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

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

li. The same observation was made in primitive people who were trephined in the modern age by their healers, particularly in Melanesia.

10 One probable reason why these primitive surgeons got away with operating through the sutures was that they used simple grinding instruments such as the tumi of the Peruvians and the shell fragments of the Polynesians. These slowly ground and pulverized the bone and were less likely to cut the dura. Meanwhile in the western world the abhorrence of trephining over the sutures continued. Authors repeated the same warning, sometimes word for word, and quoted Hippocrates as late as the seventeenth century. Several surgeons of the 14th and 15th century, however, do not make mention of the sutures. They were not bold surgeons; they avoided venturing into the interior of the skull and used small drills cautiously. Although Guy de Chauliac (1363) used a trephine, he gave little technical advice and does not mention its application over the sutures.

11 Neither was it mentioned in the numerous reissues of his work, the "guidons" published during the following three centuries. There was one notable exception. Berengario da Carpi in his book on fractures of the skull, first published in 1518,

12 flatly stated that opening of the skull through the sutures is not particularly dangerous. He even derided surgeons who were afraid to do so. Nevertheless, he advised caution and suggested that the sutures should be avoided if possible because of the adherence of the dura to the pericranium. Berengario da Carpi assured his readers that he applied his trephine over cranial sutures on several occasions with success. There was a good reason for his statement. He wrote that "when the head is wounded in the neighbourhood of the sutures, the dura mater becomes separated from the skull, either immediately or some time after, the trepan cannot hurt the veins or arteries, seeing they are already separated, and removed to some distance from the skull". Garengeot

13 in 1738 repeated that the "dura mater is almost always detached from the bone by the violence of the blow", and therefore wounding the sinus is not likely. This is interesting but not necessarily correct in view of our present day experience. An epidural hematoma or somewhat later an epidural empyema certainly can form under the broken skull depressing the dura and, with it the sinus, to a considerable degree. However, it is much more likely that the fractured bone fragments pierce the sinus. Drilling or trephining in that area or even a simple removal of the fragments may result in severe hemorrhage by undoing the tamponade. Although Berengario's advice was not headed for a long time, it was debated because of the author's eminence. His text on skull fractures was reissued many times; one copy I was able to examine was published 200 years later, still in the original Latin and showing little change in text although its title page proudly announces that it is an "editio nova, ab innumeris mendis vindicata". The very words used by Berengario became a subject of debate. Louis

14 in 1774 pointed out that in one passage Berengario used the expression "circa commissuras" and this to him suggested that he meant "near the sutures" rather than "on the sutures". The 10 Guiard, E. : La trépanation crânienne chez les néolithique et chez les primitifs modernes. Paris, Masson 1930. 11 Guy de Chauliac: On wounds and fractures. Translated by W. A. Brennan, Chicago, 1923. 12 Berengarius da Carpi: Tractatus de fractura calve sive cranei. Bologna, 1518. 13 Garengeot, R. J. C. : Traité des operations de chirurgie, pour servir de base à la théorie des lésions de la tête, par contre coup. Paris, P. G. Cavelier 1738, p. 170. 14 Louis, A.: Trépanation sur les sutures de crâne. Mém. Acad. royale de Chirurgie 5: 95—124, 1774.