Antall József szerk.: Orvostörténeti közlemények 97-99. (Budapest, 1982)

TANULMÁNYOK - Bakay, Louis: Félelem a koponya varratain át végzett trepanációtól (angol nyelven)

slowly and gradually and mentions with considerable pride that by using his method "nothing untoward can happen to the membrane even though the operator be the most ignorant and cowardly of men; yes, even if he be sleepy." In subsequent centuries the danger was more clearly defined. The outcome of the operation was thought to be fatal "from pain, inflammation, fever, spasm and convulsions, caused by laceration of the arteries, veins and nerves passing into the sutures" .

& There was, of course, a practical reason for avoiding surgery over the cranial sutures, a reason that was clearly stated by surgeons from the 16th century on. Underneath, particularly under the sagittal and lambdoid sutures, are mighty venous sinuses (longitudinal and transverse), easily injured by trephination. Once ripped open severe hemorrhage ensues, a massive bleeding uncontrollable by the early surgeons. The likelihood of fatal bleeding was exaggerated in their mind since they believed that the sinuses pulsated because arterial blood flowed in them. Vesalius

7 himself taught that branches of the internal carotid artery opened into the sinuses of the dura mater, an error that went uncorrected for two centuries. The danger was thought to be so formidable that even trephination close to the sutures was forbidden. What seems to be an almost superstitious fear had real anatomical basis. The serrated edge of a trephine close to the sagittal sinus could easily cut into a major feeding cortical vein, such as the Rolandic vein, close to its junction with the superior longitudinal sinus resulting in severe bleeding. From the earliest times until the end of the eighteenth century craniotomy was a rough procedure. It was performed with a variety of instruments. Sometimes a simple chisel and mallet were used which resulted in a quadrangular bone defect. The enlargment of an initial burr hole with rongeurs was another method. Sometimes five or six drill holes were made in a circular fashion, they were then connected with rongeurs, resulting in a round defect. From the 15th century on the trepan (which we now call trephine) made its appearance until it became the principal instrument for craniotomies. This trepan was essentially the same as that used at the present time; a circular saw. There were some other instruments used by individual surgeons, usually straight saws which made a linear cut in the skull. These trephinations were carried out almost exclusively in patients with skull fractures. It was next to impossible to avoid injuring the dura with any of these tools particularly where it was strongly adherent to the internal table as it indeed is at the suture lines. In interesting contradistinction the dogma held by the developers of western surgery was not realized by surgeons of prehistoric cultures or primitive people. Old Peruvians of the Paracas civilization performed extensive and occasionally multiple trephinations in large numbers from 2000 B. C. on, probably as a ritual act rather than for injuries.

8 They did not spare the sutures. Regeneration of the bone edges in several skulls unearthed indicate that some of these patients survived for a considerable time after operation.

9 One of these skulls reveals a large occipital craniotomy defect overlaying the formidable triangle of the superior sagittal and both tranverse sinuses joining in the torcular HerophiG Fienus : De praecipuis artis chirurgicae controversiis. Quoted by A. Louis. 7 Vesalius, A: De Humani corporis fabrica. Basel, I. Oporinus 1543, lib III, cap. p. 349. 8 Treues, J. O. : Cranial trepanationsin ancient Peru. World Neurology (Minneapolis) 3: 538—545, 1962. a Quevedo, S. A.: La trepanación incana en la region delCuzco. Cuzco 1944, p. 24—25