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The Surgical Instrument Maker: An Historical Perspective

The dawn of instrument making It was once said of Astley Cooper that he 'could operate as easily with an oyster knife as with the best bit of cutlery in Laundy's shop'1. This indirect slur on the prowess of Joseph Laundy, instrument maker to St Thomas's and Guy's Hospitals, belies the importance of the Instrument Maker in the evolution of surgical technique. As in so many other fields of human endeavour, suitable tools are a prerequisite to progress. The earliest surgical instrument makers were probably the users themselves who fashioned flint edge tools and adapted reeds and other hollow stems for crudely medical purposes. Abscesses must have been common at a time when man lived close to nature and penetrating injuries, including animal and human bites, were a daily hazard. Personal observation of the natural history of an abscess with the characteristic relief of pain following its rupture must eventually have planted the idea that surgical intervention by opening the abscess cavity with a suitable sharp object could accelerate the process and lead to even earlier resolution of the uncomfortable symptom. Attempts to relieve acute retention by bougienage or catheterization, or even by direct puncture of the bladder would also have engendered the need for suitable tools for the job. Craniotomy and the splinting of fractures are also known to be procedures practised by primitive societies and suitable instruments were devised for the purpose. In time those most skilled at fashioning tools of all kinds would have emerged as the forerunners ofthe surgical instrument maker, although it is likely that even if the implements themselves may have had particular functions, the makers would not have devoted themselves exclusively to their manufacture. Flint tools from this period exist and some ofthem may have been intended to have a specifically medical purpose, although this is not apparent now. Skulls dating from the Palaeolithic period showing evidence, in some cases, of multiple craniotomies are known, including one in the Wellcome collection. Crude surgical instruments, of a type that Neolithic and Bronze Age man may have used, have been identified in primitive cultures in New Guinea and elsewhere, in relatively recent times, examples of which may be seen in collections such as the Pitt-Rivers Museum and the Royal College of Surgeons. Little is known about the makers ofthese implements or whether they could in any way be regarded as specialists in their own right. More sophisticated tools appeared in the late Bronze and Iron ages and the early Egyptian civilization reached a high degree of skill in the production of beautiful and very functional instruments. There was considerable overlap, however, between instruments used for surgery and those used for domestic, cosmetic and funerary purposes and it is unlikely that the makers devoted themselves exclusively to any one function. It is more probable that the material in which they worked was the constant, so that the worker in bronze would have made anything from knives used in surgery to ornaments for personal adornment and likewise the worker in iron, obsidian, ivory and so on. Surgery in Roman times was dominated by military requirements and it is known that armies had their own cutlers, armourers and blacksmiths who were trained to produce surgical instruments as needed2. During this period, however, instruments with an exclusively surgical function, such as screw-acting rectal and vaginal specula, were produced and the complexity ofmanufacture of some of these suggests that the makers may have had to devote themselves largely or wholly to this activity. These men may, therefore, have been the first specialist surgical instrument makers.