White Coat Underground

My recent post on head trauma got me thinking. The practice of trepanation (the drilling of holes in the head) is thousands of years old. While looking up information on the practice I came upon this woodcut.

i-96ba39798c5f406ae0e410c0475d4d73-Peter_Treveris_-_engraving_of_Trepanation_for_Handywarke_of_surgeri_1525.png

The engraving is, I believe, from 16th century England. Over at wikipedia, editors were discussing whether or not this diagram actually showed trepanation, or some other surgical procedure (neither of which I would wish to undergo). Either way, the picture is quite revealing. According to the good folks at wikipedia, the original caption states:

This instrumente is for to worke upon the heed/whan the brayne pan is beten in/for to lyfte it up agayne.

Let’s take a closer analysis of the instrument and the patient.

If you look closely at the instrument, it would appear to be a screw drill with a scaffolding that clamps it to the scalp. It would appear from the caption and the picture, that the drill may have in fact been used to attach to a depressed piece of skull and lift it up again (although I’m not sure why a drill would be the best method).

More interesting to me is the patient himself. The artist paid very close attention to detail. Aside from the obvious hole in the head, there are several abnormalities. Knowing that my readers are generally quite bright, I’d like to see what you folks come up with by way of description and explanation for the patient’s findings.

Comments

#1 Tsu Dho Nimh
March 20, 2009

Looks like lifting a depressed skull fracture to me.
#2 scicurious
March 20, 2009

Hmmm…the second picture makes me think right side horizontal gaze palsy with facial weakness, which could result from damage to the abducens.

On the OTHER hand, weakness on one side of the tongue could be the result of medial medullary syndrome, though he’d have to have contralateral paralysis for that, right?

So? Did I get it right? huhhuhhuh?!?!
#3 PalMD
March 20, 2009

I’m still puzzling through it myself.

I’m not sure which side the gaze palsy is actually on. It appears there may be a ptosis on the left, and there is anisocoria. The tongue deviation could be due to contralateral cortical damage or ipsilateral midbrain damage, which would go better with the gaze and pupil findings, but i think i need a neuro to help play “where’s the lesion”.
#4 FutureMD
March 20, 2009

Fun!
The guy on the right: Disconjugation of gaze, right eye appears paralyzed to adduction – ptosis of eyelids – decreased nasolabial fold, drooping of corner of mouth, lack of forehead wrinkling on right side of face – leftward deviation of tongue – generally he looks obtunded or otherwise less than fully alert.

Probable Dx – blow to the head given the many cranial nerves involved I suspect intracranial pressure that is affecting the brainstem.

I bet the drill works like a wine bottle opener. Drill in and pull.
#5 Phillip IV
March 20, 2009

To tell the truth, I don’t only have doubts this shows a trepanation, I actually doubt it’s an authentic 16th century woodcut…the anatomical and perspective faults seem a little bit forced, like if a modern illustrator had tried to mimic 16th century art, and the hatching seems rather too detailed…

Are you sure somebody isn’t pulling a little prank over at wikipedia?
#6 Phillip IV
March 20, 2009

Addendum to my earlier post:

This is a woodcut by Peter Treveris, from a different book:

http://special.lib.gla.ac.uk/images/exhibitions/printing/Afy20_tpw.jpg

Looks rather different in style and detailing, doesn’t it?
#7 David
March 20, 2009

the guy on the left has left ptosis, the left pupil is larger, and the left eye is deviated out. Let’s assume the author also meant that the left eye should be deviated down as well. That’s a left 3rd nerve palsy. He also has left facial weakness, and maybe deviation of the tongue to the left. If the face and tongue weakness are supertentorial with uncal herniation, they’re on the wrong side relative to the impaired left 3rd nerve. If the VII and XII weakness are due to brainstem dysfunction, the process involves midbrain, pons, and medulla and is not treatable by a procedure at the vertex. For a supratentorial mass with pressure effect to cause dysfunction in the pons, the patient would be deeply unresponsive, not eyes open. I vote for a mistake by the artist: he/she got the side wrong for the VII and XII paralysis. I’d also support the idea that the device doesn’t go in further than the bone. At the midline, the skull sits directly on top of the sagittal sinus, and entering that would be a surgical disaster.

The artistry in the left illustration doesn’t seem as clear to me. It looks like the gaze may actually be conjugate, with deviation towards the side of facial weakness. Rather than ptosis, the patient seems to have a lower eyelid droop, which is a common part of a VIIth nerve dysfunction (central or peripheral). This patient might have a left side supratentorial lesion, and is less ill than the patient on the right. However, the procedure is once again being done in a bad choice of location.

Great fun! takes me back to neurology rounds.
#8 uqbar
March 20, 2009

This looks to me like it is a screw, but not a *screw drill.* In fact, as I see it, there are actually two screws. At the bottom is a type of “wood screw” – this would be screwed into the depressed piece of skull in order to get a grip on it. Once the “wood screw” is inserted, the upper screw (which is a sort of “machine screw”), is “un-screwed” to raise the depressed piece of skull.

The two different screw types seem quire clear to me:

- the lower “wood screw” designed to “bite” into the skull to get a grip
- the upper machine screw – designed to provide a smooth lifting action
#9 palmd
March 20, 2009

when was this type of cutting screw (the lower one) invented? Is it an anachronism?
#10 Art
March 20, 2009

Perhaps I’m reading too much into what may be the random or idealized artists conception but the working tip on the right appears to resemble a wood working burr or simple drill bit. Perhaps a spoon bit seen from the side. That design was pretty common and would eventually evolve into the paddle bit used in rough carpentry today.

The bit on the left looks to be a classic tapered-thread wood screw. Which would wedge itself firmly and allow considerable pulling force to be applied without it pulling out.

It looks in both cases the patients both have holes knocked in their skulls already. As stated in the description the desired result seems to me to be lifting the skull fragment.

As for naming the neurological deficit I will leave it to the experts but have to note that at the time the physician involved, likely a barber, didn’t have any such descriptive terminology. AFAIK their treatment methodology was likely very simple and mechanical. To pull up what was pushed in and to brace what was clearly broken. Hoping to reverse and/or allow healing of the injury.

Evidently even such a simplified theoretical approach did give some positive results. The numbers of drawings, artifacts like the machinery involved, writings going back to the Romans, and the archeological record of skulls with healed or partially healed injuries showing that they had been surgically manipulated suggests that through time and across the globe people were trying similar techniques.
#11 Sam C
March 20, 2009

I admire the knowledge and skill of the posters here playing “Spot the Ptosis”, but wow! isn’t the bravery and grit of the C16 patient and practitioner of these procedures awesome?

Obviously one’s attitude changes when “No, I’ll wait another 4 centuries for effective anaesthesia and another 5 for high grade neurological surgery” is not an option. Pain or death is not the longest menu of choices.

Doesn’t it make you feel a little pathetic? Sometimes us modern folk just aren’t appreciative enough of how lucky we are.
#12 Joe
March 21, 2009

If those devices were meant for lifting and repositioning (a part of) the skull, what should we infer about living conditions in that era? It seems they would not manufacture such elaborate instruments unless there was regular need.
#13 Tsu Dho Nimh
March 21, 2009

Joe –
Between construction accidents, brawls, horses, and warfare there was a definite need.
#14 Joe
March 21, 2009

Tsu-
That was my point.

I have some other points, however, concerning the accuracy of the renditions; as discussed by the medics here. First, this was not a snapshot. Despite the notion that trepaning was mostly painless, who would sit still for it for an artist?

Also, the instruments seem a lot taller than needed for the range of motion required. That would be a waste of time and material in fabrication. For goodness sakes, the right-hand illustration shows a device that is taller than the head whose few inches it works upon.

Perhaps the artist expanded the pieces to convey the details, and the person who posed was caught looking-around over the time.
#15 Adam Cuerden
March 22, 2009

Heh. I uploaded that. =)
#16 Adam Cuerden
March 22, 2009

Remember it likely that the fellow was heavily drunk, but not necessarily unconscious – if they could reliably make people unconscious in 1525, then the history of surgery would likely be very different.

I remember going through the book I found this in – Whole lot of boring religious imagery, then you come to this one…
#17 DLC
March 22, 2009

Bah! you’ve all got it wrong!
Clearly the man’s humors are out of balance, and the physicker is here attempting to adjust the biles.
But forsooth! the poor fellow needs a blood-letting, methink !
#18 PalMD
March 22, 2009

Heh, adam, totes cool..
#19 lecinqblog
March 27, 2009

clearly, all my above commenters have already pointed out evverything i wanted to say, the ptosis , the gaze paralysis, the drooping, the facial paralysis (weakness?)symptoms , possible stroke, possible space occupying lesion in the head yada yada.
The thing is , this procedure probably even helped people back then by relieving Raised Intracranial pressure if any. ya know. Those were the beginning or modern neurosurgery. So well. I won’t discount the procedure of all credibility and what not
#20 Harry
March 28, 2009

That’s too easy PalMD!

Clearly the patient is receiving cranial manipulation in the Osteopathic Tradition of William Garner Sutherland, D.O.

It is a vertical sheer of the cranial bones, if I may say so.