Annals of the Royal College of Surgeons of England (1985) vol.

67

The history and evolution of surgical

instruments. IV Probes and their allies

JOHN KIRKUP FRCS

Consultant Orthopaedic Surgeon, Bath Clinical Area
... put a probe into the fistula to see where it goes and
how deeply it reaches, also whether it is moist or rather
dry. . .' Celsus (1).
In the wake of the instinctive application of the forefinger,
the first mechanical probes employed by man were probably
twigs and sticks broken at random to explore deep wounds
for arrowheads and other foreign bodies buried after injury.
If the above quotation from Celsus emphasises the diagnostic
capacity of surgical probes, it is but a short step from the
diagnostic searching stick to the therapeutic extracting stick;
indeed the same instrument often fulfills both functions.
As suggested in Part II of this series (2) and more fully
analysed in Table IV, the versatile finger is a pre-cursor of
the surgical probe and related instruments. Despite short-
comings of length and breadth in exploring long narrow
fistulae, the finger's highly tactile skin and sensitive nail often
surpasses the probe by its ability to identify the precise
nature of foreign material in wounds. The nail has also been
employed for curetting granulation tissue, as described by
Paulus Aegineta in the 6th century AD'. . . the callus is to be
cut off with a properly-shaped scalpel or pared with the nails
or the point of a scalpel' (3). These actions of the nail
resemble those of the rugine and curette which instruments
are therefore allied to the probe. Further, the finger's cone-
shaped tip enables it to worm through apertures, eg the
uterine cervix, and to widen fistulous tracks, thus acting as
dilator or bougie. Finally, the finger's mobility enables it to
separate loose tissue planes, break down abscess cavities,
enucleate tumours and guide cutting instruments to the seat
of disease: these actions suggest the dissector, enucleator and
director.
If the diagnostic actions of probing, sounding and gaug-
ing, and the therapeutic actions of dilating, curetting,
rasping, dissecting, enucleating and directing are distinct,
difficulties often arise in defining the particular function of
related instrumentation. Additionally, names now attached
to many instruments are not readily equated with early
descriptions, often descending from words whose original
meaning has altered, eg bougie, a wax candle, or words
indicative of overlapping actions, eg raspatory, rasp, rugine,
elevator and curette.
Probes
GRAECO-ROMAN, ARABIC AND MEDIEVAL PERIOD (Fig. 25)
Until the Renaissance, we depend largely on the unillus-
trated accounts of authors such as Hippocrates, Celsus,
Galen and Paulus, and especially bronze artefacts from the
Roman period (4). The first illustrated work, 'On Surgery
and Instruments' by Albucasis in 1000 AD, is unfortunately
only known from later manuscript copies whose illustrations
often differ (5) (Fig. 2) and are certainly equivocal with
respect to the probe (6). The early written accounts are also
difficult to interpret; thus Milne observes Greek authors
using four separate words for probe and yet further specific
words for the common combinations of probe with spatula,
probe with spoon and so on (7).
It has been assumed that probes of organic material
preceded those of metal; certainly animal and vegetable
products were used contemporaneously with bronze for
managing fistula-in-ano. Paulus mentions swine's bristle (8),
Galen the use of wooden sounds (9) and Hippocrates a plant
stem:'... take a stalk of fresh garlic . . . push down the stalk

TABLE IV Derivatives of the probing finger

FINGER INSTRUMENT
Qualz'ty - Actioon - Diagnostic - Therapeutic
Linear Probing Probe Medicated probe
tactility Searching Sound Eyed probe
Estimating Gauge
Directional Guiding Director
control Staff
Gorget
Conical Stretching Dilator Dilator
extremity Distending Bougie
Cleavage Dissecting Dissector
flexibility Enucleating Enucleator
Nail sensitivity Scraping:
and rigidity (a) Pulling Scoop Scoop, Spoon
Curette Curette
(b) Pushing Rugine Rugine
Raspatory Raspatory
Elevator
 The history and evolution of surgical instruments ,57

FIG. 25 Roman bronze olivary-headed probes. From above down: simple

specillum; spatula-probe or spathomele; spoon-probe; scoop-probe
or ear specillum; another ear specillum. (From: Milne JS. Surgical
instruments in Greek and Roman times, 1907.)

as far as it will go, and thereby measure the depth of the

fistula' (10). The majority of metal probes of this period are
bronze instruments incorporating a spatula, spoon, scoop or
hook at the other extremity; other metals include silver, lead,
copper, tin and gold.
Specillum This is the basic probe of classical writers, often
qualified by terms such as malleable, eyed, medicated or
olivary-headed (7). The malleable probe was employed to
explore fistulae, the eyed extremity to carry ligatures to treat
fistula-in-ano and extract nasal polypi, whilst the expanded
end known as an olive or nucleus was used to convey
ointments and other semi-solid medicaments to the eyes, ears
and wounds. The olive, often of a constant size and shape,
has been considered a standard of measurement; thus Galen
writing of the cervix uteri states: 'when the woman is not
pregnant it admits the nucleus of a probe or something FIG. 26 Probing an anal fistula. The surgeon, possibly John of
slightly larger' (11). Arderne, passes a flexible probe and feels for the internal opening
Spathomele or spatula-probe Milne states this is the commonest per rectum. (From: Mackinney L. Medical illustrations in medieval
bronze instrument found in museums and was probably manuscripts, 1965; Arderne J. Fistula-in-ano, 14th century
more commonly employed in measuring and mixing cosme- manuscript (with permission).
tics, pharmaceutical preparations and artist's paints than for
surgery (12). Nevertheless, he adds, the blunt, flattened, In the 16th century, gunshot injuries stimulated the
spatula extremity was valuable as a dissector, tongue de- appearance of long probes to explore missile tracks and, in
pressor and ointment applicator and the olivary-headed the 19th century, Nelaton introduced unglazed porcelain-
probe as a simple specillum. tipped probes to identify the lead in bullets of the period.
Ear specillum This is the most frequently named specillum in Later, electrodes attached to probes in contact with metallic
classical accounts (13) and consists of a shallow scoop fragments provided electrical evidence by galvanometer
opposed to a narrow cylindrical probe. The scoop was used deflection, by sounding a bell (15) or by telephonic pick-up
to extract wax and foreign bodies from the ear and calculi using ear-phones (16).
from the urethra, and to curette, retract and dissect. The
probe end searched wounds and fistula and when wrapped
in wool saturated with liquid introduced medical prepara-
tions into the ear. Remarkably the ear scoop with probe has
persisted through two millenia to the present day (Fig. 30).
MODERN PERIOD (Figs 26, 27 and 28)
The preservation of original manuscripts from the 14th
century such as John of Arderne's account of fistula-in-ano,
the introduction of wood block illustration and printing in
the 15th century and the conservation of some instruments
from the 16th century provide a more complete record. In
this period silver became the standard metal for probes,
providing convenient malleability and greater resistance to
corrosion than iron and steel; typically it was blunt at one
extremity and eyed at the other. In the 17th century
Woodall reminds us of its continued importance as an
applicator: '. . . armed with drie lint and dipped into some
lotion, oyle or liquor, therewith to mundifie, corrode or heale FIG. 27 Modern probes. From above down: bullet, silver; small-eyed,
the griefe according to the due occasion thereof, and will of silver; double lachrymal, silver, Couper's; gallstone with scoop and
the Artist; sometimes to inquire the depth of a wound, ulcer, director, pewter, Moynihan's; radium-needle, graduated, steel;
or fistula. . . .' (14). dental, plated; uterine, aluminium, Playfair's.
58 John Kirkup
.asnokLa A . --
cervix. After falling into disuse in the middle ages, it was re-
Fig. 94. introduced in the 19th century by SirJ Y Simpson. . .' (21).
Gun-Shot Probe, plated, Fig. 94 .... .... ... ... O -s a However, the purpose of Simpson's instrument was diagnos-
Ditto stout, silver . . ... 0... 4 tic, to estimate the patency, direction and length of the
Ditto flexible metal ... ... .., ... O LI 0
Ditto steer ...
.... ... ... ... O 0 uterine cavity, in the absence of pregnancy (22); probe or
Ditto whalebone ... ... .. ... ... O 02
6 gauge would seem more accurate terms than sound,
although no doubt the expert gynaecologist can 'sound' the
VAUNF- ANN" & us
rw -MiNIMEM-0 wall of the fundus.
Specialised gauges include those for estimating skull thick-
Gun-Shot Probe, r4inch, electro-plated, with eye and porcelain bulb, ness during trepanning (23) and for the measurement of
Fig. 95 . 0 4 6 screws and nail lengths in orthopaedic surgery.
Ditto ditto with metal and porcelain bulbs 0 4 6
Staffs and directors (Fig. 30)
GoI The lithotomy staff evolved from the lithotomy sound and is
Fg 96.
Gun-Shot Probe, spiral wire, with porcelain end, Fig. 96 essentially a sound grooved or channelled distally to function
D)itto ditto ditto (Wilson's). as a director. The staff is therefore an operative sound, either
curved, eg Syme, or straight, eg Wheelhouse, which localises
bladder calculi with its tip and directs knives and gorgets to
rig. 97. the bladder base when cutting for stone or stricture.
Gun-Shot Probc (Nclaton's), with porcelain end, S-inch, Fig. 97 The first grooved metal directors probably appeared in
the 15th century for the opening of fistulous tracks. Later
* e _. .sa~~s
developments include the hernia director and the gorget
whose wide groove was utilised to direct fingers and forceps
Fig. 989 towards the stone during perineal lithotomy (Fig. 32).
G un-Shot Probe:, vertebrated, silver (Sayre's). (This instrument can
also be used as a catheter.) Fig. .98 1 15
0 Bougies and dilators (Fig. 29)
Ditto ditto stoutly plated . 10 0
Bougie is derived from Bejaia, an Algerian port concerned
FIG. 28 Gunshot probes (Arnold and Sons. Catalogue of surgical with the wax trade, and indeed the first surgical bougies were
instruments, 1895.) wax candles or tapers for investigating and treating urethral
strictures. Bougies of gum elastic resin were first noted in
Paris in 1779 (24), and soon displaced the less predictable
Sounds and gauges (Fig. 29) wax article. Later gum elastic bougies were manufactured
The lithotomy sound is a specialised metal probe to prove for oesophageal and rectal strictures. Metallic bougies ad-
the presence of a calculus by the sound or ring imparted to vertised in instrument catalogues are strictly dilators, for by
the metal when a stone is probed or struck. Milne considers original definition bougies should be soft and pliable.
that no classical author described this particular diagnostic John Woodall (25) and John Hunter (26) were among
action (17) whilst Spink and Lewis note that although those who applied caustic to wax bougies, the so-called
Albucasis recommended a sound when extracting calculi in medicated bougie for treating urethral stricture. For this
the female, the sound was introduced into the bladder via the same condition filiform, whip, beaded, tapered and torpedo-
operative incision and not the urethra (18). In the 14th ended bougies are recorded.
century, Chauliac recorded the employment of a metal Metallic dilators are either mechanically complex, based
sound or catheter to push calculi aside when causing urinary on pivoting forceps and multi-bladed screw expansion, or
retention but not for lithotomy (19). The earliest application simple, derived from the probe. Simple dilators mounted on
of the sound to ring for stone is uncertain but Marianus wooden handles are mentioned by Hippocrates, '. . . dilate,
before 1524 and Franco before 1561 (20) both described and if necessary straighten the cervix with a dilator of tin or
sounding with curved metal staffs when undertaking perineal lead beginning with a fine one. . .' (27). Graduated dilators
lithotomy. such as Hegar's in metal, vulcanite or glass remain important
Milne states, 'The uterine sound is frequently mentioned items in the gynaecological armamentarium. Similar
by Hippocrates for correcting malpositions of the uterus and graduated sets are available for dilating lachrymal, bile and
dilating and applying medicaments to the interior of the other ducts.

FIG. 29 Dilators, sounds and bougies. From above down: lachrymal
dilators, silver, in case; urethral dilator, Ryall's; bladder sound,
Lister's; urethral bougie, gum elastic; uterine sound, Simpson's
type; uterine dilator, hollow, Ramsay's; uterine dilator, double,
Hegar's.
FIG. 30 Staffs, directors, dissectors and enucleators. above down: bladder
staff, Wheelhouse's; bladder staff, Syme's; ear probe-director and
scoop; anal probe-director, Brodie's; hernia director, Key's; thyroid
dissector, Kocher's; gland enucleator, Macdonald's; probe-pointed
bistoury with oar-like dissecting handle.

Dissectors and enucleators (Fig. 30)
The flattened leaf-like handle of Roman scalpels and the
expanded oar-like equivalent of modern scalpels are tradi-
tionally claimed to facilitate blunt dissection; specialised
blunt dissectors, such as Durham's and Watson Cheyne's,
are late 19th century developments. Specific dissectors in-
clude those for thyroidectomy and for tonsillectomy.
Gland enucleators include Macdonald's general purpose
instrument and, among prostatic forms, the metal finger stall
of Dalby (28).
Spoons, scoops and curettes (Fig. 31)
It is probable that the narrow spoon of Greek and Roman
pharmacy (Fig. 25) was the antecedent of the surgical scoop
as exemplified by the ear specillum, previously noted for its
multiplicity of function and problems in terminology.
Indeed, even recent instrument catalogues confuse spoon,
scoop, scraper and curette and definitions are necessary and
here suggested.
Surgical spoons should resemble the domestic article and
be broad and shallow whereas scoops are narrow and deep
and hence advantageous in ducts and fistulae. Curettes or
scrapers, sometimes termed sharp spoons or scoops, may be
fenestrated; they are characterised by a cutting margin,
intermediate in quality between a blunt spoon and a knife
edge. The spoon and scoop are collecting instruments for
removing loose material such as calculi from the urinary and
biliary tracts, loose bodies from joints, wax from the ear and
so on.
Curettes, from th French curer, to cleanse, involve the
freeing and excavation of tissue including cancellous bone in
the furtherance of treatment or biopsy. Their employment
demands volar flexion and a basic pulling action towards the
surgeon, as in scraping with a flexed finger nail; this contrasts
with the extended wrist and pushing action required for
many raspatories and rugines.
Raspatories, rugines and elevators (Fig. 31)
For this group of bone instruments terminology is even
more perplexing. Early references infer that raspatories
are scrapers; thus Hippocrates on skull fractures writes:
. .. scrape the bone with a raspatory ... for the sake of the
fractures which are not seen . . . For the scraping discovers
the mischief. . .', (29) but its form is uncertain for no ancient
raspatory has been preserved (30). Classical authors describe
elevators for tooth extraction and for raising depressed skull
fractures but these are levers, whereas the hypospathister,
mentioned by Paulus, for raising the pericranium is a true
.~~~~~~~~~~~~~~~~~~~~~--
FG tiee o oersaoy
sp c
abvdon deta elvtr bn ade
peistu elvtr Laestp;sulrsaoyadprotu
elvtrbon sco,dul;ueiefnsrtdcrte obe
Gevss bon cuet,Vlmn'.T ih:bn_uie
_arabeufs
The history and evolution of surgical instruments 159
......
FIG. 32 Probe-guarded instruments. From above down: bladder gorget
with cutting edge,, ebony handle; fistula bistoury, tortoiseshell
handle; aneurysm-needle, tortoiseshell handle, Cooper's; dressing
scissors; tonsillar scissors, Erichsen's. To right: herniotomy bistoury,
ebony handle, Cooper's; hernitomy or fistula knife, unusual shape,
ivory handle.
elevator related to the modern raspatory (31). Albucasis
illustrates scrapers or raspatories with serrated edges (32)
whereas today serrations are unusual. By contrast the
surgical rasp is always file-like being employed to smooth
asperities or reduce irregularities. Filing resembles sawing
and thus the rasp does not qualify as an ally of the probe.
In 20th century instrument catalogues the terms raspatory
rugine and periosteal elevator are often interchanged
haphazardly, though rugine tends to be reserved for instru-
ments of French design. Indeed, the French translation of
raspatory is rugine and, to clarify English usage, either one
or the other should be discarded. Albeit that most rugines
and elevators function by pushing away from the surgeon, a
pulling action is also possible, especially when the rasping
edge is sharply curved and when a rib raspatory is employed.
Probe-guarded instruments (Fig. 32)
Probe-pointed or guarded knives are not clearly described
before Albucasis who illustrates a hook-like knife with blunt
end used to extend abdominal wounds when impacted with
prolapsed gut (33). From the early Renaissance, blunt and
probe-ended knives, bistouries and syringotomes evolved for
incising fistula-in-ano and for relieving strangulated her-
niae; in the 19th century, similar knives were designed for
tenotomy and lithotomy.
Deliberately blunt needles include those for liver suture
and the handled-needle for aneurism ligature usually as-
cribed to Astley Cooper.
Probe-pointed scissors for dressing purposes and for open-
ing vessels and bowel at post-mortem are blunt on one shank
whereas Erichsen's tonsillectomy scissors are blunt on both
shanks.
Other probe-guarded instruments include the ancient
lenticular chisel of skull surgery, Adams' saw for femoral
osteotomy and Lebsche's chisel for sternal splitting.
I wish to acknowledge the help of Mrs Gina Machin and Mrs Sally
Jenner of the Photographic Unit, Royal United Hospital, Bath for
their careful reproduction of the illustration and instruments
figured.
References
1 Celsus translated. In: Milne JS. Surgical instruments in Greek
and Roman times. Oxford: Clarendon Press, 1907:53.
2 Kirkup JR. The history and evolution of surgical instruments.
Ann R Coil Surg Engl 1982;64:125.
60 John Kirkup
3 Paulus Aegineta. The seven books, translated by Adams F.
London: Sydenham Society, 1846: vol 2; 396.
4 Kirkup JR. The history and evolution of surgical instruments.
Ann R Coll Surg Engl 1981;63:281.
5 Spink MS, Lewis GL. Albucasis on surgery and instruments.
London: Wellcome Institute, 1973:xii.
6 Spink MS, Lewis GL. Albucasis on surgery and instruments.
London: Wellcome Institute, 1973: 346, note ii.
7 Milne JS. Surgical instruments in Greek and Roman times.
Oxford: Clarendon Press, 1907:51-69.
8 Paulus Aegineta. The seven books, translated by Adams F.
London: Sydenham Society, 1846; vol 2, 399.
9 Milne JS. Surgical instruments in Greek and Roman times.
Oxford: Clarendon Press, 1907:16.
10 Hippocrates. The genuine works translated by Adams F.
London: Sydenham Society, 1849: vol 2; 816.
11 Galen Translated. In: Milne JS. Surgical instruments in Greek
and Roman times. Oxford: Clarendon Press, 1907:54.
12 Milne JS. Surgical instruments in Greek and Roman times.
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13 Milne JS. Surgical instruments in Greek and Roman times.
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14 WoodallJ. The surgions mate. London: Lisle, 1617:12.
15 Longmore T. Gunshot injuries, 2nd ed. London: Longmans,
Green, 1895:467.
16 Mayer and Phelps. Catalogue of surgical instruments and
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17 Milne JS. Surgical instruments in Greek and Roman times.
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18 Spink MS, Lewis GL. Albucasis on surgery and instruments.
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19 Chauliac G. La grande chirurgie, Editor Joubert L. Lyon:
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20 Cooper S. A dictionary of practical surgery, 4th edition.
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21 Milne JS. Surgical instruments in Greek and Roman times.
Oxford: Clarendon Press, 1907:79-80.
22 Hart DB, Barbour AHF. Manual of gynaecology, 4th ed.
Edinburgh and London: Johnston, 1890:121.
23 Down Bros. Catalogue of surgical instruments and appliances.
London: Down, 1936:200.
24 Cooper S. A dictionary of practical surgery, 4th ed. London:
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25 Woodall J. The surgions mate. London: Lisle, 1617:23.
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27 Hippocrates translated. In: Milne JS. Surgical instruments in
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28 Down Bros. Catalogue of surgical instruments and appliances.
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29 Hippocrates. The genuine works, translated by Adams F.
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32 Spink MS, Lewis GL. Albucasis on surgery and instruments.
London: Wellcome Insitute, 1973: 569 and 575.
33 Spink MS, Lewis GL. Albucasis on surgery and instruments.
London: Wellcome Institute, 1973:539.

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