Surgical Procedures - Trepanning/Trepanation

Trepanning is basically the medical art of drilling holes in people's heads. It was historically done for many reasons even in prehistoric times. Part of the reason was the hope of letting the demons contained in the skull out - the demons being what we today call epilepsy, migraines and psychological disorders. However, it was also an important medical procedure. In medicine it was used to relieve the pressure caused expansion of the dura mater and pooling of blood under the skull as well as to allow easier removal of bits of bone that happened to fall in when someone fractured their skull following a fall or an argument that didn't really go all that well for them. Of the resources I've read, the earliest person to cover this in any scientific (well, somewhat scientific) detail was no less than the Father of Medicine: Hippocrates.

“For a person wounded to the same, or a much smaller, extent, and by weapons of the same size and quality, and even much less, will sustain a =much greater injury, provided he has received the blow at the sutures [of the skull], than if it was elsewhere. And many of these require trepanning, but you must not apply the trepan to the sutures themselves, but on the adjoining bone.” (Hippocrates, On Injuries of the Head, Hippocratic Writings, Translated and Edited by Francis Adams, Encyclopedia Britannica, Inc., Chicago, 1952p. 67)

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Front Page of he surgions mate Since we are looking at sea surgery, we turn to the procedure outlined by the first sea surgeon to address a book to those involved in the procedure: John Woodall. According to John Kirkup in his forward to a re-published version of Woodall's book, Woodall wrote his book "...to guide novice surgeons’ mates who for the most part were articled apprentices, and inexperienced surgeons expected to treat medical and surgical emergencies peculiar to ships, far from land for prolonged periods and under tropical conditions.” (John Kirkup, Forward to the surgions mate 1617 edition, p. xvi) Being a sort of textbook, it is fitting that we use Woodall's text. I have only minimally altered the text by inserting paragraphs and changing some of the more obscure uses of letters (u for v, v for u, vv for w for example). I have preserved the spelling.

"The cure of the wounds of the head is not alwayes to be presumed upon, though small, nor yet despaired of, though great. Consider therefore diligently, whether the braine it selfe be hurt or no, if the braine be offended, it is to bee knowen partly by the inflammation, dolour, apostumation, retraction, convulsion or deprivation of the functions of the senses, and death also is suspected presently, or within a few dayes to follow, and if the palsie possesse the opposite part, it being sound and whole, it is doubtfull, and the sympathie of parts will cause oft times an absesse in the Liver and Messenterium, and an Intemperature of the vitall faculty with a continuall fever and death. It shall therefore be necessary for the wise Artist to know the manner of the hurt, that he may wisely prognosticate the danger, for if onely the Pericranium be hurt by incision, without any contusion, and symptoms arise with a tumour in the head, then dilation is needefull that the contused bloud which is between the Cranium and Pericranium may bee extracted, and let it be quickly done, so shall the symptomes cease and the cure will be easie, but and if the offence of the Pericranium be in the suture of seame it is more dangerous, because the braine doth sympathize with it, if the Fibres passing through the sutures of the Pericranium from Dura mater be wounded or contused it exceeds the other in danger, therefore to resist putrefaction, let the wound be mundified: and if no fracture of the bone be (the wound appearing onely in the flesh (without any offence of the Pericranium, the cure shall be as in other wounds.

John Woodall, Surgeon But if a fracture in Cranium chance, there is required great care, namely, let the forme and magnitude thereof be well considered, observing also diligently what bone it is, and in what part it is hurt, and whether the fragments are great or little, or sharp, pricking the Membranes or not, which of what sort soever they be they are dillgently to be drawne out with as much ease as may be to the Patient, and if they cannot being broader within, then without, let the Trapan be carefully used, the use whereof is touched in the booke of instruments, under the name Trapan. Sometimes there is onely a depression, and then a Levatorie instrument will excuse the use of a Trapan, and take away the spills and fragments which are upon the Membrane, and the bloud also which shall issue out upon the Membrane, and the bloud also which shall issue out upon the same may by a spung be taken away: keepe it likewise from cold, and of a temperate heat, and the place hurt being well clensed, poure rosarum warme into the wound, or two parts of Hony, and one part of oyle or syrupe of drie Roses, or common Honey with Terpintine, with the yolke of an egge, which are remedies mundifying, and gratefull to the Membrans, and ought to be applied warme, but above all others the linament of Arceus is the chiefest Balsame in the head. The generall remedies for wounds of the head must neither overmuch refrigerate, nor overmuch calefie, but be of a moderate or temperate calor.

The generall manner to proceede to the cure of wounds in the head, is as followeth. First let the haire be shaven away, the next if any loose bones be, take them out, the next to be done is , if a depression of the Cranium bee, strive with the elevatorie to raise it. The next is to stay the fluxe of bloud if any be, leaving of the griefe undressed for two daies that the vaines may knit, then inquire of the Patient if hee have the benefit of nature, if not, procure him one, not many stooles, and onely see he have naturall stooles once a day, or in two daies, not by potion nor pills, but rather by glister or suppositorie.

the surgions mate, p. 312
Trepanning Tools The second opening of the wound, if occasion serve, use the Trapan, or take out any spills or bones that seeme to offend, if they be very loose, not else, force nothing out of the wound, except the Patient his great necessitie force thee thereunto; for Nature is kinde, and ready to do wondrous helpe in the cure of the head. For the second application, have ready of the noble linament of Arceus never sufficiently commended, and being somewhat hotter then the partie would willingly beare it, annoint the wound therewith in each place, with a little soft lint on a Probs end, leaving the said lint therein, and with plegents of lint drie fill up the orifice, and after annointing about the edges of the griefe, apply a plaster, either of Emplast betonie, Stipticum Paracelsi, Minium, Mellilote, or Diacalsitheos, in want of Arceus linament you may take oleum rosaraum, and mell rosarum which are not inferior much to the former, being warme applied: Some use therewith a l-so a digestive of Terpintine, and the yolke of an egge well mixed, ana a like quantitie, wherewith they spread plegents, and then dippe them in the warme mell and oyle mentioned, and so apply them, which is very good, and and the most ancient practise in curing of wounds of the head.

In want of oyle of Roses, oyle of Olive will do well, and common honey for mell rosarum, though not so well: and if cause be, some Artists mix spirit of wine, or good aqua vitæ with the former medicine, and it comforteth well the braine, and very much futhereth good and speedy healing, good bowlstring, and ligature dothe much availe to the cure of wounds of the head: also it is good to keepe the party lying and in a darke place, till the greatest danger of accidents be past, remembring withal that the overstrickt keeping him in, may also be very offensive to the sicke.

Let good diet stricktly be observed, if occasion be, and the use of glisters likewise upon good reasons is also to be approved, and it is good to open the Cephalicke vaine if the braine have beene long uncovered, or yeelde a spunmous white and thicke excrement, which seemes to bee a portion of the substance of the braine: likewise to purge the body, mundified the wound, and corroborate the braine with Cordialls, and fomentations fitting, as the chiefest is good wine and hony to foment with, but I seldome use any fomentations, my selfe have cured divers fractures in Cranium without any fomentations at all, and for the use of them at sea I know is troublesome, and dangerous except great cause. Be carefull also to observe the danger of the wound according to the accidents thereof, for if it bee little and superficiall it is cured as an other wound, but if it pierce the second table, it must not be passed lightly over, for if you be occasioned to use the Trapan it is to be applied the third, fourth, of fift day after the hurt at the farthest, but the choice of the day is not materiall, as some suppose, where there is apparent necessity, except on the day of the full of the Moone, and then there is danger more than else, but necessity hath no rules." (John Woodall, the surgions mate, 1617 edition, p. 134-7)