From Sumeria to the United States, in Ancient Greece and the Hindu lands of India, surgery has sometimes made the difference between a patient living or dying. Though surgery in the West is today a discipline of strictures and safety precautions, there was a time not too long ago that patients died as much from being on the operating table as they did from their wounds. And as surgery improved, so too did the implements used by the skilled hands holding them.
Improvisation
The development of tools coincides with the development of medicine. Crude implements that archaeologists believe were used in trepanning – the practice of cutting holes in the head to relieve pressure from trauma or headaches – have been found in Neolithic sites around the world. Richard Restak, in “Mysteries of the Mind,” asserts that 40 skulls with the round holes of trephines were found at a Neolithic burial site in France.
These first surgical tools weren’t specialized in the slightest. As John Kirkup remarks in “The Evolution of Surgical Instruments,” the horse hooves, bone needles, and sharpened rocks used in prehistory were most likely borrowed from domestic items. Kirkup references G.W. Harley, who published a study on the medical practices of the Mano tribe of Liberia in 1941, as an example of isolated peoples who adapt common household items to their surgical tools.
Needles, knives, thread, and most any other type of household item have, at one point, been used in surgery. In fact, Kirkup asserts that most contemporary surgical instruments – bone saws, surgical needles, scalpels, and similar items – are adaptations of their nonsurgical predecessors.
The Ancient World
Some of the first specialized surgical tools came about in Ancient Greece, forged from iron, bronze, silver, and even gold – each designed solely for surgical use. According to Lawrence Bliquez’s “The Tools of Ascelpius,” the common Greek surgeon’s tools had handles of copper alloy and cutting edge or useful tip of steel, giving the surgeon the ability to swap out new blades as needed. Galen of Pergamum, one of the most influential Greek surgeons of the second century A.D., is said to have required that his surgical tools be made from iron ore found only in the Celtic kingdom of Noricum.
In terms of exact tools, a Grecian healer could expect to own a scalpel or two of varying lengths, forceps used to crush the uvula before extracting it, hooks for use in dissection or wound repair, bone drills and forceps, catheters, bladder sounds, and maybe a speculum as well, in addition to other instruments of the time. All of this would be carried in a portable medical chest – the ancient equivalent of the doctor’s black bag.
The Sushruta Samhita, one of the most important surgical textbooks ever written, describes 20 sharp and 101 blunt surgical tools that were used in around the Indian subcontinent from roughly the sixth century B.C. onward. Much of surgery on the subcontinent focused on cosmetic applications, and surgeons in this region used forceps, knives, and lancets made of steel to fix amputated noses and perform cataract surgery among other things.
The Ancient Egyptians developed specialized tools of bronze for use in their mummification rituals, specifically paying attention to the tools they used in pulling the brain out before drying out the body.
The Medieval Era
After the fall of the Roman Empire, and the loss of knowledge about antiseptics, surgical tools actually devolved. Amputations, trepanning, and other noninvasive procedures were the only ones performed with any regularity in Europe. However, surgeons such as Abu al-Qasim al-Zahrawi, known in the West as Albucasis, practiced extensively in the Arab nations and kept the evolution of surgical tools ongoing.
Albucasis’ surgical text, Al-Tasrif liman ‘Ajiza ‘an Al Ta’leef or The Method of Medicine, written circa 1000 A.D., was the first known text to include drawings of surgical instruments. Kirkup (25) shows a picture of several drawings taken from Albucasis’ text, which includes three-pronged iron cauteries for pulmonary and splenic disorders, circular iron cauteries for early spinal carries or sciatica, and saws used to extract diseased bone from ulcers and fistulas.
Albucasis not only details more than 200 instruments, but also describes the materials they should be made out of. He goes so far as to contradict the ancient assertion that gold is the best metal used for cauterizing and offers up iron as “quicker and more correct.”
Albucasis and Galen were the most important medical sources in this period. Many medieval surgeons copied Galen’s designs for their own tools, and Albucasis’ text was referenced time and again as the period went on. Guy de Chauliac, the attending physician of Pope Clement VI, who quoted from Albucasis’s work in his own 1363 surgical treatise, “Inventarium sive chirurgia magna,” was one of many surgeons to do so. Additionally, de Chauliac described a basic tourniquet developed from two bandages tied together to staunch bleeding during amputations.
The Renaissance and Enlightenment
Surgical tools became much more ornate during the Renaissance, with filigreed handles and designs that didn’t offer any additional functionality to the scalpels, forceps, cauteries, dilators and bone saws that allowed surgeons to make their living. The rediscovery of ligature, the practice of suturing, by Ambroise Par in the 1500s and his invention of the crow’s beak hemostat improved the practice of ceasing blood flow during amputation.
During the Renaissance was also when specialization received more attention. Rather than the improvisation of previous periods, the surgeon had access to tools made solely for his or her craft. By the end of the 17th century, decoration on surgical instruments had all but disappeared in favor of pure functionality, and the rough tools of earlier eras became even closer to their contemporary equivalents.
Catlins, long double-bladed knives used in amputation, were first used in the late Renaissance and stayed popular until the middle of the 19th century. The surgeon used his catlin as a precursor to the bone saw, pulling aside any obstructions in the limb before amputating.
The 19th and 20th Century
Prior to the 1800s, surgery was merely a surface procedure. Many countries had cultural taboos against cutting into the body – Ancient Greece and Imperial China, for example – but the development of antiseptic and anesthesia allowed those nations that didn’t share those taboos to invent new tools for doing internal surgery.
The latter half of the 19th century also saw the rise of thermal sterilization. This resulted in dozens of rusted steel and organic tools being replaced by all-metal implements protected by copper and nickel plating (Kirkup), and a veritable explosion of dissertations on instrument quality and materials. The first catalogs of surgical instruments also arose in this period, from cutlers who focused their energies solely on delivering equipment to surgeons.
Stainless steel began replacing nickel implements in the 1920s and ’30s, and was eventually accepted as the standard by the International Standards Organization. As of 1996, when Kirkup was writing, the ISO accepted 16 grades of stainless steel for surgical tools; they also have specific guidelines about which grades are to be used for which implements.
The 21st Century and Beyond
As computers become more and more a part of society’s lifeblood, the medical profession looks into incorporating them into all areas of practice. Surgery is not exempt from this, and Kirkup references RH Taylor’s 1996 theory on computer-integrated surgery as something that might very well happen.
Today, in addition to stainless steel, surgical tools are also made from chrome, vanadium and titanium. Surgeons have access to precision instruments that allow them to operate on ever-smaller sections of the human body, including inserting a graft into the body and maneuvering it into place with only two small incisions as the way in. Whatever the surgical task, new tools will develop to meet the need.
Sources
Bliquez, Lawrence J. “The Tools Of Asclepius.” Presentation to The Northwest Society for Classical Studies. 2002.
Kirkup, John. The Evolution of Surgical Instruments: An Illustrated History from Ancient Times to the Twentieth Century. Norman Publishing: 2006.
Restak, Richard. “Fixing the Brain.” Mysteries of the Mind. Washington, D.C.: National Geographic Society: 2000.
