices, motiva- tions, and effects on long-term identity and social integration. Previously identified cases of pre-Hispanic pedal amputation include those published by Vélez López (1913), Alva and Donnan (1993), Verano (1997), Ver- ano et al. (2000), Chauchat et al. (2009), and Więck- owski (2016) (Table 1). Some of these examples of foot removal, all of which were found on the north coast of Peru, are presumed to have been well-healed ante- mortem amputations due to bony remodeling of the affected area. However, other examples of missing feet in the bioarchaeological record are less easily interpretable. Although Verano (1997) and Alva and Donnan (1993) note that a footless “guard” was placed at the entrance to Tomb I and at the entrance to Tomb II at Sipán (an elite Moche burial site), the poor pres- ervation of these skeletons inhibited observation of their distal lower leg bones. It is therefore unclear whether the missing feet of these tomb guardians reflect antemortem amputation or postmortem removal. Of the individuals who do provide evidence for an- temortem foot amputation, the earliest were found at the site of Mocollope, the El Brujo complex, and the Huacas de Moche complex (Fig. 1). All of these early cases are associated with the Moche culture (A.D. 100–700) (Chauchat et  al. 2009; Vélez López 1913; Verano et  al. 2000). The contextual evidence does not suggest that these individuals were inten- tionally amputated to serve as tomb guardians. While the motivation is unknown, it is evident that each in- dividual survived long enough to support substantial remodeling of the ankle joint after removal of the foot. The amputees found at the Castillo de Huarmey (Więckowski 2016) (Fig. 1), associated with the Wari culture (A.D. 600–1100), also seem to have been long- term survivors of amputation. However, they ulti- mately served as tomb guardians. They were buried in a distinct location in the floor of the antechamber to the Wari imperial mausoleum of elite women. The placement of footless individuals as apparent guardians at the entrance to elite tombs suggests a sym- bolic or spiritual importance of feet and foot amputa- tion among the Moche as well as the Wari. This possibility is supported by the frequent depiction of isolated feet and foot amputees in Moche ceramics (Paico Vílchez and Paico Zumaeta 2020; Vélez López 1913) and the appearance of isolated feet in Wari ceramics (Trigo Rodríguez and Hidalgo Rocabado 2012; Więck- owski 2016). However, although a general cultural fas- cination with feet and foot removal is suggested by this type of artistic expression, ceramics might also lend evidence to punitive or therapeutic theories regarding the motivations underlying amputation. For example, amputees depicted by the Moche sometimes have a mutilated nose and lips, which could be interpreted either as punitive maiming or as a symptom of a patho- logical condition such as nasal leishmaniasis (Verano et al. 2000). Amputation of the foot (or feet) could have been an additional punitive measure or intended as a treatment for a pathological condition that affected hands and feet. As it is depicted in ceramics, amputa- tion motivated by advanced leishmaniasis, or a similar condition, is considered unlikely due to the unaffected appearance of non-amputated extremities. Nonethe- less, this does not rule out other medical reasons for amputation in the ceramic or bioarchaeological record. Non-punitive amputation that is not ideologically motivated is suggested by the burial of some individ- uals in traditional, non-guardian burial contexts. This includes the burial contexts of amputees found at El Brujo and Mocollope (Verano et al. 2000), Hua- cas de Moche (Chauchat et  al. 2009), and Túcume (this publication). Archaeological Context Túcume is an extensive archaeological complex located within the La Leche River Valley, approxi- mately 30 kilometers north of the modern Lam- bayeque regional capital of Chiclayo. Initially associated with the Lambayeque culture (A.D. 900– 1350), the history of Túcume covers more than 400 years of occupation and three major shifts in political control (Heyerdahl et al. 1995; Shimada 1981, 2009). Monumental construction at Túcume commenced during the Late Intermediate Period at the site (A.D. 1050), and it continued for roughly three centuries until the region was incorporated into the north coastal Chimú empire around A.D. 1350 (Heyerdahl et al. 1995). Around A.D. 1470, the Inca empire that was rapidly expanding from Peru’s southern high- lands conquered the Lambayeque Valley region. The Inca appear to have used Túcume as their primary regional administrative center until the arrival of the Spanish in A.D. 1532, when the site was burned and ultimately abandoned (Covey 2008; Narváez Vargas 1995b; Sandweiss 1995). The administrative and religious core of the complex consists of 26 truncated adobe pyramids Caring for Foot Amputees in Late Pre-Hispanic Túcume6 (Fig. 2)—called huacas due to their status as sacred pre-Hispanic monuments. These huacas were built during the Lambayeque occupation around a steep rocky outcropping named Cerro La Raya (Delgado Elías and Narváez Vargas 2016; Narváez Vargas 1995b; Narváez Vargas and Delgado Elías 2011; Sand- weiss 1995). They vary greatly in size and structural complexity due to their differential uses for adminis- trative, ceremonial, and elite residential purposes. Huaca Las Balsas and Huaca Las Abejas are among those found in the southwestern sector of the archae- ological complex. They appear to have functioned as residences and mortuary monuments for associated cemeteries containing social elites (Delgado Elías and Narváez Vargas 2016; Narváez Vargas 1995a; Narváez Vargas and Delgado Elías 2011). Huaca Las Balsas is a moderately sized platform mound, measuring approximately 35 × 25 m, with a height of approximately 4.5 m (Narváez Vargas and Delgado Elías 2011). Despite its smaller size, Huaca Las Balsas has been the subject of much archaeologi- cal inquiry due to the presence of intricate carved murals on its walls. The murals depict maritime scenes, including divers collecting Spondylus and an- thropomorphic bird figures sailing on wooden rafts (balsas). Along with these murals, which inspired the huaca’s modern name, the main features of the con- struction include superficial residential structures, cooking areas, two descending ritual platform areas, and a small platform containing eight burials. These Lambayeque burials (approximately A.D. 1240–1300) include adult males and females as well as juvenile in- dividuals, and grave associations indicate middle elite social status (Delgado Elías and Narváez Vargas 2016; Narváez Vargas and Delgado Elías 2011). Huaca Las Abejas measures approximately 57 meters in length and width and 8 meters in height. The initial architectural survey revealed three con- struction phases of ritual platforms and a ramp, likely from the Late Intermediate Period (A.D. 900–1470) (Escudero Villalta 2018). Unlike Huaca Las Balsas, excavations have yet to identify residential structures or burials on top of Huaca Las Abejas. However, a small cemetery to the north of the huaca contained Figure 2. (a) Burial of Case 1 (Las Balsas, unit IB, Entierro 1) shown in situ with extended body position. (b) Burial of Case 2 (Las Abejas, unit XA, Entierro 1) shown in situ, seated and flexed with a few grave goods. (c) Map of the Túcume archaeological complex, with Huaca Las Abejas and Huaca Las Balsas circled. Figure created by Toyne. Caring for Foot Amputees in Late Pre-Hispanic Túcume 7 28 well-preserved human burials that are of a similar demographic profile to the burials excavated from Huaca Las Balsas. The interred individuals were of middle elite status, although they have been dated to the Late Horizon (approximately A.D. 1470–1532) based on associated ceramic materials and the seated, flexed burial positioning that are characteristic of Chimú-Inca occupation (Escudero Villalta 2018). Materials and Methods Toyne conducted osteological analysis of the skele- tons in the field in 2009 and 2014, including metric and morphological observations, following the stan- dards established by Buikstra and Ubelaker (1994) and Ubelaker (1999). Biological assessment of age at death and sex were estimated based on morphologi- cal characteristics of the os coxae and crania. Stature was estimated using tibial condylomalleolar length (CLT) using the regression equation proposed by Pomeroy and Stock (2012) (stature = 57.748 + 2.800CLT), which was recommended for regional accuracy by Anzellini and Toyne (2020). Macroscopic observations of pathological bone modification were recorded based on visual examinations, including ev- idence for traumatic damage, bone remodeling, and inflammatory response (Ortner 2012). Other patho- logical changes observed include cranial modifica- tion, dental pathology, and osteoarthritic joint changes. Finally, key skeletal elements (right and left humeri, femora, and tibiae) were transported to the Econor diagnostic imaging clinic in Lambayeque, Peru, where standard film, single-plane radiographs were taken. Analysis of these individuals was conducted according to standard bioarchaeology of care guidelines (Tilley 2015; Tilley and Cameron 2014). The following sections of this report document the process of bioarchaeology of care analysis through four prescribed steps. These steps ensure appropriate consideration of functional impair- ment and the healthcare that might have been necessary for an impaired person’s survival. They include: (1) description, diagnosis, and doc- umentation of the pathological condition from skeletal and other bioarchaeological evidence; (2) determination of whether or not an individual would have received medical and/or other care from their community; (3) construction of a model of care that might have been necessary for an impaired individual’s survival; and (4) inter- pretation of the model of care in a broader social context. Description, Diagnosis, and Documentation Description of Case 1: Las Balsas, Unit IB, Entierro 1 This individual (female, between 30 and 40 years) was buried atop Huaca Las Balsas in a simple pit. The skeleton was in an extended position with slight flexing of the legs, positioned with the head to the south (Fig. 2). This burial was part of the group of eight burials, including a camelid. Radiocarbon dates from nearby Entierro 5 produced a date between cal A.D. 1240 and 1300 (720 +/– 40 B.P.), Figure 3. The almost-complete skeleton of Case 1 (Las Balsas, unit IB, Entierro 1). Photo by Toyne. Caring for Foot Amputees in Late Pre-Hispanic Túcume8 which corresponds to the Lambayeque occupation of the Late Intermediate Period. Grave position and associations of the individual from Huaca Las Balsas are similar to materials recov- ered from other Lambayeque-style burials at the site (Narváez Vargas 1995a). For individuals identified as female based on skeletal indicators, burial treatment generally consisted of interment in the extended or slightly flexed position and accompaniment by a va- riety of functional vessels and weaving-related items. In this particular grave, there were four gourd bowls, one small ceramic cooking pot, two small copper beads near the cranium, and 68 spondylus shell beads near the right and left wrists. The weaving-related items found in the grave include three decorated wooden weaving loom pieces, a gourd needle con- tainer, three copper needles, various balls of threads, and chalk. The body was wrapped in a poorly pre- served, simple, brown cotton textile. This individual was represented by an almost com- plete, well-preserved skeleton with minor tapho- nomic breakage and surface erosion (Fig. 3). Missing skeletal elements included the left calcaneus, talus, tarsal bones, metatarsal bones, and pedal phalanges (although these elements are thought to be missing due to pathological rather than taphonomic reasons). Using the non-pathological right tibia, stature was estimated to be 144.6 cm. This is slightly shorter than the average height of 147.9 cm (σ = 3.08 cm) that was calculated for the seven other adult females interred within similar burial contexts at Túcume. The cranium is intact and exhibits a moderate de- gree of cranial modification, showing flattening across the frontal and occipital bones that resulted in bilateral bulging of the parietal bones. Remodeled macroporosity on the posterior bones of the cranial vault is consistent with healed porotic hyperostosis. Observations of the dentition revealed a moderate degree of dental attrition that resulted in flat occlusal surfaces of all teeth, four well-healed alveolar sockets indicative of antemortem tooth loss, some hypoplas- tic defects of the anterior dentition, and four alveolar abscesses that caused resorption of the maxilla. There was also a large carious lesion of the mandibular sec- ond molar and minimal dental calculus on the labial surfaces of most teeth. In the postcranial skeleton, two small Schmorl’s nodes were observed on the su- perior bodies of the ninth and twelfth thoracic verte- brae. Minor osteophytic lipping affected the anterior body margins of the sixth through twelfth thoracic vertebrae. The key pathological feature on the skeleton was the osteological (morphological and radiographic) modification of the distal portions of the left tibia and fibula (Fig. 4). Although fragility of the affected bone seems to have contributed to some postmortem fragmentation of relevant pathological features, vi- sual observations of the medial malleolus of the tibia Figure 4. (a) Detailed anterior oblique view of the left distal tibia and fibula of Case 1 (Las Balsas, unit IB, Entierro 1). (b) Fragments of the distal artic- ular surface of the tibia showing bone proliferation. Photos/figure by Toyne. Caring for Foot Amputees in Late Pre-Hispanic Túcume 9 showed that it was not consistent with normal mor- phology. The recovered fragments of the articular re- gion demonstrate active bone proliferation. There was evidence of healed periosteal reaction along the posterior aspect of the midshaft of the tibia and an area of raised sclerotic bone at the attachment site of the flexor digitorum longus. On the fibula, irregular thickening of the distal metaphysis was present. There was also mild medial displacement of the lat- eral malleolus, possibly the result of a healed fracture. The distal tibio-fibular and talar articular surfaces were completely remodeled so that no facet remained, and the fibular summit was rounded rather than py- ramidal in shape. The attachments for the flexor hal- lucus longus and soleus muscles along the left fibular midshaft also showed pronounced rugosity com- pared to the right side. Radiographs of both tibiae and fibulae (Fig. 5a) il- lustrate the difference in cortical thickness and bone density between the right and left sides of the body. The cortical bone of the right tibial and fibular diaph- yses are denser and thicker than the left tibial and Figure 5. (a) Anterior-view plain film radiograph of the tibiae and fibulae of Case 1 (Las Balsas, unit IB, Entierro 1). (b) Anterior-view plain film radio- graphs of the femora of Case 1. (c) Anterior-view plain film radiographs of the humeri of Case 1. Figure created by Toyne. Caring for Foot Amputees in Late Pre-Hispanic Túcume10 fibular diaphyses. This suggests use-related atrophy and reduced biomechanical forces applied to the left lower leg. Additional radiographs of the femora (Fig. 5b) and humeri (Fig. 5c) also demonstrate asym- metrical bone thickness and density that is consistent with reduced limb use on the left side of the body. The appearance of reduced cortical density in the left humerus is what might be expected if this individual were using a crutch or cane, as one-sided crutch and cane use typically occurs contralaterally to the af- fected lower limb (Edelstein 2019). Description of Case 2: Las Abejas, Unit XA, Entierro 1 The second individual (female, approximately 30 to 34 years) was buried in a circular pit in front of the Huaca Las Abejas platform. Stratigraphic registra- tion and grave associations confirm that this burial, as well as the other 27 burials recovered together, date to the later fifteenth-century Chimú-Inca occupa- tion. Burial position also supports this cultural affili- ation, as the interred was situated in a seated and flexed body position, with the face collapsed down- ward over crossed arms and legs (Fig. 2). Typical Chimú-Inca burial practices for middle elite people at Túcume consisted of wrapping bodies in layers textiles and then interring them in a seated, flexed position. Grave accoutrements for middle elite women typically included functional vessels and weaving tools as well as decorative accessories such as beaded jewelry. As with other, better-preserved burials from Hua- cas Las Abejas, the individual described in Case 2 was likely wrapped in several layers of woven cloth textiles to create an egg-like bundle. However, only a few remnants of the burial fabrics remained at the time of excavation. The grave goods associated with this individual include a small ceramic bowl, two in- tentionally damaged copper sewing needles, a weav- ing loom end bar, 25 wooden spindles and threads of various colors within a gourd bowl, and a small ball of dark brown wool. Copper and shell beads were found near the wrists. The grave context also in- cluded a small, simply decorated jar that contained the seeds of the bichayo (Capparis crotonoides) shrub, a plant indigenous to the north coastal region of Peru and commonly used for firewood and animal fodder. The flower and leaves of this plant also have medici- nal properties for treating skin rashes and other con- ditions. When boiled, it can be drunk in a tea to treat bronchitis or inhaled under sauna-like conditions as a remedy for arthritis and bone aches (Bussmann and Sharon 2015). The adult female skeleton was almost complete and generally well preserved (Fig. 6), although the left cal- caneus, talus, tarsal bones, metatarsal bones, and pedal phalanges were absent. Termites caused exten- sive taphonomic damage by burrowing into the mid- shaft of the right femur and the distal portion of the left femur, possibly due to the presence of wooden materials within the grave (Huchet et al. 2011). There was also postmortem fragmentation of the left os Figure 6. The almost-complete skeleton of Case 2 (Las Abejas, unit XA, Entierro 1) from an anterior oblique view, showing termite damage to right femur. Photo by Toyne. Caring for Foot Amputees in Late Pre-Hispanic Túcume 11 coxa, ribs, and scapula. Bone brittleness might have contributed to this postmortem fracturing, but oste- oporosis was not observed. Using the right tibia, her stature was estimated to be approximately 144.6 cm, similar to the estimated stature of the Lambayeque individual from Huaca Las Balsas. Observations of the dentition found moder- ate-to-pronounced dental wear that resulted in flat- tened cusps, as well as a thin layer of dental calculus covering almost all lingual and buccal tooth surfaces. The right maxillary first molar was lost antemortem, as indicated by a well-healed alveolus. Interproximal caries developed between the upper left premolars, and it appears that the third molars of the maxilla and mandible were congenitally absent. Observations of osteopathology revealed no porotic hyperostosis or cribra orbitalia on the bones of the cranium, but the cranial vault did demonstrate a moderate degree of fronto-occipital modification. There were also osteo- arthritic changes to some joint surfaces, including those of the shoulders, hips, and right knee. These os- teoarthritic changes included minor osteophytic lip- ping and cortical thinning. The individual demonstrated significant modifica- tion to the distal articular surface of the left tibia and the distal epiphysis of the left fibula. The side-by-side comparison of the right and left lower leg bones is illustrated in Figure 7. In addition to healed periosteal reaction along the medial aspect of the tibia’s distal shaft, extensive bony proliferation densely filled the tibio-talar articulation, and the collicular features of the medial malleolus were remodeled. Only a small area of the original joint surface could be observed to indicate that there had been a normal facet prior to bony remodeling. Although the distal fibula presented with a fairly normal tibio-fibular articulation, there was alteration of the talar articulation. Bone prolifera- tion filled the malleolar fossa and the apex was flat- tened. There also appeared to be a sharply defined oval void between the two bones at their distalmost point of adjacency, perhaps encapsulating a pocket of soft tissue or a cyst-like feature that provided a barrier to bony proliferation in that specific area. Radiographs of both tibiae (Fig. 8a) illustrate structural changes to cortical thickness and density in the bones of the left limbs. The midshaft of the left tibia demonstrated thin cortical bone and irregular distal cortical density, and radiographic translucence of the distal periarticular area is indicative of atrophy due to reduced weight-bearing. The left fibula demon- strated similar characteristics. Radiography also revealed possible tendinopathy of the greater tro- chanter (Fig. 8b) and some minor decreases in corti- cal bone thickness of the right humerus relative to Figure 7. Detailed anterior oblique view of the distal tibia and fibula of Case 2 (Las Abejas, unit XA, Entierro 1). Photo by Toyne. Caring for Foot Amputees in Late Pre-Hispanic Túcume12 what is observable in the left humerus (Fig. 8c). This observation is complemented by what appears to be localized demineralization of the subchondral region of the right humeral head. The osteochrondritic radi- odensity of the left humeral head may be an artifact of imaging or perhaps some evidence of avascular ne- crosis suggesting damage to the shoulder joint. Differential Diagnosis The individuals found at Huaca Las Balsas (Case 1) and Huaca Las Abejas (Case 2) likely had their left feet removed via disarticulation of the ankle joint several or many years before their deaths. The nature of the bone response at the distal ends of the left tib- iae and fibulae is indicative of survival after surgical amputation, as opposed to congenital absence or in- complete archaeological recovery of foot bones. Un- affected diaphyseal morphology indicates maturation was not disrupted by unbalanced limb functionality, and thus the talus and other foot bones were likely removed after the individuals reached adulthood. Di- aphyseal and distal metaphyseal morphology of the tibiae are normal, and abnormal bony proliferation within the talar articular cavity seems to have occurred over a previously functional joint surface in both cases. Although the distal left fibula of the indi- vidual from Huaca Las Balsas shows significant me- taphyseal remodeling due to an apparent fracture, the distal left fibula of the individual from Huaca Las Abejas is of normal morphology, except for the devel- opment of a more bulbous epiphysis. Figure 8. (a) Anterior-view plain film radiograph of the tibiae and fibulae of Case 2 (Las Abejas, unit XA, Entierro 1), picturing a right tibial midshaft cut for sampling and a left fibula with postmortem fragmentation. (b) Anterior-view plain film radiographs of the humeri of Case 2. Figure created by Toyne. Caring for Foot Amputees in Late Pre-Hispanic Túcume 13 This amputation procedure seems to have been intentional and methodical. Accidental or traumatic amputation is unlikely as there is no evidence of severe trauma in either Case 1 or Case 2 to the mal- leoli of the tibia and fibula, which constitute part of the ankle joint adjacent to the normal position of the talus. Although no cut marks are present on the distal lower leg bones to evidence surgical removal of the foot in either case, it is possible for a well- trained healer to disarticulate the ankle joint by cutting only the soft tissue between the articular surfaces (Kirkup 2007; Markatos et  al. 2019). This would not leave cut marks on the bone sur- faces. Additionally, if cut marks on the bone were made, it is very likely that bone remodeling would have obscured them over time. In modern and historic contexts, intentional am- putation has been performed as punishment or as a ritual practice (Adejumo and Olabisi Adejumo 2005; Bosmia et  al. 2014; Kirkup 2007; Mavroforou et  al. 2014). Some have suggested these potential motiva- tions for pre-Hispanic north coast Peruvian amputa- tions (Kirkup 2007; Verano et al. 2000; Więckowski 2016). However, the contexts in which the amputees from Túcume were buried does not indicate that their amputations were performed for a punitive or ideological purpose, as they were not interred in a de- viant fashion (Murphy 2008; Shay 1985). Their burial location, body positioning, and grave accoutrements are typical of middle elite women’s burials during their respective time periods. Evidence seems to suggest that the amputations were performed for therapeutic purposes. This con- clusion is supported by the fact that, to date, no indi- viduals with severe pathological conditions of the foot have been discovered at Túcume. Absence of evidence for foot trauma, disease, or malformation in unamputated feet suggests that such conditions might have typically been treated with amputation. Although trauma, disease, or malformation can be causes for amputation, none of these conditions is strongly evidenced in the amputees from Túcume. The possible healed fracture identified on the distal fibula of the amputee from Huaca Las Balsas (Case 1) could indicate trauma that preceded, succeeded, or was associated with the amputation of the foot. Alternatively, a localized infection or a chronic dis- ease that leaves few or no skeletal indicators could be to blame. For example, diabetes might have led to ul- cer development that necessitated pedal amputation. Although there is no skeletal evidence for this condi- tion (Biehler-Gomez et al. 2019; Dupras et al. 2010) in either Case 1 or Case 2, diabetes mellitus is the lead- ing cause of non-traumatic lower limb and foot am- putations in the modern world and in Peru specifically (Biehler-Gomez et  al. 2019; Villena 2015). Approxi- mately 50% of foot amputations are attributed to the disease (Moulik et al. 2003), and it is known to have existed in antiquity (Dupras et al. 2010; Sanders 2002) outside of Peru. Aside from diabetes, there are a number of other medical conditions that might have resulted in the removal of a foot. As noted in the introduction to this article, amputation is used in modern times as a treatment for trauma (Ahmad et al. 2019; Barla et al. 2017; Moini et al. 2009), circulatory and neuropathic issues (Nanwani et  al. 2019), localized infections (Boffeli 2015), and necroses that result from frostbite or other factors (Zhao et al. 2020). Any of these con- ditions might be considered a potential precursor to amputation in the young adult women buried at Túc- ume, although necrosis that is specifically related to Figure 9. Oblique medial posterior view of the right femur of Case 1 (Las Balsas, unit IB, Entierro 1) illustrating musculoskeletal bone modification. Photo by Toyne. Caring for Foot Amputees in Late Pre-Hispanic Túcume14 frostbite should be considered extremely unlikely in the relatively warm coastal desert environment of Túcume. Congenital defects of the foot, such as club- foot, might also have been a reason for amputation (Wright 2011). However, unilateral congenital mal- formations of the foot would have likely caused de- velopmental consequences for the lower limbs due to asymmetrical weightbearing during development. In both Case 1 and Case 2, aside from reduced cortical density of the bones of the left leg, the morphology of the right and left lower limbs is symmetrical. This would seem to indicate that differential use of the lower limbs did not occur until skeletal maturity. The Case for Care Regardless of the reason, or reasons, for amputation, changes to the distal tibiae and fibulae suggest that the individuals were still probably capable of locomo- tion (although locomotion might have been altered or required assistance). In both individuals, the slight loss of bone density in the affected left leg, as com- pared to the right leg, suggests a shift to preferred use of the right leg for supporting body weight. However, remodeling seems to have occurred in response to some force applied to the end of the left lower leg bones. This would appear to suggest that, while they were not using their left legs in a normal ambulatory fashion, the amputated limb might have contributed limited weight-bearing while standing, walking, or performing other activities. It is worth noting that the individual from Huaca Las Balsas (Case 1) additionally demonstrates remod- eling and pronounced thickening of the muscular at- tachment sites for the adductor magnus and biceps femoris muscles on the right femur (Fig. 9), possibly suggesting increased or irregular usage of the right leg. However, it is not clear if this change occurred as a result of biomechanical modification of the use of the lower limbs due to the amputation of the left foot. It could have also occurred separately due to another musculoskeletal injury. Continued mobility after the amputation of the left foot could have involved the use of a crutch or pros- thesis, which would have improved the efficiency of modified ambulation. Earlier Moche ceramic vessels depicting amputees often include crutches and cup- like coverings for amputated feet (Checa 2010; Paico Vílchez and Paico Zumaeta 2020; Urteaga-Ballon 1991; Vélez López 1913). Vélez López (1913) and Chauchat et  al. (2009) describe prosthetics made of wood found in a Moche archaeological context. The fact that no such materials were recovered from the graves of the amputees at Túcume does not rule out the possibility that they were used by these indi- viduals during life. In fact, the asymmetrical cortical bone density of the humeri of both individuals could be a product of crutch use. Additionally, a wooden crutch or prosthetic might help to explain the termite activity in Case 2. The unilateral amputation of a foot does not seem to have caused total immobility in the young adult females excavated from Huaca Las Balsas and Huaca Las Abejas (Case 1 and Case 2, respectively). However, it is important to acknowledge the long- term consequences of amputation-related physical limitations that affected the lives of those with missing body parts. In these cases, amputation would have affected gait efficiency and left the indi- viduals relatively less mobile than unamputated community members. It is possible that they walked with an uneven gait and likely could not participate in fast-paced or physically strenuous ambulatory activities. With or without the use of a crutch or prosthesis, ambulation would have required great- er-than-average energy expenditure, leaving them unable to easily transverse Túcume’s urban core. Amputees might have relied on assistance and ac- commodation from community members for es- sential chores like food acquisition and other locationally tied economic exchanges. They also might have required assistance with pain manage- ment after the amputation procedure, which in it- self would have required the attention of a person who had some level of practical anatomical knowl- edge and skill. Unilateral amputation of the foot would not have prohibited these individuals from participating in typical gender-specific craft production activities, such as weaving, that do not involve strain on legs and feet. Cloth production would have probably af- forded them some level of economic independence, in addition to their limited ambulatory independence with the use of a weight-bearing device. However, ev- idence of an amputation that was probably therapeu- tic in nature suggests that these individuals did, in fact, receive dedicated medical care at least once in their lives. Amputees likely relied on care and atten- tion from kin, neighbors, and medical specialists during and after the surgery. Modeling Care Medical and emotional care for amputees The lack of evidence for reduced social standing or greatly reduced quality of life after amputation in the two young adult females from Túcume suggests Caring for Foot Amputees in Late Pre-Hispanic Túcume 15 availability of surgical care, societal accommodation of physical impairment, and possible involvement of kin-based support systems in physical and emotional post-operative care. These amputees were evidently able to access the expert medical care needed to per- form amputation by disarticulation, possibly due to their elite social status or wealth. Additionally, skele- tal remodeling suggests that they were provided with appropriate medical and general care after the surgi- cal procedure (Buquet-Marcon et  al. 2007; Van der Merwe et al. 2010; Zäuner et al. 2013). The procedure itself would have required anatomi- cal familiarity and skill in execution, suggesting that practitioners of amputation operated as knowledge- able medical specialists and probably held unique po- sitions in society, such as healers or shamans (Mendoza 2003). The apparent disarticulation proce- dure that was performed at least twice during differ- ent time periods at Túcume would have likely been executed similarly to a modern-day Syme amputa- tion, which involves cutting a fish-mouth incision around the ankle joint so that the tarsal bones can be easily accessed and pulled apart (Yu and Hudson 2001). The fatty flesh of the heel pad is later used to cover the end of the newly footless ankle. In addition to the disarticulation of the ankle joint, the Syme procedure typically also involves the resection of the malleoli of the tibia and fibula (Yu and Hudson 2001), creating a more solid weight-bear- ing surface. Neither of the cases discussed here show intentional removal of the malleolar portions, and clefted stubs depicted in Moche representations of amputees suggests this was not common practice on the Peruvian north coast in preceding centuries (Verano et al. 2000). Despite this inconsistency, the Syme procedure provides what is probably the best baseline for estimating pre-Hispanic amputation methodology. A healer or shaman performing an amputation would have needed at least a basic understanding of how to stop bleeding during and immediately after the procedure. This might have been achieved through tourniquets, limb elevation, and/or bandag- ing, as has been done historically in other parts of the world (Kirkup 2007). Blood loss could also have been reduced with the use of local plant-based remedies for bleeding and hemorrhaging (Bussmann and Sha- ron 2006, 2015). Finally, cauterization or suturing might have been used to close the wound. Precedent for such practices exists elsewhere in the pre-His- panic Andes (Cabieses Molina 2007; Mendoza 2003; Moodie 1929; Toyne 2015b). Appropriate administration of naturopathic anes- thetic and pain-relieving drugs (Bussman and Sha- ron 2006, 2015; Martin 1970) would have greatly benefitted patient comfort during and after the surgi- cal process. Other necessary short-term post-opera- tive care would have included wound hygiene and provision of food and water when the physical exer- tion required for self-care would have resulted in ex- cessive pain or disruption to healing tissues. It would have likely involved changing bandages and admin- istering anti-inflammatory and/or infection-combat- ting drugs as well (Kirkup 2007; Pullen 2010). Some endemic plant species are used by local people in the modern day to ward off bacterial, viral, and parasitic infection, and these plants were likely used for the same or similar purposes in the distant past (Bussmann and Sharon 2006, 2015). Another probable responsibility of ancient ampu- tees’ caretakers was to aid in their efforts to relearn basic skills, such as walking (Kirkup 2007). Although rehabilitation after a unilateral Syme amputation is less challenging than doing so after an amputation procedure that more dramatically alters the limb, the amputees from ancient Túcume likely felt imbal- anced and required interpersonal assistance while they adjusted to their new reality (Finkler et al. 2017). Assistance could have been given by people of close relation to the amputees, such as members of their immediate family. However, this is speculative. Short-term post-operative care might have also been performed by medical practitioners or other commu- nity members. Naturopathic treatments for pain and discomfort also probably played a role in amputees’ long-term care routines. The bichayo plant, for example, whose seeds were found in the burial context of the amputee from Huaca Las Abejas (Case 2), can serve as a rem- edy for arthritis, bone aches, and skin irritations (Bussmann and Sharon 2015:127). Its presence in the grave of this individual could suggest that the plant became associated with her identity after frequent use, possibly as a solution to joint pain caused or ex- acerbated by habitual compensatory movements after loss of the left foot. Use-related migration of the heel pad and subsequent ulceration (Bibbo 2013) or the cyst-like structure present at the amputated ankle joint might also have been a cause of discomfort that the amputee and her caretakers attempted to treat through the use of bichayo. Heel pad migration and ulceration are common in modern amputees whose feet were removed via the Syme procedure, in which the fatty heel pad is used to cover the newly footless ankle stub (Bibbo 2013), but it is unclear whether or not the surgeons of pre-Hispanic Túcume used the heel pad to cover the amputation wound. Ultimately, it is important to note that the care necessary during post-amputation life includes phys- ical as well as emotional support. Studies of Caring for Foot Amputees in Late Pre-Hispanic Túcume16 contemporary amputees show that amputation of lower extremities not only causes physical trauma, but also emotional and psychological damages. Pa- tients often suffer from anxiety, depression, grief, and social discomfort associated with changes to body image (Liu et  al. 2010; Madsen et  al. 2016). Histori- cally, these same post-amputation physical and psy- chological struggles were documented in civil war soldiers recovering from amputation as they at- tempted to come to terms with new limitations in functionality and shifts in their social identities (Bonnan-White et al. 2016; Miller 2015). It is impossi- ble to know the emotional struggles of individuals who lived in the distant past, especially in societies not represented by written histories, but it is import- ant to recognize that lived experiences encompass more than solely physical events. The social circles of the amputees from Huaca Las Balsas and Huaca Las Abejas likely provided important emotional support. Implications of Care Social integration of amputees Despite physical impairment and its emotional con- sequences, it is important to consider the fact that in- dividuals affected by unilateral foot amputation might not have been classified as disabled within the societal norms of Late Intermediate Period and Late Horizon Túcume. Some modern scholars studying the anthropology of disability choose to make a clear distinction between impairment and disability, with disability being defined as the social stigma that is as- sociated with psychological or physiological impair- ment or malformation (Kasnitz and Shuttleworth 2001). Ethnographic research on disability in a num- ber of modern cultures has revealed that impair- ment-related stigma is not applied according to universal standards. Atypical functional phenotypes are sometimes even seen as supernatural or sacred. Rösing (1999), for example, relates several anecdotes of physical im- pairments in the modern Andes that suggest recogni- tion of disability is dependent on an impaired individual’s community contribution, and in some cases (such as those involving medicine men with crippled hands) impairment might actually be viewed as sacred. She presents the hypothesis that: “In the Andes having more disablement often means being less disabled. The reasons are, amongst others, the broader space allowed for compensation within the framework of the norms of reciprocity and represen- tation, as well as the sacred legitimization resource” (Rösing 1999:40). The distinction between impairment and stigma- tized disability provides some interpretive implica- tions related to burial practice and social identity. Social exclusion based on physical impairment could result in deviant burial—a burial style that deviates from the typical model (Murphy 2008; Shay 1985). In the Andes, deviancy is often argued through atypical body treatment, separate burial location, lack of asso- ciated burial goods, or some combination of these characteristics. Most examples of deviant burial in Peru have been associated with sacrifice and warfare (Eeckhout and Owens 2008; Verano 1995). Although deviant burials of human sacrifices are found near the Temple of the Sacred Stone at Túcume (Toyne 2015a, 2016), burials of this character have not been found elsewhere at the site. The amputees at Huaca Las Balsas and Huaca Las Abejas were seemingly not stigmatized for their lost left feet. All indications in the mortuary record point toward a conclusion of social normativity rather than social deviancy for these young female amputees. In fact, it is possible that they might not even have been considered disabled. The apparently high level of so- cial integration experienced by these individuals sug- gests that they were not outcasts or criminals whose left feet were removed for punitive purposes, despite the depictions of amputees in Moche ceramics that seem to suggest punishment as one potential motiva- tion of amputation (Vélez López 1913; Verano et  al. 2000). Instead, they were probably individuals with unexceptional social positions and reputations whose feet were amputated as treatment for a medical condition. Pre-Hispanic amputation as social practice The amputations discussed in this paper might have had a ritual or sacred significance due to earlier de- pictions of feet and individuals with amputated feet by Moche and Wari ceramic vessels, which suggest symbolic importance of the lower extremities. Such a conclusion could also be supported by the presence of footless guardians in grand Moche (Alva and Don- nan 1993; Verano 1997) and Wari (Więckowski 2016) tombs. However, while valid parallels can be drawn between pre-Lambayeque art, pre-Lambayeque mor- tuary symbolism, and the chronologically later am- putation cases at Túcume, there is not a consistent pattern for ritually motivated amputation in these cases. Andean gendered cosmologies could also be used to construct an argument for ritually or sym- bolically motivated foot amputation at Túcume, although this is not strongly supported by contex- tual evidence. The dualistic gendered symbolism Caring for Foot Amputees in Late Pre-Hispanic Túcume 17 of Andean cosmology denotes parallelism and complementarity that is ref lected in religious and political practices (Silverblatt 1987; Vogel 2018). Therefore, pre-Hispanic Andean religious rituals often involved separate but parallel spatial organi- zation within sacred spaces (Silverblatt 1987). This included the body. In pre-Hispanic Andean cosmology, the left side of the body and the feet were often characterized as feminine, while the right side and head were characterized as mascu- line (Baumann 1996). The appearance of two young adult women of similar social standing with left- side foot amputations at Túcume could potentially indicate a gendered ritualistic practice. However, other known cases of pre-Hispanic pedal amputa- tion on the Peruvian north coast are inconsistent with this pattern (Table 1). At other sites, male in- dividuals are found with bilaterally or unilaterally amputated right and left feet, as are females (Chauchat et  al. 2009; Vélez López 1913; Verano et al. 2000; Więckowski 2016). This research, in concert with the amputation cases published by Verano et al. (2000) and Chauchat et  al. (2009), show that non-symbolic amputations occurred in pre-Hispanic north coast Peru. Motiva- tions for foot removal were likely diverse, and medi- cine might not have been the only reason that these surgeries were performed. Nonetheless, there do ap- pear to be some shared characteristics between am- putees. All presently known cases of amputation in the ancient Andes have been identified on the north coast of Peru, all have occurred in individuals who survived the procedure to die as adults, and all seem to have been buried as relatively high-status people (or were buried alongside them). This evidence sug- gests that amputation-related medical knowledge has deep roots in earlier cultures. Also, access to medical care such as amputation might have been an elite privilege that was not accessible to people of lower status. Conclusion The medical history and post-amputation care prac- tices of the young adult females with amputated left feet found at Huaca Las Balsas and Huaca Las Abejas provide new evidence for medical knowledge, socie- tal conceptions of functional impairment and dis- ability, and broader patterns in amputation in pre-Hispanic north coastal Peru. This research demonstrates that pedal amputation via disarticula- tion at the ankle joint has an even longer and more dynamic regional history than has been previously published. The Lambayeque and Chimú-Inca amputees from Túcume illustrate a regional continuity of medical knowledge that transcends major sociopolitical dis- ruptions and power transitions over hundreds of years between Moche regional dominance and the arrival of the Spanish. Additionally, the evidence shows that amputation had a multidimensional and perhaps contextually specific social significance in Lambayeque and later cultures of the Peruvian north coast. While past bioarchaeological and ceramic evi- dence has suggested that amputation was used for punitive and symbolic reasons, amputation at Túcume seems to have been a primarily therapeutic practice. These female foot amputees appear to have been integrated members of society who were able to access advanced surgical care and then survive for years afterward—through care and accommodation by community members—without severe social stigmatization despite newly limited physical functionality. This research sheds new light on amputation as a community practice in pre-Hispanic north coast Peru. However, perhaps more importantly, it lends new temporal and cultural depth to broader anthro- pological understandings of functional impairment and healthcare. The experiences of elite-status ampu- tees at Túcume should fuel further thought about the ways in which class status, community support, and other variables affect medical care and social accom- modation for functionally impaired people. Acknowledgements We thank Alfredo Narváez Vargas for his long-term commitment to archaeological explorations at Túc- ume. Daniel Sandweiss has also been a great col- league. Excavations at Huaca Las Balsas were completed under the authorization of the National Directorial Resolution No 812/INC, 2009, and at Huaca Las Abejas, the National Directorial Resolu- tion No 288-2017/CGPA/VMPCIC/MC. We also are extremely grateful for the decades-long support and friendship of Oswaldo Chozo Capuñay, manager of the archaeological collections at the Museo Túcume, and the many archaeologists, staff, and workers. We would like to specifically thank Mila Cancino and Felix Angel Gutierrez. For contributions in the lab, Toyne thanks Stefani Wai, Paige Douglas, Taylor Remley, and Wesley Garrett. Radiographic assistance came from Dr. Mislav Čavka, Dr. Fabio Cavelli, and Dr. Fabrice Dedouit, Zagreb. Finally, we are grateful for the valuable feedback from reviewers. Caring for Foot Amputees in Late Pre-Hispanic Túcume18 References Cited Adejumo, Adebayo, and Prisca Olabisi Adejumo. 2005. Time to act against medical collusion in punitive amputations. British Medical Journal 330(7502):1277. DOI: 10.1136/bmj.330.7502.1277. Ahmad, Aziz, Omar Ashfaq, Nizar Akhtar, Tabassum Rana, and Momi Gul. 2019. Causes of lower limb amputation in pa- tients registered at Pakistan Institute of Prosthetic and Or- thotic Sciences Peshwar-Pakistan. Khyber Medical University Journal 11(1):41–44. DOI: 10.35845/kmuj.2019.18096. Alva, Walter, and Christopher B. Donnan. 1993. Royal Tombs of Sipán. Fowler Museum of Cultural History, University of Cal- ifornia, Los Angeles. Anzellini, Armando, and J. Marla Toyne. 2020. Estimating the stature of ancient high-altitude Andean populations from skeletal remains of the Chachapoya of Peru. American Journal of Physical Anthropology 171(3):539–549. DOI: 10.1002/ ajpa.23977. Barla, Manuela, Bertrand Gavanier, Mickaël Mangin, Jauffrey Parot, Camille Bauer, and Didier Mainard. 2017. Is amputa- tion a viable treatment option in lower extremity trauma? Or- thopaedics and Traumatology: Surgery and Research 103(6):971–975. DOI: 10.1016/j.otsr.2017.05.022. Baumann, Max Peter. 1996. Andean music, symbolic dualism, and cosmology. In Cosmología y música en los Andes, edited by Max Peter Baumann. Vervuert Verlag, Frankfurt, pp. 15–66. Becker, Gay, and Edwina Newsom. 2003. Socioeconomic status and dissatisfaction with health care among chronically ill Af- rican Americans. American Journal of Public Health 93(5):742–748. DOI: 10.2105/AJPH.93.5.742. Bibbo, Christopher. 2013. Modification of the Syme amputation to prevent postoperative heel pad migration. The Journal of Foot & Ankle Surgery 52(6):766–770. DOI: 10.1053/j. jfas.2013.07.006. Biehler-Gomez, Lucie, Elisa Castoldi, Elisa Baldini, Annalisa Cappella, and Cristina Cattaneo. 2019. Diabetic bone lesions: A study on 38 known modern skeletons and the implications for forensic scenarios. International Journal of Legal Medicine 133(4):1225–1239. DOI: 10.1007/s00414-018-1870-0. Boffeli, Troy J., ed. 2015. Osteomyelitis of the Foot and Ankle: Medical and Surgical Management. Springer, New York. Bonnan-White, Jess, Jewelry Yep, and Melanie D. Hetzel-Rig- gin. 2016. Voices from the past: Mental and physical outcomes described by American Civil War amputees. Journal of Trauma and Dissociation 17(1):13–34. DOI: 10.1080/15299732. 2015.1041070. Bosmia, Anand, Christoph J. Griessenauer, and Shane Tubbs. 2014. Yubitsume: Ritualistic self-amputation of proximal dig- its among the Yakuza. Journal of Injury and Violence Research 6(2):54–56. DOI: 10.5249/jivr.v6i2.489. Buikstra, Jane E., and Douglas H. Ubelaker, eds. 1994. Standards for Data Collection from Human Skeletal Remains. Arkansas Archeological Survey Research Series, 44, Arkansas Archeo- logical Survey, Fayetteville. Buquet-Marcon, Cécile, Charlier Philippe, and Samzun Anaïck. 2007. The oldest amputation on a Neolithic human skeleton in France. Nature Precedings. DOI: 10.1038/npre.2007.1278.1. Bussmann, Rainer W., and Douglas Sharon. 2006. Traditional medicinal plant use in northern Peru: Tracking two thousand years of healing culture. Journal of Ethnobiology and Ethno- medicine 2: 60–70. DOI: 10.1186/1746-4269-2-47. Bussmann, Rainer W., and Douglas Sharon. 2015. Plantas Me- dicinales de los Andes y la Amazonía: La Flora Mágica y Medicinal del Norte del Perú. William L. Brown Center, Mis- souri Botanical Garden, St. Louis. Byrnes, Jennifer F., and Jennifer Muller, eds. 2017. Bioarchaeol- ogy of Impairment and Disability: Theoretical, Ethnohistori- cal, and Methodological Perspectives. Springer, New York. Cabieses Molina, Fernando. 2007. La Salud y los Dioses: La Me- dicina en el Antiguo Perú. Universidad Científica del Sur, Miraflores. Chauchat, Claude, Belkys Gutiérrez, Daphné Deverly, Nicolas Goepfert, and Jean-Bernard Huchet. 2009. La plataforma Uhle en Moche: Una Síntesis de los descubrimientos. Revista del Museo de Arqueología, Antropología e Historia 11:85–110. Checa, Angel. 2010. Evidences of rheumatic disorders and or- thopedic practices in Moche art. Rheumatology International 30(3):419–421. DOI: 10.1007/s00296-009-1200-4. Covey, R. Alan. 2008. Multiregional perspectives on the archae- ology of the Andes during the Late Intermediate Period (c. A.D. 1000–1400). Journal of Archaeological Research 16(3): 287–338. DOI: 10.1007/s10814-008-9021-7. Delgado Elías, Bernarda, and Alfredo Narváez Vargas. 2016. Huaca Las Balsas y las pirámides de Túcume. In Lambayeque: Nuevos Horizontes de la Arqueología Peruana, edited by An- tonio Aimi, Krzysztof Makowski, and Emilia Perassi. Le- dizioni, Milan, pp. 218–241. Dettwyler, Katherine Ann. 1991. Can paleopathology provide evidence for “compassion”? American Journal of Physical An- thropology 84(4):375–384. DOI: 10.1002/ajpa.1330840402. Dupras, Tosha, Lana Jo Williams, Marleen De Meyer, Christoph Peeters, David Depraetere, Bart Vanthuyne, and Harco Wil- lems. 2010. Evidence of amputation as medical treatment in ancient Egypt. International Journal of Osteoarchaeology 20(4):405–423. DOI: 10.1002/oa.1061. Eeckhout, Peter, and Lawrence Stewart Owens. 2008. Human sacrifice at Pachacamac. Latin American Antiquity 19(4):375– 398. DOI: 10.1017/S104566350000434X. Edelstein, Joan. 2019. Canes, crutches, and walkers. In Atlas of Orthoses and Assistive Devices, edited by Joseph B. Webster and Douglas P. Murphy, 5th ed. Elsevier, Philadelphia, pp. 377–382. Escudero Villalta, Jose Manuel. 2018. Informe final: Investi- gación, conservación y puesta en valor del sub sector suroeste. Túcume. Fernandes, Teresa, Marco Liberato, Carina Marques, and Eu- génia Cunha. 2017. Three cases of feet and hand amputation from Medieval Estremoz, Portugal. International Journal of Paleopathology 18:63–68. DOI: 10.1016/j.ijpp.2017.05.007. Finkler, Elissa S., Daniel A. Marchwiany, Adam P. Schiff, and Michael S. Pinzur. 2017. Long-term outcomes following Syme’s amputation. Foot and Ankle International 38(7):732– 735. DOI: 10.1177/1071100717702462. Heyerdahl, Thor, Daniel H. Sandweiss, and Alfredo Narváez Vargas. 1995. Pyramids of Túcume: The Quest for Peru’s For- gotten City. Thames and Hudson, London. Huchet, Jean-Bernard, Daphné Deverly, Belkys Gutiérrez, and Claude Chauchat. 2011. Taphonomic evidence of a human skeleton gnawed by termites in a Moche-civilisation grave at Huaca de la Luna, Peru. International Journal of Osteoarchae- ology 21(1):92–102. DOI: 10.1002/oa.1110. Jolly, Sarah, and Danielle Kurin. 2017. Surviving trepanation: Approaching the relationship of violence and the care of “war wounds” through a case study from prehistoric Peru. In New Developments in the Bioarchaeology of Care, edited by Lorna Tilley and Alecia A. Schrenk. Springer, New York, pp. 175–236. Caring for Foot Amputees in Late Pre-Hispanic Túcume 19 Kasnitz, Devva, and Russell Shuttleworth. 2001. Introduction: Anthropology in disability studies. Disability Studies Quar- terly 21(3):2–17. DOI: 10.18061/dsq.v21i3.289. Kirkup, John. 2007. A History of Limb Amputation. Journal of Chemical Information and Modeling. Vol. 53. Springer, New York. Kristiansson, Charlotte, Eduardo Gotuzzo, Hugo Rodriguez, Alessandro Bartoloni, Marianne Strohmeyer, Göran Tomson, and Per Hartvig. 2009. Access to health care in relation to so- cioeconomic status in the Amazonian area of Peru. Interna- tional Journal for Equity in Health 8:11–19. DOI: 10.1186/1475-9276-8-11. Liu, Fen, Rhonda M. Williams, Hsueh Erh Liu, and Nai Hui Chien. 2010. The lived experience of persons with lower ex- tremity amputation. Journal of Clinical Nursing 19(15– 16):2152–2161. DOI: 10.1111/j.1365-2702.2010.03256.x. Madsen, Ulla Riis, Ami Hommel, Carina Bååth, and Connie Bøttcher Berthelsen. 2016. Pendulating—A grounded theory explaining patients’ behavior shortly after having a leg ampu- tated due to vascular disease. International Journal of Quali- tative Studies on Health and Well-being 11(1):1–10. DOI: 10.3402/qhw.v11.32739. Marcovitch, Harvey, ed. 2009. Black’s Medical Dictionary. A & C Black Publishers Limited, London. Markatos, Konstantinos, Marianna Karamanou, Theodosios Sa- ranteas, and Andreas F. Mavrogenis. 2019. Hallmarks of am- putation surgery. International Orthopaedics 43(2):493–499. DOI: 10.1007/s00264-018-4024-6. Martin, Richard T. 1970. The role of coca in the history, religion, and medicine of South American Indians. Economic Botany 24:422–438. Mavroforou, Anna, Konstantinos Malizos, Theofilos Kara- chalios, Konstantinos Chatzitheofilou, and Athanasios D. Gi- annoukas. 2014. Punitive limb amputation. Clinical Orthopaedics and Related Research 472(10):3102–3106. DOI: 10.1007/s11999-014-3480-6. Mays, Simon A. 1996. Healed limb amputations in human osteoar- chaeology and their causes: A case study from Ipswich, UK. In- ternational Journal of Osteoarchaeology 6(1):101–113. DOI: 10.1002/(SICI)1099-1212(199601)6:1<101::AID-OA232>3.0.CO;2-Y. Mendoza, Ruben G. 2003. Lords of the medicine bag: Medical science and traditional practice in ancient Peru and South America. In Medicine Across Cultures: History and Practice of Medicine in Non-Western Cultures, edited by Helaine Selin. Klewer Academic Publishers, Dordrecht, pp. 225–257. Miller, Brian Craig. 2015. Empty Sleeves: Amputation in the Civil War South. The University of Georgia Press, Athens. Moini, Majid, Mohammad R. Rasouli, Ali Khaji, Farshad Far- shidfar, and Pedram Heidari. 2009. Patterns of extremity traumas leading to amputation in Iran: Results of Iranian Na- tional Trauma Project. Chinese Journal of Traumatology (En- glish Edition) 12(2):77–80. DOI: 10.3760/cma.j.issn.1008-1275. 2009.02.003. Moodie, Roy L. 1929. Studies in paleopathology XXIII: Surgery in pre-Columbian Peru. Annals of Medical History 1:698–728. Moulik, Probal K., Robert Mtonga, and Geoffrey V. Gill. 2003. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care 26(2):491–494. DOI: 10.2337/diacare.26.2.491. Murphy, Eileen M. 2008. Deviant Burial in the Archaeological Record. Oxbow Books, Oxford. Nanwani, Bhawna, Prem Shankar, Ravi Kumar, and Faizan Shaukat. 2019. Risk factors of diabetic foot amputation in Pa- kistani type II diabetes individuals. Cureus 11(6):e4795. DOI: 10.7759/cureus.4795. Narváez Vargas, Alfredo. 1995a. Death in ancient Túcume: The southern cemetery and Huaca Facho. In Pyramids of Túcume: The Quest for Peru’s Forgotten City, edited by Thor Heyerdahl, Daniel H. Sandweiss, and Alfredo Narváez Vargas. Thames and Hudson, London, pp. 169–178. Narváez Vargas, Alfredo. 1995b. The pyramids of Túcume: The monumental sector. In Pyramids of Túcume: The Quest for Pe- ru’s Forgotten City, edited by Thor Heyerdahl, Daniel H. Sand- weiss, and Alfredo Narváez Vargas. Thames and Hudson, London, pp. 79–130. Narváez Vargas, Alfredo, and Bernarda Delgado Elías, eds. 2011. Huaca Las Balsas de Túcume: Arte Mural Lambayeque. Mu- seo de Sitio Túcume, Túcume. Nerlich, Andreas G., Albert Zink, Ulrike Szeimies, and Hjalmar G. Hagedorn. 2000. Ancient Egyptian prosthesis of the big toe. Lancet 356(9248):2176–2179. DOI: 10.1016/ S0140-6736(00)03507-8. Ortner, Donald J. 2012. Differential diagnosis and issues in dis- ease classification. In Companion to Paleopathology, edited by Anne L. Grauer. Blackwell Publishing, New York, pp. 250–267. Paico Vílchez, Emiliano, and Emiliano Paico Zumaeta. 2020. Prótesis del miembro inferior de los mochicas. Acta Heredi- ana 63(1): 23–29. DOI: 10.20453/ah.v63i1.3699. Palma Málaga, Martha R., and Krzysztof Makowski. 2019. Bio- archaeological evidence of care provided to a physically dis- abled individual from Pachacamac, Peru. International Journal of Paleopathology 25:139–149. DOI: 10.1016/j. ijpp.2018.08.002. Pomeroy, Emma, and Jay T. Stock. 2012. Estimation of stature and body mass from the skeleton among coastal and mid-alti- tude Andean populations. American Journal of Physical An- thropology 147(2):264–279. DOI: 10.1002/ajpa.21644. Pullen, Richard L. 2010. Caring for a patient after amputation. Nursing 10(1):15. DOI: 10.1097/01.NURSE.0000365908.40394.4e. Reid-Cunningham, Allison Ruby. 2009. Anthropological theo- ries of disability. Journal of Human Behavior in the Social En- vironment 19(1): 99–111. DOI: 10.1080/10911350802631644. Rösing, Ina. 1999. Stigma or sacredness: Notes on dealing with disability in an Andean culture. In Disability in Different Cul- tures: Reflections on Local Concepts, edited by Brigitte Holzer, Arthur Vreede, and Gabriele Weigt. Transcript Verlag, Biele- feld, pp. 27–43. Sachs, Michael, Jörg Bojunga, and Albrecht Encke. 1999. Histor- ical evolution of limb amputation. World Journal of Surgery 23(10):1088–1093. DOI: 10.1007/s002689900628. Sanders, Lee J. 2002. From Thebes to Toronto and the 21st cen- tury: An incredible journey. Diabetes Spectrum 15(1):56–60. DOI: 10.2337/diaspect.15.1.56. Sandweiss, Daniel H. 1995. Cultural background and regional prehistory. In Pyramids of Túcume: The Quest for Peru’s For- gotten City, edited by Thor Heyerdahl, Daniel H. Sandweiss, and Alfredo Narváez Vargas. Thames and Hudson, London, pp. 56–78. Shakespeare, William. 1597. An Excellent Conceited Tragedie of Romeo and Iuliet: As it Hath Been Often (With Great Ap- plause) Plaid Publiquely, by the Right Honourable the L. of Hunsdon his Seruants. Iohn Danter, London. Shay, Talia. 1985. Differentiated treatment of deviancy at death as revealed in anthropological and archeological material. Journal of Anthropological Archaeology 4(3):221–241. DOI: 10.1016/0278-4165(85)90004-2. Shimada, Izumi. 1981. The Batan Grande-La Leche Archaeologi- cal Project: The first two seasons. Journal of Field Archaeology 8(4):405–446. DOI: 10.1179/009346981791504815. Caring for Foot Amputees in Late Pre-Hispanic Túcume20 Shimada, Izumi. 2009. Who were the Sicán? Their development, characteristics and legacies. In The Golden Capital of Sicán, edited by Izumi Shimada, Ken-ichi Shinoda, and Masahiro Ono. Tokyo Broadcasting System, Tokyo, pp. 25–61. Silverblatt, Irene M. 1987. Moon, Sun, and Witches: Gender Ide- ologies and Class in Inca and Colonial Peru. Princeton Uni- versity Press, Princeton. Stewart, T. Dale. 1977. The Neanderthal skeletal remains from Shanidar Cave, Iraq: A summary of findings to date. Proceed- ings of the American Philosophical Society 121(2):121–165. Sutherland, M. Linda. 2019. Use of Computed Tomography scanning in a ‘virtual’ bioarchaeology of care analysis of a Central Coast Peruvian mummy bundle. International Jour- nal of Paleopathology 25:129–138. DOI: 10.1016/j. ijpp.2018.12.006. Tilley, Lorna, ed. 2015. Theory and Practice in the Bioarchaeology of Care. Springer, New York. Tilley, Lorna, and Tony Cameron. 2014. Introducing the Index of Care: A web-based application supporting archaeological re- search into health-related care. International Journal of Paleo- pathology 6(1):5–9. DOI: 10.1016/j.ijpp.2014.01.003. Tilley, Lorna, and Marc F. Oxenham. 2011. Survival against the odds: Modeling the social implications of care provision to seriously disabled individuals. International Journal of Paleo- pathology 1(1):35–42. DOI: 10.1016/j.ijpp.2011.02.003. Tilley, Lorna, and Alecia A. Schrenk, eds. 2017. New Develop- ments in the Bioarchaeology of Care: Further Case Studies and Expanded Theory. Springer, New York. Toyne, J. Marla. 2015a. The body sacrificed: A bioarchaeological analysis of ritual violence in ancient Túcume, Peru. Journal of Religion and Violence 3(1):137–171. DOI: 10.5840/jrv20155217. Toyne, J. Marla. 2015b. Variation in large ectocranial lesions from pre-Columbian Kuelap, Peru. International Journal of Paleopathology 11:30–44. DOI: 10.1016/j.ijpp.2015.08.003. Toyne, J. Marla. 2016. Life before death: A paleopathological examination of human sacrifice at the Templo de la Piedra Sagrada, Túcume, Peru. In Ritual Violence in the Ancient An- des: Reconstructing Sacrifice on the North Coast of Peru, ed- ited by Haagen D. Klaus and J. Marla Toyne. University of Texas Press, Austin, pp. 215–243. Tremblay Critcher, Lori A. 2017. An exploration of a modified bioarchaeology of care methodological approach for historic institutionalized populations. In New Developments in the Bioarchaeology of Care, edited by Lorna Tilley and Alecia A. Schrenk. Springer, New York, pp. 277–288. Trigo Rodríguez, David E., and Roberto C. Hidalgo Rocabado. 2012. Tiwanaku-Huari: Los Miembros Inferiores y sus Repre- sentaciones en las Ofrendas del Horizonte Medio. Produc- ciones CIMA, La Paz. Ubelaker, Douglas H. 1999. Human Skeletal Remains: Excava- tion, Analysis, Interpretation. 3rd ed. Taraxacum, Washing- ton, DC. Urteaga-Ballon, Oscar. 1991. Medical ceramic representations of nasal leishmaniasis and surgical amputation in ancient Peru- vian civilization. In Human Paleopathology: Current Synthe- ses and Future Options, edited by Donald J. Ortner and Arthur C. Aufderheide. Smithsonian Institution Press, Washington, DC, pp. 95–101. Van der Merwe, Alta E., Maryna Steyn, and Ericka N. L’Abbé. 2010. Trauma and amputations in 19th century miners from Kimberley, South Africa. International Journal of Osteoar- chaeology 20(3):291–306. DOI: 10.1002/oa.1035. Vélez López, Lizardo R. 1913. Las mutilaciones en los vasos an- tropomorfos del antiguo Perú. In Proceedings of the XVIII ses- sion of the International Congress of Americanists, 1912. London, pp. 267–275. Verano, John W. 1995. Where do they rest? The treatment of hu- man offerings and trophies in ancient Peru. In Tombs for the Living: Andean Mortuary Practices, edited by Tom D. Dille- hay. Dumbarton Oaks Research Library and Collection, Washington, DC, pp. 189–227. Verano, John W. 1997. Human skeletal remains from Tomb 1, Sipán (Lambayeque river valley, Peru); and their social implications. Antiquity 71(273):670–682. DOI: 10.1017/ S0003598X00085392. Verano, John W., Laurel S. Anderson, and Régulo Franco. 2000. Foot amputation by the Moche of ancient Peru: Osteological evidence and archaeological context. International Journal of Osteoarchaeology 10(3):177–188. DOI: 10.1002/1099- 1212(200005/06)10:3<177::AID-OA520>3.0.CO;2-O. Villena, Jaime E. 2015. Diabetes Mellitus in Peru. Annals of Global Health 81(6):765–775. DOI: 10.1016/j.aogh.2015.12.018. Vogel, Melissa A. 2018. New research on the late prehistoric coastal polities of northern Peru. Journal of Archaeological Research 26(2):165–195. DOI: 10.1007/s10814-017-9108-0. Walters, Sarah, and Marc Suhrcke. 2005. Socioeconomic Inequal- ities in Health and Health care Access in Central and Eastern Europe and the CIS : A Review of the Recent Literature. WHO European Office for Investment for Health and Development, Venice. Wesp, Julie K. 2017. Caring for bodies or simply saving souls: The emergence of institutional care in Spanish colonial America. In New Developments in the Bioarchaeology of Care, edited by Lorna Tilley and Alecia A. Schrenk. Springer, New York, pp. 253–276. Więckowski, Wiesław. 2016. A case of foot amputation from the Wari imperial tomb at Castillo de Huarmey, Peru. Interna- tional Journal of Osteoarchaeology 26(6):1058–1066. DOI: 10.1002/oa.2517. Wright, Lori E. 2011. Bilateral talipes equinovarus from Tikal, Guatemala. International Journal of Paleopathology 1(1):55–62. DOI: 10.1016/j.ijpp.2011.02.005. Yu, Gerard V., and Justin R. Hudson. 2001. The Syme’s amputa- tion technique. In The Proceedings of the Annual Meeting of the Podiatry Institute 2001. The Podiatry Institute, Decatur, pp. 138–145. Zäuner, Steve P., Joachim Wahl, Yavor Boyadziev, and Ioannis Aslanis. 2013. A 6000-year-old hand amputation from Bul- garia—the oldest case from south-east Europe? International Journal of Osteoarchaeology 23(5):618–625. DOI: 10.1002/ oa.1277. Zhao, Jing Chun, Xing Fan, Jia Ao Yu, Xiu Hang Zhang, Kai Shi, and Lei Hong. 2020. Deep frostbite: Clinical characteristics and outcomes in northeastern China. Journal of Tissue Via- bility 29(2):110–115. DOI: 10.1016/j.jtv.2020.01.006.