{"id":"8b378698-44ff-4549-aa3b-27b42d45483f","slug":"sni-17-579","title":"From ritual trepanation to legal regulation: The emergence of Persian neurosurgery, from its origins to the Achaemenid era","authors":["Keyvan Mostofi"],"abstract":"Background: The history of cranial trepanation is almost invariably narrated through ancient Egypt, European Neolithic communities, or pre-Columbian civilizations. Ancient Persia remains largely absent from international syntheses on the history of neurosurgery, despite a substantial body of archaeological and textual evidence. This article retraces the Iranian trajectory of cranial surgery, from the earliest material evidence of Bronze Age trepanation to the emergence of legal and professional regulation of surgical practice in the Avestan/Achaemenid era, laying the foundations of a tradition that would reach institutional maturity under the Sassanids. Methods: A critical historical and epistemological analysis was conducted, cross-referencing the archaeological and paleopathological evidence available on the trepanned skull from Shahr-e Sukhteh (c. 2800 BCE), the prescriptions of the Vendidad concerning surgical practice and the certification of medical competence, and secondary historiographical literature on pre-Islamic Iranian medicine and on the comparative, worldwide history of trepanation. Results: Three convergent lines of evidence establish the existence of a continuous, structured Persian surgical tradition: the oldest documented material evidence of successfully performed cranial surgery on Iranian territory; the recognition of a distinct professional status for the surgeon within the Avestan corpus (kareto baēšaza, “medicine by the knife”); and the Vendidad’s institution of an outcome-based certification rule (three successful operations performed on non-Zoroastrian patients), constituting one of the oldest documented forms of regulation of surgical practice, applied without distinction of creed. Conclusion: Ancient Persia developed, independently of the Hippocratic and Egyptian traditions, a trajectory of its own, running from the empirical practice of trepanation to its legal and professional regulation. This trajectory directly prepares the Sassanid institutionalization of medicine at the Academy of Gondishapur and the scholarly synthesis that would culminate in the work of Avicenna, restoring to the history of neurosurgery an Iranian substrate that has remained largely understudied.","thumbnailUrl":null,"publishDate":"2026-10-16T00:00:00.000Z","doi":"10.25259/SNI_1069_2026","categories":["History of Medicine","Original Article"],"fullTextUrl":"https://surgicalneurologyint.com/api/articles/8b378698-44ff-4549-aa3b-27b42d45483f/pdf"}