The Royal College of Surgeons ofEngland Ann R Coll Surg Engl 2002; 84: 149-155

Original article The history and evolution of surgical instruments: XI Retractors, and related inset pivoting instruments

John R Kirkup

Honorary Curator Historical Instruments Collection, Royal College ofSurgeons ofEngland, London, UK

Dilaters, by whose helpe the wound may be held open, that so the hidden bodyes may be seen:for when you presse together the two ends ofthis Instrument, the other two open and dilate themselves. Pare 16341

As outlined in Part X of this series,2 articulating with incentric or inset pivots, function in reverse I fashion to forceps with centric pivots. Typically, the limbs of incentric forceps engage but do not cross at the pivot, dictating that closure of the handles separates the jaws, as . . :..k- *: e. ..;? in the case of retractors or dilators (Fig. 1). Commonly their .. .. .'Z" jaws are held in contact by a closing spring mechanism inserted between the handles, and retraction or dilatation is achieved against this resistance, being maintained by a rack or ratchet (Fig. 1B-D). Incentric instruments include certain hinged specula, wound, tracheal and uterine dilators, the French 'valet a patin' artery forceps, Assalini's artery holder, mouth gags, and a variety of self-retaining wound retractors (Figs 1-8). Figure 1 (A) Assalini artery forceps with closing spring; note the accessory spring to convey ligatures; ivory and steel, by Savigny, Early history c. 1860. (B) Bailey's tracheal with closing spring, rack and Excavated bronze specula of Graeco-Roman origin, indude cam control; stainless, by Mayer & Phelps, c. 1950. (C) Gelpi's self retainer, with rack and cam control: stainless, by Thackray, c. an incentric bivalvular form (Fig. 2B) subjected to recent re- 1960. (D) Cone's scalp , jaws pivoting through 1500, rack appraisal byJackson. He conduded this rectal instrument was controls, stainless, by Down, c. 1960. also employed as a wound dilator for the extraction of arrow heads and other embedded foreign bodies3 if so, narrow apertures might require wound enlargement as emphasised It is remarkable that Ardeme (14th century), famous by Paulus (7th century).4 During the medieval and early for an illustrated and detailed operative account of Renaissance periods, few illustrations of incentric controlled fistula-in-ano, did not employ a speculum ani5 and forceps have been identified. instead used a cochlear or wooden spoon. In 1561, Franco

Correspondence to: Mr John R Kirkup, Weston Hill, 1 Weston Park East, Bath BAl 2XA, UK.

Ann R Coll Surg Engl 2002; 84 149 KIRKUP THE HISTORY AND EVOLUTION OF SURGICAL INSTRUMENTS XI

A ' Figure 2 (A) Forceps, no pivot, probably secured by organic bindings, jaws with teeth; bronze, Greece, c. 1800 BC.25 (B) Rectal speculum and probable wound dilator (in two planes); bronze, Roman, 79 AD.3 (C) Franco's lithotomy dilator with screw control; steel, c. 1561.6 (D) Franco's lithotomy speculum, note decorative handles; steel, c. 1561.6 (E) Heister's 'valet a patin' artery forceps in use with ligature; steel, c. 1718. illustrated an inset hinging speculum and a dilator (Fig. For if there happen into the orifice of thefundament any 2C,D) both designated for lithotomy;6 other functions were excoriation or exulceration, then can nothing better be probable. Pare recommended simple incentric dilators in brought to the grieved place than by this speculum: 1564 (Fig. 3B)7 for arrow and gunshot missile extraction, and neither can the griefe be seen without it:...For I hold none for examining the nose and anal canal. In 1617, Woodall so witlesse which cannot make use thereof, when they illustrated a classical speculum ani and commented: once see but the instrument; and yet let not the young

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A B yqt.-r Figure 3 (A) Franco's lithotomy outward cutting shears with screw control; steel, c. 1561.10 (B) Pare's dilators for extracting arrow heads and bullets; steel. c. 1564.7 (C) Come's lithotome cache, outward cutting blade shown separately: steel and ebony, c. 1?48.26 (D) 'Valet a patin' artery forceps: note closure incomplete due to failing spring; steel c. 1750 (photograph courtesy of Prof. Amelia Ricon- Ferraz, Museu Nacional de Historia da Medicina, Oporto).

150 Ann R Coll Surg Engl 2002; 84 THE HISTORY AND EVOLUTION OF SURGICAL INSTRUMENTS XI KIRKUP

A

5~~~~~~~C~~~~~E

Figure 4 (A) Heister's mouth gag: stainless, modem version by Mayer & Phelps, c. 1930. (B) Colt's mouth gag: note accessory tube for anaesthetic gases; stainless, by Down, 1907. (C) Meatome, with outward cutting blade: nickel-plated, by Allen & Hanburv, 1930. (D) Cusco-Brewer vaginal speculum: nickel-plate, by Bell & Croydon, 1954. (E) Payr's intestinal crushing , not fully closed; stainless, by Bell & Croydon, 1954.

Artist be too busie in using this instrument without good development of general anaesthesia after 1846 resulted in reason.8 an increased demand for jaw opening devices, many employing an incentric pivot.12 Tracheal dilators of this Outward cutting incentric blades are the feature of so- design also flourished in the 19th century (Fig. 1B) and are called incision shears, used to enlarge narrow wound tracks associated particularly with the name of Trousseau.'3 in the search for missiles, and noted by Brunschwig in 14979 The establishment of aseptic techniques in the 1890s and Franco in 1561 (Fig. 3A).10 Woodall maintained incision stimulated more radical and adventurous including shears were little used and a plain knife was much simpler abdominal and pelvic exploration, dependant on for wound enlargement." 'The 'lithotome cache' invented prolonged wound retraction. When manual retractors were found by Frere Come in 1748 (Fig. 3C) also had an incentric physically exhausting by assistants, especially before muscle outward cutting blade designed to act within adjustable relaxant anaesthesia, self-retaining mechanical retractors limits during stone extraction. A smaller version of this were devised, many with inset pivoting mechanisms (Fig. instrument, designed by Savigny in 1798, was employed to 1C). Later, such retractors were adapted for other body divide paraphimotic or penile meatal adhesions, and cavities, the spine and joint surgery. remained in use until the mid 20th century (Fig. 4C). Incentric instruments of the late 19th and early 20th A mouth gag of incentric pattem, introduced by Heister centuries include certain obstetric uterine in 1714, was still advertised 250 years later (Fig. 4A). The perforators, dilators, multipivot bone cutting forceps and gouges, multi- Table 1 Incentricforceps as a percentage ofall pivoting instruments pivot tonsil guillotines and intestinal crushing clamps (Fig. (late Roman to 20th century) 4E), and simple ligature knot tiers (Fig. 8B). Author Date Pivot Incentric instruments forceps Distribution (n) (%) Jackson Roman 7 14 Those instrument collections suitable for analysis show, Pare 1575 36 14 over time, increasing numbers of pivoting instruments Woodall 1617 14 14 but a decline in the proportion of incentric instruments Heister 1709 28 22 Garangeot 1723 18 17 (Table 1). This reduction is set against a background of B. Bell 1782 33 3 continued expansion in specialised centric pivoting Brambilla 1785 78 19 instruments, especially haemostats, intestinal clamps, and Bourgery 1837-40 100 17 Truax 1899 293 11 needle-holders, in the later 19th century. Of pivoting Allen & Hanbury 1938 428 11 instruments in Allen and Hanbury's catalogue of 1938, Holbom 1963 348 7 only 46 (11%o) were incentric; including 13 mouth gags, 9

Ann R Coll Surg Engl 2002; 84 151 KIRKUP THE HISTORY AND EVOLUTION OF SURGICAL INSTRUMENTS XI

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Figure 6 Graph to demonstrate variability in closing spring power of identical Assalini forceps. (Estimated by author, courtesy of the Science Museum, London.)

Figure 5 (A) Bivalve anal speculum: nickel-plated, by Mathieu, specula are more angular and uncomfortable than others. c. 1950. (B) Morey's mastoid retractor, handles overlap to form Cusco's duck bill vaginal speculum introduced about 1859 rack and catch on a cam; stainless, by Hospital Supply Co., c. proved more refined and practical than most (Fig. 4D), 1950. (C) Gardner's phimosis dilator with centric pivot, converted to incentric function by crossing blades; cross screw stimulating Thomas to write in 1872: 'no instrument of this control; nickel-plated, by Ferris, c. 1930. variety with which I am acquainted equals in beauty and utility that ofM. Cusco. It is compact, easily introduced, and shows the cervix very clearly.'"6 This speculum and modifications remain in use today. retractors, 7 obstetric and gynaecological instruments, and In 1902, Colt analysed the defects in previous mouth 7 nasal instruments.'4. However. it is probable mouth gags gags to achieve a scientifically designed instrument, after and pivoting retractors will continue to be employed as statistical analysis of measurements made on 500 long as general anaesthesia is required and open patients.17 He added anaesthetic tubes to the jaws and exploratory wounds are necessary. maintained that Coleman's dental gag of 1861 was the origin of subsequent mouth gags (Fig. 8A).'8 Structural considerations Hinging retractors show a wider range of jaw variation but, in general, terminations extend at right angles to the Inset pivots line of the instrument. These may project as single points (Fig. 1C) to engage skin and subcutaneous tissues, or be Pivot joint constructions assume four arrangements.15 divided into several teeth, or present elongated undivided Firstly, a female section engages a male section on the plates for deep tissues. Assalini's artery forceps has sharp opposite limb which rotates on a pivot pin fixed in the hook-like terminations which lock together to make the female section (Figs 1B,C & 5B), by far the commonest instrument an effective self-holding (Figs 1A & inset pivot. Secondly, both sections contribute equally 6). Variations in the length of the jaw or blade sections show except that the pivot pin is fixed in one, about which the the jaw to total instrument length ratio averages 51.1% (48 other rotates (Figs 7A & 8B). Thirdly, the pivot is divided incentric instruments) compared to 35.5% (47 centric into two separate halves which articulate close to the very instruments).2 In the case of scissors, the ratio is even smaller short proximal handle of the instrument, as for most at 28.2% (104 instruments),'9 indicating much shorter blades vaginal and rectal hinged specula (Fiqs 4D & 5A). or jaws. All specula, dilators, mouth gags and hinging Fourthly, the pivot is a centric lay-on joint, combined with retractors examined have a jaw to length ratio of more than cross-over blades which convert potential jaw conver- 37.3%, whereas dental forceps, needle holders, haemostats, to that is inset function 5C). gence separation, (Fig. tissue holders, fracture clamps and vulsellum forceps fall below this figure. Blades and jaws Handles Specula have straight blades or valves to guarantee direct visual access. Necessarily, valve margins are smooth to Tracheal dilators and most retractors have bow handles reduce excess pressure on delicate tissues although certain controlled by thumb and fingers (Fig. 1B-D); in practice,

152 Ann R Coll Surg Engl 2002; 84 THE HISTORY AND EVOLUTION OF SURGICAL INSTRUMENTS XI KIRKUP

Table 2 Incentricforceps analysed by length and jaw/length ratio Instrument Average Length Jaw Ratio number (n) (cm) (cm) (%) Dilators 4 17.1 6.7 39.1 Mouth gags Adult 7 18.0 7.4 40.9 Child 3 14.4 5.6 38.9 Retractors Large 12 20.9 12.1 57.7 Small 11 16.2 9.6 59.2 Specula and rectum 5 17.7 11.1 62.5 Nose and ear 5 14.8 5.5 37.3

From scale drawings, Down Bros. Catalogue, 1952-55. Figure 7 (A) Dahlgren's skull forceps with accessory jointed cutter, two spare cutters and take apart pivot: the jaws hold a crayon; nickel-plated, by Aesculap, c. 1940. (B) Ballenger's tonsil these average only 37.5% of their length (Table 2). By guillotine actuated through secondary pivot with divided contrast, nasal and aural specula, which are shorter opening spring; the jaws grasp a crayon: stainless, by Down, c. instruments penetrating to lesser depth, still require 1960. (C) Simpson's uterine dilator with closing spring and cross significant handles averaging 62.7% of total length. In screw control; steel, by Weiss, c. 1880. reality, controlling handles must bear close relationships to the size of surgeons' hands irrespective of other dimension. Only a few powerful instruments such as Collin's jaw opener and Dahlgren's skull cutter (Fig. 7A) have handles at 75% or more of their length.

a Springs Apart from retractors and certain specula, the vast majority A of incentric instruments have powerful springs between the handles which dose theirjaws when not in use to maintain a starting position for immediate insertion into natural body channels and wounds (Figs 1B & 7C). The artery forceps of Assalini20 of Milan (Fig. 1A) I proved a popular instrument, at least in Britain where it Figure 8 (A) Coleman's mouth gag with little finger rack was advertised throughout the 19th century and as late as control: steel, c. 1861. (B) Carroll's knot tier in a deep wound; 1914;21 remarkably, in France. it was termed 'la pince steel, c. 1880. (C) Harris' wire tightener for bone surgery; anglaise'.22 On finding several packs of Assalini forceps in , c. 1950. the Reserve Collection of the Science Museum, London, greased and unused from the manufacturer Savigny and larger abdominal retractors often require the power of two Company, the opportunity was taken to measure the hands to expand fully. Mouth gags, mouth openers and power required to open the jaws against their springs. Dahlgren's skull cutting forceps (Fig. 7A) are characterised Two packs each containing 11 forceps were examined. by plain handles to accommodate the power of palmar The 22 forceps appeared closely identical without pressure. Assalini-type forceps have asymmetrical handles evidence of rust: they were manufactured about 1880. with one component stabilised in the palm and the other Accurate measurements revealed some variations in controlled by the thumb (Figs 1A & 6). dimensions and weight. The short proximal limb which As suggested by the above jaw ratios, handles are secures the spring actuated by the thumb averaged 3.47 relatively short averaging less than half an instrument's cm in length for the first eleven and 3.45 cm for the length in contrast to their centric pivoting cousins. second; the distal limbs or jaws were identical for both Indeed, vaginal and rectal specula have very short groups averaging 3.45 cm. The first eleven averaged 13.0 handles although spuriously lengthened by adjusting g weight and the second 12.9 g. In contrast to these minor screws which also act as holders (Figs 4D & 5A); even so, differences in dimensions, calculations of spring opening

Ann R Coll Surg Engl 2002; 84 153 KIRKUP THE HISTORY AND EVOLUTION OF SURGICAL INSTRUMENTS XI powers23 revealed extremely wide variations - from 550 g maximal resistance less clearly, although generally the to 2.6 kg (average, 1.55 kg; Fig. 6). It is likely that precise maximal opening of specula is mechanically circumscribed manufacture and fitting of each small spring was difficult to safe limits for the average individual. with only minor changes producing great differences in power; alternatively, after more than a century under Temporary dilatation tension, some springs had undergone fatigue failure? From Roman times until the 19th century, some arrow and bullet tracks were suitable for dilatation with incentric Screw and slide catches forceps.3 However, for small wounds, a dilator's excursion Control of the opening or aperture of many specula is was limited rapidly by skin resistance whilst its limbs partly maintained by a cross screw between the handles, usually blocked access. Eventually, it was recognised that wound close to the pivot (Figs 4D & 5A); by contrast, the screws of enlargement was necessary, leading ultimately to the use of Simpson's uterine (Fig. 7C) and Gardner's urethral dilator retractors. During the 19th century, tracheostomy became a (Fig. 5C) are sited remote from the pivot. In these instances, routine procedure and specific dilators (Fig. 1B) were the screw opens the valves against the muscular tension of devised to define and enlarge the tracheal opening prior to the body aperture under examination. Quadrangular slide accurate placement of tracheostomy tubes. catches are characteristic of Colt's and similarly constructed mouth gags (Fig. 4B), the serrated catch engaging on Permanent dilatation serrations of the gag immediately proximal to the pivot area. This procedure was applied to pathologically contracted channels, especially stenosis of the uterine cervix during the Rack catches 19th and early 20th centuries, using Sims and Simpson's The majority of incentric wound retractors are controlled by hinging dilators (Fig. 7C), since abandoned in favour of local rack and catch mechanisms; many maintaining their open incision with a metrotome or scissors, or graduated position with a pivoting rack, hinged on one handle which stretching with cylindrical dilators passed in series. passes through an aperture in the other containing a catch (Fig. By these an instrument for 1B,C). mechanisms, Retraction unimanual insertion and removal is achieved. Mechanical retraction and dilatation are different degrees of the same surgical manoeuvre. In general, dilatation was Functional considerations and is restricted to physiological channels and to small Most incentric instruments function by distension, dilatation wounds associated with embedded arrows and bullets. and retraction of normal body channels and of traumatic or Retraction is applied to the opening and exposure of elective wounds. Tissue distension and retraction are larger wounds, especially elective incisions designed to temporary, whereas dilatation is either temporary or explore deeper tissues. Many hinging retractors have jaws permanent. 'Valet 'a patin' (Fig. 3D) and Assalini artery with vertical extensions which engage tissues according to forceps act by compressing or holding vessels prior to their depth and area; the shorter extensions have sharp ligature whereas hidden lithotomy, meatome and metrotome teeth to engage skin and subcutaneous tissues (Fig. 1C,D), blades, Ballenger's tonsil guillotine (Fig. 7B) and Dahlgren's and the longer are smooth or less invasive to engage skull nibbler (Fig. 7A) act by cutting. muscular layers, peritoneum and visceral organs. By using large area jaw extensions, retraction power is distributed widely to prevent tissue damage, unless Distension continued for long periods. Specula for the ear, nose, vagina and rectum, and mouth gags aim to enlarge channels briefly, avoiding physiological Compression and holding permanent changes. For patients without anaesthesia, the valves of specula are opened gradually against natural The Assalini forceps has sharp interlocking jaws which muscular tonus which limits full distension. With anaes- seized vessels precisely and hence acted as a self-holding thesia, and this is usual when mouth gags are employed, tenaculum. Vessels were not compressed but underwent distension may be considerable but finally meets the skin torsion and/or ligature. However, these incentric arterial and cartilaginous limits of the ear and nose, or ligamentous forceps were restricted to a single spring power which, as and cartilaginous constraints of the mandibular joints: the indicated above, varied widely from instrument to more elastic tissues of the vagina and rectum signal safe instrument.

154 Ann R Coll Surg Engl 2002; 84 THE HISTORY AND EVOLUTION OF SURGICAL INSTRUMENTS XI KIRKUP

Cutting References The lithotome cache for bladder surgery (Fig. 3C) and its 1. Pare A. The Workes. London: Cotes & Young, 1634; 422. smaller derivative for herniotomy and meatal stricture 2. Kirkup J. The history and evolution of surgical instruments, part X. Clamps, haemostats and related pivot-controlled forceps. Ann R Coll (Fig. 4C). or related hysterotomes for cervical uterine Surg Enql 1999; 81: 420-8. stenosis were inserted closed with their blades hidden 3. Jackson R. Roman bivalve dilators and Celsus 'instrument like a (cache) and acted when the outward cutting blade was Greek letter'. In: Le Latin Medicale. Publications de l'Universite de opened during withdrawal. The extent of the cut was Sainte Etienne, 1991, 101-8. regulated by an adjusting screw set before operation. 4. Adams F. (ed) The Seven Books ofPaulus Aegineta, vol. II. London: Sydenham Society, 1846; 418-22. 5. Jones PM. Medieval Medicine in Illuminated Manuscripts. London: Miscellaneous functions British Library, 1998; 88-91. 6. Nicaise E. (ed) Traite des Hernies, Pierre Franco, 1561. Paris: Alcan, 1895; In the 19th century, Velpeau illustrated an incentric knot 106-7. tier carrying ligatures through terminal eyes24 and Carroll a 7. Pare A. Dix Livres de la Chirurgie avec le Magasin des Instruments n6cessairs a Icelle. Paris: Le Royer, 1564; 9-12. very similar instrument with terminal hooks (Fig. 8B), 8. Woodall J. The Surgions Mate. London: Griffin, 1617; 9. designed to tighten ligatures at the bottom of deep wounds 9. Brunschwig H. Dis ist das Buch der Cirurgia. Strasbourg: [Gruninger], by separating the two ends transversely close to the knot. 1497; xix. This most simple of incentric forceps has no spring or catch 10. Nicaise E. (ed) Traite des Hernies, Pierre Franco, 1561. Paris: Alcan, 1895; and is controlled by finger and thumb action through bow 111. 11. Woodall J. The Surgions Mate. London: Griffin, 1617; 12. handles. The more complex Harris's wire knot tier for 12. Charriere J. Notices des Instruments de Chirurgie Humaine et Veterinaire. fractures (Fig. 8C) of the mid 20th century acts in Paris: author, 1862; 36-7. comparable fashion but requires initial approximation of 13. Trousseau A. Memoire sur un cas de tracheotomie pratiquee dans la the jaws, achieved by grasping each plain handle to force periode extreme de croup. J Connaiss Med Chir 1833; 1: 5, 41. them apart against springs and thereby open the jaws to 14. Anon. A Catalogue ofSurgical Instruments. London: Allen & Hanbury, 1938. tighten the wire. Payr's gastric crushing clamp has four 15. Down GM. The manufacture of surgical instruments. Trans Inst Br linked incentric joints (Fig. 4E) with the effect of converting Surg Technicians 1949; 1: 99-139. the initial 'dilating' movement of the handles into centric 16. Thomas G. Diseases of Women. 1872. Cited by Tiemann G. In: American clamping action of the jaws, very similar to compound Armamentarium Chirurgicum. New York: author, 1889. acting bone cutters and gouge cutters. 17. Colt GH. The gag. Lancet 1907: 2: 1011-7. 18. Coleman A. An instrument for keeping the mouth open in operations under chloroform. Medical Times & Gazette 1861; 1: 105-6. 19. Kirkup J. The history and evolution of surgical instruments, part IX. Acknowledgements Scissors and related pivot-controlled cutting instruments. Ann R Coll Surg Enql 1998; 80: 422-32. I acknowledge the advice of Robert Arnott and Ralph 20. Assalini P. Manuale di Chirurgia, vol I. Milan: Pirola, 1812; 175-6 & Jackson concerning Figure 2A and 2B, respectively. I am Plate I. indebted to Prof. Amelia Ricon-Ferraz of Oporto for 21. Anon. A Catalogue ofSurgical Instruments. London: Down Bros, 1914; arranging the photograph of a rare 'valet a patin' artery 18. 22. Bourgery JM. Traite Complet de l'Anatomie de l'Homme Comprenant la forceps (Fig. 3D) and to the Photographic Unit at The Medecine Ope'ratoire, vol. VI. Paris: Delaunay, 1837; plate 34. Royal College of Surgeons of England for all other 23. Patkin M. Surgical instruments and effort referring especially to photographic studies. ratchets and needle sharpness. Med I Aust 1970: 255-6. I thank the Science Museum, London for permission to 24. Velpeau A. Nouveaux tl.ments de Medecine Operatoire Atlas. Paris: study Assalini artery forceps spring pressures (Fig. 6). Once Bailliere, 1832; plate 2. 25. Amott P. Surgical practice in the pre-historic Aegean. Med Hist J 1997; again, I am grateful to Martyn Cooke and members of the 32: 249-78. Conservation Unit at The Royal College of Surgeons of 26. Baseilhac J. Nouvelle Methode d'Extraire la Pierre de la Vessie Urinaire. England for their continued support. 1779.

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