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Volume 14, Issue 3-4

Issues

Biomaterials – a history of 7000 years

Hartmut F. Hildebrand
  • Corresponding author
  • Biomaterials Research Group, U 1008 INSERM “Medicaments and Biomaterials with controlled delivery”, Faculty of Medicine, Lille 2 University Law & Health, F – 59045 LILLE cedex, France
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Published Online: 2013-12-05 | DOI: https://doi.org/10.1515/bnm-2013-0014

Abstract

Prosthetic devices have existed for centuries. Originally prosthetics were simply replacements for missing limbs, but now they help people have extremely active lives. Such improvements have been made possible because of new surgical techniques, advancement of components for making prosthetics, and creative engineering ideas. In this article we will attempt to provide an insight to the history of prosthetics and some of the surgical techniques employed, albeit very basic. Mythological tales prove that some revered gods and goddesses of ancient cultures could have a handicap. We then develop the disabling causes in old civilisations going from legs and foot prostheses to arm and hand prostheses. For these limb replacements, we give examples of famous amputees. We then consider the head as a favorite place for implants and prostheses and develop trepanation with skull implants, eye and nose prostheses to finally treat the large domain of dental restorations.

Keywords: ancient cultures; biomaterials; mythology; prostheses

Introduction

Prosthetic devices began at the dawning of human medical thought, the historical twists and turns paralleled with the development of medical science.

The earliest evidence of man’s recognition of deformity and the need for rehabilitation is difficult to establish, as many ancient civilisations had no written records and historical accounts were orally recorded in songs, poems and sagas. To discover the beginnings we have to rely on anthropologists and archaeologists to interpret the myths, artwork and remains.

Disabled people played a special role in our societies and in the different worldwide mythologies. Many important mythological figures from Greek, Egyptian or pre-Columbian (in Meso- and South-America) civilization are known to have lost an arm, a hand, a leg, a foot, or other parts of the body, which have been replaced by “implants” or “prostheses”. Implantation and prosthetic reconstruction along with their success are directly related to early medical practice and its evolution. Early prosthetic principles that were developed still exist to this day, and were amazingly efficient in function.

Those first essays of prostheses or implants have already appeared during the Neolithic period. Archaeologists claim that remains of Neanderthal man show evidence of having lived after amputation, although limb loss was probably more likely to be due to accident, punishment or magic rituals rather than any surgical intent. The most frequent surgical interventions concerned bone repair, teeth replacements, and head trepanation. A large variety of materials were used from the very beginning: the first-appeared natural-origin materials were wood, nacre and ivory, but also allogenic or even xenogenic bone for orthopaedic constructs. As to teeth substitutes, the antique dentists applied different animal teeth, in particular from dogs, calves, seals and narwhals. Later, with the technological progress, the surgeons and “scientists” – most often the same person – introduced metal as prosthetic and implant material, in particular gold, silver, copper and lead with more or less high degree of purity. The success, at least physically, of such medical devices is confirmed by multiple archaeological findings, which clearly show that the operated patients survived the surgical operation.

In the following text, I will give an overlook of the earliest prosthetics in ancient cultures and their progressive improvements until our modern times with a glimpse at some famous implant and prosthesis bearers [1]. A lot of the presented documents were collected in my travels – private or professional – and visits of historic sites and museums. They, then, were completed by bibliographical studies and internet surfing. The page limits do not allow for much expanded explanations and oblige me to present a little but essential part of my collection of photos, drawings and other images.

Implants and prostheses in the mythology

Cultures around the world have their own mythological tales of handicapped or disabled individuals. Certain myths focus on deities or kings who are born with or who develop a physical disability in their life. Other myths are origin stories that explain the creation of disabled bodies at the hands of gods or goddesses. Greek, Sumerian, Chinese and African mythologies explore the theme of handicapped bodies.

In central China there is an origin myth that tells the story of a brother and a sister, Nuwa and Fuxi, who marry one another. The siblings fashion human beings out of clay and lay them out in the sun to dry. As it begins to rain, Nuwa and Fuxi hurry to collect the clay models and sweep them into a dustpan. Some of the clay figures lose their limbs or are injured in the process, which leads to the creation of disabled people. In the Taoist pantheon, Li Tieguai is the first of eight legendary people to become immortal and teach Taoist principles to people. Li has the ability to leave his body and travel around the world as a spirit. One day, Li cannot return to his body because a disciple burns it. The only body Li finds to inhabit is the body of a dead, crippled beggar. Li decides to inhabit the crippled body and uses an iron crutch to help him walk.

Amputation or accidental loss of limb(s) was common in ancient physical or devine heavenly life, which could be due to multiple causes: accident, war, punishment, religious ceremonial amputation, etc. As people from ancient times tended to compare their deities to humans – with similar qualities and mostly also with similar defaults – gods could also appear as disabled beings, with different “medical devices” to replace the lacking organ.

One of the most famous mythological implant bearers was certainly the god Pelops, who gave his name to the Peloponnesian peninsula in Greece. Pelops was a son of Tantalus and – following the authors – either of Dione, Euryanassa or Eurythemista. Either to test Zeus’ ability to know all, or simply to show what a good host he was, Pelop’s father, king at Mount Sipylus in Anatolia, wanted to make an offering to the Olympians. He slaughtered his own son, Pelops, cut him up, stewed the pieces and served them as a meal at a feast of the gods. The Greek goddess of agriculture, Demeter, Zeus’ sister, in deep mourning after the abduction of her daughter Persephone by Hades, absentmindedly accepted the offering and ate the left shoulder. The other gods, however, sensed the plot and held off from eating of the boy’s body. Pelops was finally ritually reassembled and brought back to life, his shoulder replaced with one of ivory made for him by Hephaestus (Figure 1). Pindar mentioned this tradition in his First Olympian Ode, only to reject it as a malicious invention: his patron claimed descent from Tantalus. Hundreds of existing presentations (paintings, ceramics, and statues) of Pelops: all show his more-than-before beauty, rather than his handicap.

Pelops on a Greek vessel; should the white shoulder remind the ivory implant he got after being reassembled by the Olympic gods?
Figure 1

Pelops on a Greek vessel; should the white shoulder remind the ivory implant he got after being reassembled by the Olympic gods?

Still in the Mediterranean space, another famous god underwent a similar destiny: the Egyptian god and mysterious king, Osiris, the eldest son of the Earth god Geb and the sky goddess Nut. The myth described Osiris as having been killed by his younger brother Set, who wanted Osiris’ throne. Enraged, Set tore the body into fourteen pieces and scattered them throughout the land and into the Nile River. His sister Isis gathered up all the fragmented pieces of Osiris, less the phallus (which was eaten by a catfish) and bandaged them together for a proper burial. Isis fashioned a golden phallus. The gods were impressed by the devotion of Isis and helped her to bring Osiris back to life for a limited time by use of a spell that she learned from her father. This spell gave her time to become pregnant by Osiris before he again died. Isis later gave birth to Horus. As such, since Horus was born after Osiris’ resurrection, one can imagine that the golden phallus fashioned by Isis allowing her to get pregnant, is one of the very first functional implants.

It is interesting to see, in the same geographical space, the similarity of the god’s destiny of being cut into pieces, and an influence of one culture onto another is possible, but just cannot tell which one influenced the other. Besides these similarities, the representative characteristics for each culture also can be noted: e.g., the Olympic feasts in Greece and the often practiced incest in the Egyptian dynasties. Moreover, Osiris’ burial indicates the use of afterlife prosthesis to complete a person for entering the beyond life [2].

Handicapped gods were also known in other cultures and mythologies without any geographical relation to European and African spaces: the Aztec god Tezcatlipōca and Peruvian god Aia Paec.

Tezcatlipōca was a central deity of creation and revenge in Aztec religion. He is associated with a wide range of concepts, including the night sky, the night winds, hurricanes, the north, the earth, obsidian, enmity, discord, rulership, divination, temptation, jaguars, sorcery, beauty, war and strife. He is often shown with his right foot replaced with a bony piece or an eagle foot – an allusion to the creation myth in which he lost his foot during battling with the crocodilian Earth Monster Cipactli. To attract her, Tezcatlipōca used his foot as bait, and Cipactli ate it (Figure 2) [3].

The Aztec deity Tezcatlipōca with his right foot replaced by an eagle foot.
Figure 2

The Aztec deity Tezcatlipōca with his right foot replaced by an eagle foot.

The Mochicas, native Americans who predated the Incas, worshipped the Peruvian god Aia Paec (Ai Apec). He may have been the son of their “remote, almost indifferent, supreme being and creator deity, who was a sky god,” according to Arthur Cotterell’s “A Dictionary of World Mythology” [4]. Though Aia Paec was missing one of his arms (Cotterell didn’t tell which arm Aia Paec lost) below his elbows, he was a powerful deity and fit enough to prowl beneath the creator-god’s throne, which was usually set atop a high mountain, as the dictionary says. However, Luis Castillo, professor of archeology at the Universidad Catholica Pontifica of Lima and scientific supervisor of Peruvian archaeology and the Museo Nacional de Arqueología, Antropología e Historia del Perú, does not agree with Cotterell’s version of Aia Paec’s handicap; he believes that this god of creation had neither deformity nor amputation (Figure 3) (personal communication).

Representation of the Peruvian god of creation, Aia Paec, always shown without his handicap, he was said missing one of his arms below his elbows. Photo HFH.
Figure 3

Representation of the Peruvian god of creation, Aia Paec, always shown without his handicap, he was said missing one of his arms below his elbows. Photo HFH.

The Irish god, New Hah, lost his left arm in a battle and had it replaced by a four fingered hand, made of silver. It is said that, for his prosthesis, this Celtic deity was nicknamed “Airgedlamh” [4].

None of these gods, except Tezcatlipōca who was proud of his fight with Cipactli, were represented with their handicap, certainly due to the great veneration from people to them.

Limb and foot prostheses

In Egypt, extraordinary toe replacements were found. The Cairo Toe was originally found in 2000 by the German pathologist Andreas Nerlich from Ludwig-Maximilians-University, Munich, attached to an ancient Egyptian mummy. It was an elder woman believed to have lost her right big-toe due to complications from diabetes. Moreover, this artefact could very possibly hold many clues about the Egyptians of antiquity, including insight into medical technology, religious practices and everyday vanity. The faux-toe, which is dated between 1550 and 700 BC, was constructed of wood and leather, allowing it to wear in like a new pair of shoes and provide some elasticity for increased comfort for the amputee (Figure 4).

The Cairo Toe was attached to an ancient Egyptian mummy (between 1550 and 700 BC), an elder woman believed to have lost her right big-toe to complications from diabetes was constructed of wood and leather. It was definitely worn by the patient during her lifetime.
Figure 4

The Cairo Toe was attached to an ancient Egyptian mummy (between 1550 and 700 BC), an elder woman believed to have lost her right big-toe to complications from diabetes was constructed of wood and leather. It was definitely worn by the patient during her lifetime.

The Cairo Toe also has a companion – the Greville Chester Great Toe, an ancient Egyptian phalange prosthesis made from cartonnage (papier maché consisting of linen, glue and plaster) – which will also be modelled for experimentation by the Human Performance Laboratory at the University of Salford, U.K., to determine the extent of prosthetic function [5].

As signs of wear have been reported on both cases particularly on the contacting skin of the mummies, they were definitely worn by the patients during their lifetime and they cannot be considered as completing member for the afterlife.

In India, halfway around the world from Greece, Vishpla, a mythical warrior queen, ambulated on an artificial leg. Her story is briefly recorded in the Indian poem Rig-Veda, a sacred poem written in Sanskrit as long ago as 3500 BC. Vishpla lost her leg in a battle – the Rig-Veda does not say which one. She was fitted with an iron prosthesis, which made her able to return to battle. Her story is said to be the first recorded document referring to a prosthetic limb.

Vishpla’s iron prosthesis largely predates what was previously believed to be the oldest limb prosthesis, the Roman Capua Leg, which was made of bronze and dates from about 300 BC. The leg was held by the Royal College of Surgeons in London but was destroyed by Luftwaffe bombs during the Second World War, the only photo existing is shown in Figure 5.

The Roman Capua Leg (about 300 BC) was made of bronze. The leg was held at the Royal College of Surgeons in London but was destroyed by Luftwaffe bombs during the Second World War.
Figure 5

The Roman Capua Leg (about 300 BC) was made of bronze. The leg was held at the Royal College of Surgeons in London but was destroyed by Luftwaffe bombs during the Second World War.

Several surgical techniques were reported to be practiced by the south-American pre-Columbian cultures e.g., Lambayeques, Mochicas and Incas, and several relics from Cuzco have shown surgical challenges such as the replacement of tibiae by centro-medullar wooden or ivory sticks. Some drawings have tried to represent these surgical principles (Figure 6), but we could not find more precise description and/or photographic images nor archaeological pieces, which have probably been lost (personal communication).

Schematic presentation of centro-medullar bone tibia from the Inka civilisation.
Figure 6

Schematic presentation of centro-medullar bone tibia from the Inka civilisation.

Most of the prosthetic devices were just wood or metal pegs as shown by Pieter Brueghel the Elder on his famous painting “The Beggars” (1568) in the Louvre Museum in Paris (Figure 7).

Prosthetic wooden devices shown by Pieter Brueghel the Elder on his famous painting “The Beggars” (1568). Louvre, Paris. Photo HFH.
Figure 7

Prosthetic wooden devices shown by Pieter Brueghel the Elder on his famous painting “The Beggars” (1568). Louvre, Paris. Photo HFH.

Limb loss was often due to accidents in particular in mountain regions, and leg or foot pegs seem so common that they even appeared on pre-Columbian ceramic vessels from the Mochica culture between 50 and 800 AD (Figure 8).

Ceramic vessel from the Mochica culture (50–800 AD) representing a man with wooden foot prosthesis. Museo Lorca, Lima. Photo HFH.
Figure 8

Ceramic vessel from the Mochica culture (50–800 AD) representing a man with wooden foot prosthesis. Museo Lorca, Lima. Photo HFH.

Other frequent causes of amputation and subsequent limb replacement were due to wars and battles as already mentioned for Vishpla and Romans. Typical limb prosthesis of Arabian surgery of the 12th century is found on a soldier represented on a mosaic floor in the Lescar Cathedral near Pau in the French Pyrenees (Figure 9).

Typical limb prosthesis of Arabian surgery of the 12th century on a soldier. Floor mosaic in the Lescar Cathedral near Peau in the French Pyrenees. Photo HFH.
Figure 9

Typical limb prosthesis of Arabian surgery of the 12th century on a soldier. Floor mosaic in the Lescar Cathedral near Peau in the French Pyrenees. Photo HFH.

Other famous bearers of leg prostheses were the ancient Dutch governor of New Amsterdam (later New York), Pieter Stuyvesant (1592–1672), which he defended against the English. A cannonball destroyed his right leg in the battle attacking the Spainish island St. Martin in 1644. Peter Stuyvesant was certainly proud of his investment for his new country and considered perhaps his limb prosthesis as a kind of war decoration that he changed on different occasions. Near one hundred memorials exist in the USA to venerate him and show him each time with a more or less differently decorated stick (Figure 10).

Pieter Stuyvesant (1592–1672) with a decorated wooden peg (City of Kinston, New York).
Figure 10

Pieter Stuyvesant (1592–1672) with a decorated wooden peg (City of Kinston, New York).

Józef Sowiński(1777–1831), general of the Polish artillery and hero of the Polish uprising in November 1830, lost a leg at the Battle of Mozhaysk during Napoleon’s invasion of Russia (1812). He was certainly a less vainglorious person and had only one wooden leg now preserved in the Polish Army Museum in Warsaw (Figure 11).

The wooden leg of the artillery General Józef Sowiński(1777–1831) preserved in the Polish Army Museum in Warsaw. Photo HFH.
Figure 11

The wooden leg of the artillery General Józef Sowiński(1777–1831) preserved in the Polish Army Museum in Warsaw. Photo HFH.

The nineteenth century brought innovation to prosthetic devices. The Anglesey Leg was invented in 1800 by London’s James Potts and patented in 1805 (Figure 12). The prosthesis was named after the brave Henry William, Lord Paget, the second Earl of Uxbridge, and the first Earl of Anglesey, who was shot and immediately had his leg amputated, without anaesthesia, at the Battle of Waterloo. James Potts fitted his prosthetic leg consisting of a wooden shaft and socket, steel knee joint, and an articulated foot with artificial cords or catgut tendons that connected knee flexion with foot flexion. The tendon system caused the first incorporation of dorsiflexion and plantar flexion of the foot with accordance to knee movement, an aspect of prosthetic feet production that is used and desirable today [6]. Though amputated, the limb went on to lead a somewhat macabre after-life as a tourist attraction in the village of Waterloo in Belgium; Potts’ prosthesis made for Anglesey can still be admired at the Science Museum in London.

The Anglesey Leg invented in London by James Potts in 1800 and patented in 1805. The prosthetic was named after Lord Paget Henry William, the second Earl of Uxbridge, and the first Earl of Anglesey.
Figure 12

The Anglesey Leg invented in London by James Potts in 1800 and patented in 1805. The prosthetic was named after Lord Paget Henry William, the second Earl of Uxbridge, and the first Earl of Anglesey.

In 1858, Doctor Douglas Blyof Rochester, New York invented and patented a prosthetic leg with an articulated ankle made of an ivory ball in a vulcanized rubber socket. The articulated ankle allowed for inversion and eversion, the movement that brings the sole of the foot inward and outward [7]. Bly admitted that his prosthetic leg had its flaws when compared to an anatomical leg: “Though the perfection of my anatomical leg is truly wonderful, I do not want every awkward, big fatted or gamble-shanked person who always strided of shuffled along in a slouching manner with both his natural legs to think that one of these must necessarily transform him or his movements into specimens of symmetry or beauty as if by magic.” [8].

Open socket peg legs had cloth rags to provide cushioning for the distal end of the stump, and allow a free range of motion. These limbs would have been functional and used many basic principles of prosthetic fitting.

The best known leg prosthesis bearer among all is certainly Captain Ahab, the demoniac captain of the Pequod in Herman Melville’s novel “Moby Dick” (1819–1891), hundreds of manifestations have been imagined with statues, paintings, drawings, cartoons, movies, stamps, etc. Upon them, no one can any more be sure which leg the captain really lost, the right or the left one?!

Arm and hand prostheses

Various editions of Paré’s different texts show examples of some interestingly complex prosthetics. He explains that he has “caused them to be portrayed, or set down, that those that stand in need of such things, after the example of them, may cause some Smith, or such like work-man to serve them in the like case.” [9]. Most of these artificial limbs would be well beyond the means of the average warrior and certainly well beyond the means of most battles to fight, but they are sort of fun to look at. Given how heavy such armor-like prosthetics must have been, it might have actually been preferable to be stuck with the wooden peg arm and hook!

Marcus Sergius was a Roman general during the Second Punic War (218 to 201 BC). He sustained 23 injuries and a right arm amputation. He is famed in prosthetics circles as the first documented user of a prosthetic hand. The iron hand was constructed to allow him to hold his shield in battle. Following the uses of these times, he had to renounce the chance to be a priest because one needed two normal hands to practice this honourable profession (Figure 13).

The first documented prosthetic hand belonged to Marcus Sergius, a Roman general during the Second Punic War (218 to 201 BC). His full prosthetic arm was complex as imagined by Ambroise Paré (p. 917;1575) [7].
Figure 13

The first documented prosthetic hand belonged to Marcus Sergius, a Roman general during the Second Punic War (218 to 201 BC). His full prosthetic arm was complex as imagined by Ambroise Paré (p. 917;1575) [7].

Don Melchor Portocarrero Laso de la Vega (1636–1705), Count of Mondova, lost his arm in the famous Dune Battle of Dunquerque in 1658. His arm was replaced by an articulated Silver prosthesis. In 1688, he was named 23rd vice-king of Peru by the Spanish king Carlos II. His tomb was lost and recovered 300 years later – in 1977 – during renovation works in the Lima Cathedral (Figure 14). The silver arm prosthesis was the crucial object to confirm, that it was really the tomb of Laso de la Vega.

Articulated Silver prosthesis of Don Melchor Portocarrero Laso de la Vega (1636–1705), Count of Mondova, who lost his arm in the famous Dune Battle of Dunquerque in 1658. His arm was rediscovered in 1977 during renovation works in the Lima Cathedral. Photo HFH.
Figure 14

Articulated Silver prosthesis of Don Melchor Portocarrero Laso de la Vega (1636–1705), Count of Mondova, who lost his arm in the famous Dune Battle of Dunquerque in 1658. His arm was rediscovered in 1977 during renovation works in the Lima Cathedral. Photo HFH.

Another famous arm amputee was Horatio Nelson, 1st Viscount Nelson (1758–1805). He was a British flag officer famous for his service in the Royal Navy, particularly during the Napoleonic Wars. He was noted for his inspirational leadership and superb grasp of strategy and unconventional tactics, which resulted in a number of decisive naval victories. He was wounded several times in combat, losing one arm during the battle of Cap St. Vincent and the sight in one eye. His arm was amputated later and replaced by prosthesis in his last years. In spite of his wounds and handicaps, he continued to serve his king. Of his several victories, the best known and most notable was the Battle of Trafalgar in 1805, during which he was shot and killed.

The most famous German amputee is certainly the knight Goetz von Berlichingen (1480–1562), who had his right arm amputated. Though he was a plundering knight, mercenary and all around bastard had, his arm prosthesis was no crudely shaped hunk of metal – it was a mechanical masterpiece, centuries ahead of its time. The iron hand not only allowed Götz to return to battle, but later helped lay the foundation for modern prosthetics. This complex with articulated fingers, spring action and an array of levers and buttons, allowed him to fight with a sword, to hold a lance, to write with a feather, and to offer a rose to his love (Figure 15).

Schematic presentation of the articulated arm and hand prosthesis of the German knight Goetz von Berlichingen (1480–1562).
Figure 15

Schematic presentation of the articulated arm and hand prosthesis of the German knight Goetz von Berlichingen (1480–1562).

Finally, one should not forget the Captain Hook, the infamous pirate in the story of Peter Pan, who had one hand replaced by a hook. This technique was certainly one of the easiest – and perhaps also of the cheapest ones – to give the arm a new hand function; it is still practiced nowadays and a large choice of hooks as hand replacement can be purchased nowadays via the Internet.

Rare are the pictorial representations of these disabled personalities (except Captain Hook), probably for the psychological battle they daily fought with their handicap, well described by Herman Melville in his novel Moby Dick. On the other hand, Nelson and Stuyvesant seemed to be proud of their lost of limbs and considered them as war trophies, and numerous paintings and monuments show them with their limb substitute.

Elongation, trepanation and skull implants

The human head was a centre of interest with early assays to increase intelligence by deforming and elongating heads such as in pre-Columbian cultures and in the Egyptian king Ankhenaton’s family (1380–1334 BC): nobody knows the length of his head under his crown, but the elongated head is evident for his daughters Ankhesenpaaten and Ankhesenamun, shown in a family idyll on his throne: induced elongation or heredity? Unbelievable but true, this practice is not yet given up in our days and still exists in some Polynesian tribes.

The human heads was also a favourite place for trepanation, which was a popular surgical challenge in all ancient civilisations. Multiple trepanised skulls have been found in China which date from 5000 BC, and the most famous are the skulls from Fujia (Guangrao County) in the north-western Shandong province, which has played a major role in Chinese history from the very beginning of civilisation along the lower reaches of the Yellow River. Elsewhere, they were also found in Yangshan (Minhe County) and Shangsunjiazhai (Datong County) in the eastern Qinghai province, and Pingyang (Tailai County) in the western Heilongjiang province [10].

The pre-Columbian cultures are definitely the masters of trepanation, and hundreds of trepanised and implanted skulls have been found in the Andean countries. A large collection of them is exposed in the Museo del Oro and the Museo Nacional de Arqueología, Antropología e Historia del Perú in Lima.

The reasons of performing trepanations could be due to congenital madness (don’t forget that incest was prevalent in families of high social level), but also to religious ceremonial acts. Evidence of surviving from the surgical operation is given by skulls that show the bone repair, which certainly serve as the witness for the physiological success of the surgery, but little for mental health.

Those surgery acts were performed with or without anaesthesia, analgesics and advanced tools. For curative or religious purpose, ancient surgeons used plant extracts, such as nepenthes, opium, hemp, mandrake, henbane, hemlock, and alcohol. Asperic acid, derived from tree bark, Analgesic plants were used to relieve pain. Antiseptics, such as smoke, honey, wine and cautery with hot oil were also used.

Tools, such as stone or bronze axes were the standard surgical instruments, some Peruvian skulls show clearly traces of drills and knives (Figures 16 and 17). The Tumis are sacrificial ceremonial axes or knives distinctly characterised by a semi-circular blade, made of either bronze, copper, gold-alloy, wood, or silver alloy. They are usually made of one piece and used by some Inca and pre-Inca Andean cultures (Mochicas, Lambayeques, Chancay, etc).

Mochica skull trepanised with drills. Museo Nacional de Arqueología, Antropología e Historia del Perú in Lima. Photo HFH.
Figure 16

Mochica skull trepanised with drills. Museo Nacional de Arqueología, Antropología e Historia del Perú in Lima. Photo HFH.

Trepanised Inka skull closed with gold plate exhibiting clear bone reconstruction and osseointegration proving the survival of the patient. Museo del Oro, Lima. Photo HFH.
Figure 17

Trepanised Inka skull closed with gold plate exhibiting clear bone reconstruction and osseointegration proving the survival of the patient. Museo del Oro, Lima. Photo HFH.

Very soon, “simple” trepanation evolved to techniques closing the skull wholes by implants, called nowadays cranioplasty. In multiple cases, copper, silver or gold plates were inserted to protect the brain against external aggression (Figure 17). In addition, copper and silver have a known antiseptic effect and certainly have played an important role in preventing infections. A perfect osseointegration of these implanted plates could be stated in most cases. Some patients even went through multiple trepanations and certainly died at the last operation, which doesn’t complete bone repair. The use of wooden implants is also reported but this is really difficult to believe in the effectiveness of such degradable material in direct contact with living tissue.

Ocular prostheses

An extraordinary discovery was made in December 2006: Iranian and Italian archaeologists unearthed the world’s earliest artificial eyeball (2900 BC) in Shahr-i Sokhta (“burnt city”) in the southeast of Iran, an archaeological site of a sizable Bronze Age urban settlement, associated with the Jiroft civilisation [11]. The artificial eyeball was worn by a woman; with her shining golden eye; she must have been a striking figure, perhaps a soothsayer or an oracle (Figure 18A).

Skull with an artificial eyeball was worn by a woman (2900 BC) in Shahr-i Sokhta (“burnt city”) in the southeast of Iran (A); an artificial eyeball with gold remaining (B).
Figure 18

Skull with an artificial eyeball was worn by a woman (2900 BC) in Shahr-i Sokhta (“burnt city”) in the southeast of Iran (A); an artificial eyeball with gold remaining (B).

The eyeball has a hemispherical form and a diameter of just over 2.5 cm (1 inch). It consists of very light material, probably bitumen paste. The surface of the artificial eye is covered with a thin layer of gold, engraved with a central circle (representing the iris) and gold lines patterned like sun rays. On both sides of the eye are drilled tiny holes, through which a golden thread could hold the eyeball in place (Figure 18B). Since microscopic research has revealed that the eye socket showed clear imprints of the golden thread, the eyeball must have been worn during her lifetime. The woman with the artificial eye was 1.82 m tall (6 feet), much taller than the ordinary women of her time, between 2900 and 2800 BC dated by her skeleton. It should also be emphasised that this artificial eyeball is certainly the first known medical device made of a polymeric material.

In addition to this, an early Hebrew text also recorded a woman who wore an artificial eye made of gold (Yer. Ned. 41c; comp. Yer. Sanh. 13c). Roman and Egyptian priests are known to have produced artificial eyes as early as the fifth century BC constructed from painted clay attached to cloth and worn outside the socket.

The first in-socket artificial eyes were made of gold with coloured enamel, later evolving into the use of glass (thus the name “glass eye”) by the Venetians in the later part of the sixteenth century. These products were crude, uncomfortable and fragile, and the production methodology remained known only to Venetians until the end of the 18th century, when Parisians took over as the centre for artificial eye-making. But the centre shifted again, this time to Germany because of their superior glass blowing techniques. Shortly following the introduction of the art of glass eye-making to the USA, German goods became unavailable because of World War II. As a result, the US instead made artificial eyes from acrylic plastic.

A great evolution was then made from the burnt city eye and the Maya afterlife eye prostheses via the $4 American iridising glass-ball to the nowadays bionic eyes and biosensors. If blind Homer could profit from such an evolution, he probably would have changed his philosophy.

Nose prosthesis

Other parts of the head have also been replaced by prosthetic material. Although very little is known of early ear prostheses, it is worthwhile to remind one of the earliest and best known and analysed nose prosthesis.

Tycho Brahe(1546–1601), born Tyge Ottesen Brahe, was a Danish nobleman known for his accurate and comprehensive astronomical and planetary observations. He was well known in his lifetime as an astronomer and alchemist.

While studying at the Rostock University in Germany, on 29 December 1566, Tycho lost a part of his nose in a sword duel against his third Danish cousin, Manderup Parsberg. Tycho had earlier quarrelled with Parsbjerg over the legitimacy of a mathematic formula, at a wedding dance in Professor Lucas Bachmeister’s house on the 10th, and again on the 27th. Since neither had the resources to prove the other wrong, they ended up in a duel two days later (in the dark), which resulted in Tycho’s losing the bridge of his nose. In any way, they reconciled later. From this event, Tycho became interested in medicine and alchemy. For the rest of his life, he was said to have worn a replacement made of silver and gold, with paste or glue to fix it (Figure 19). Some people, such as Fredric Ihren and Cecil Adams, have suggested that his false nose also contained copper, by writing that when Tycho’s tomb was opened on June 24, 1901, green marks were found on his skull, making evidence of copper. Cecil Adams also mentions that the medical experts examined the remains and found green colouring. Some historians have speculated that he wore a different prosthetic nose for different occasions, noting that a copper nose would have been more comfortable and less heavy than a precious metal one. Nonetheless, in November 2012, Danish and Czech researchers, after chemically analyzing “a small bone sample from the nose” from the body exhumed in 2010, reported the prosthetic was “made out of brass” (https://en.wikipedia.org/wiki/Tycho_Brahe).

The golden nose of Tycho Brahe (1546–1601); Monument in Rostock (Germany). Photo HFH.
Figure 19

The golden nose of Tycho Brahe (1546–1601); Monument in Rostock (Germany). Photo HFH.

Dental restorations

The most frequently fabricated and used implants and prostheses in all cultures and all times, however, were the teeth.

Whereas the master-centre of development and success for trepanation and bone implantation was the pre-Columbian tribes in the Meso- and South-American area, the world centre of development of dental prostheses – and even of dental implants – was the Mediterranean space.

The Mediterranean cultures – and in particular Romans – usually tried to conserve their teeth until they deteriorated completely [12]. The ancient physicians Dioscorides, Pliny, Celsius and Scribonius recommended multiple natural ingredients such as wine, vinegar, poppy-head skins and herbs (Mandragora or Hyoscyamus roots) to alleviate toothaches. Only when they no longer could support the pain, the tooth was extracted by surgeons with forceps.

Egyptians and in particular Phoenicians first started to fabricate dental prostheses by anchoring unstable teeth with gold wires and replacing eventually lost teeth by dog teeth (Figure 20A) [13]. This art was then directly transmitted to the Etruscan civilisation. From the Phoenician heritage, they greatly developed multi-material dental bridgework composed of gold teeth and carved dog or calf teeth joined by gold plates and wires. Many examples were found in Etruscan tombs, some patients had even two or more multi-material bridges or dental restorations [14]. Modern dentists have recognised some of them as really functional (Figure 20B). We should emphasise that more than 80% of these dental restorations were worn by women. The first reason for that was certainly that the family head wanted to give an exterior sign of his richness. Another reason, which also should not be forgotten, is the expression of the female vanity.

Typical Phoenician dental restoration by anchoring moving teeth with gold wires (A) and Etruscan multi-material dental bridgework composed of carved dog or calf teeth joined by gold plates (B).
Figure 20

Typical Phoenician dental restoration by anchoring moving teeth with gold wires (A) and Etruscan multi-material dental bridgework composed of carved dog or calf teeth joined by gold plates (B).

Roman and Greek also tried single iron dental implants; microscopic analyses revealed strong corrosion and – even more interestingly – bone reconstruction around the implants, which proved them not to be an after-life implantation.

Several studies also report wrought iron dental implants. One of the most interesting examples is that of a right second upper premolar from a Gallo-Roman necropolis at Chantambre (Essonne, France), from the first or second century AD [15]. The patient was a man over 30 years old when he died. The minor reactions of the periodontium indicate that the subject was probably fitted with his implant more than 1 year before his death. X-ray microanalysis (energy dispersive spectroscopy), together with scanning electron microscopy of the apical fragment, identify the implant as iron or non-alloy steel. The implant and the socket fit perfectly together and the osseointegration appears successful (Figure 21).

Iron dental implant from a 30-year-old man substituting a right second upper premolar from a Gallo-Roman necropolis at Chantambre (Essonne, France). First or second century AD [15].
Figure 21

Iron dental implant from a 30-year-old man substituting a right second upper premolar from a Gallo-Roman necropolis at Chantambre (Essonne, France). First or second century AD [15].

A similar iron dental implant was found in 2006 in a Celtic tomb from the Celtic necropolis near Troyes (France) [16]. The tomb of a woman, certainly of high social level – with respect to the ornamental tomb gifts – was dated from about 300 BC. The iron tooth is much corroded, and one cannot really define whether it was implanted on life or after death (Figure 22).

Iron dental implant found in 2006 in a Celtic tomb from the Celtic necropolis near Troyes (France). The tomb of a woman was dated from about 300 BC [16].
Figure 22

Iron dental implant found in 2006 in a Celtic tomb from the Celtic necropolis near Troyes (France). The tomb of a woman was dated from about 300 BC [16].

These and other iron tooth substitutes must have been implanted with some rudimental tools (simple hammer); they certainly completed the dentition after tooth lost, but it is difficult to imagine that they calmed down the patient’s pain.

The most famous and beautiful art work of dental implantology is on the skull from the Peruvian Mochica culture, a complete replacement of all teeth with carved rose quartz, implanted – one by one – by a “dental artist”. This “art work” is probably the product of a religious ceremonial procedure. It is not yet confirmed whether these artificial teeth were implanted for completing the skull afterlife or during the life-time of the person, The latter is probably more credible, since some zones around the teeth look like reconstructed bone (Figure 23).

Beautiful art work of dental implantology is the skull from the Peruvian Mochica culture with a complete replacement of teeth by rose quartz carved teeth. Museo del Oro, Lima [17]. Photo HFH.
Figure 23

Beautiful art work of dental implantology is the skull from the Peruvian Mochica culture with a complete replacement of teeth by rose quartz carved teeth. Museo del Oro, Lima [17]. Photo HFH.

Roman were also the inventors of tooth crowns. Rosenfeld et al. [17] examined four crown-like prosthetic bronze artefacts that probably covered premolar teeth, dated to the 2nd ~ 4th century AD; which, to our knowledge, were not reported in the literature and may contribute to the history of dentistry during the Roman period. These artefacts were purchased in the Jerusalem antiquity market together with Roman glass beads and were reported to have been found in the Judean Mountains. They are cubic in shape with triangular facets at the corners, each with a central cylindro-conical cavity on the bottom (Figure 24). Chemical analyses of the cavities revealed remnants of C, P and Ca, which were considered by the authors as components of some kind of bone cement, used for improving the adhesion of the bronze crown to the tooth. These crown-like dental works could be early attempts to apply bronze to dental prostheses and were probably mainly used as jewellery for aesthetic purposes. They are now exhibited at the Hecht Museum, in the University of Haifa.

Crown-like prosthetic bronze artefacts that probably covered premolar teeth, first sample of crowns from Roman dentistry. The bronze crowns were dated to the 2nd–4th century AD [18].
Figure 24

Crown-like prosthetic bronze artefacts that probably covered premolar teeth, first sample of crowns from Roman dentistry. The bronze crowns were dated to the 2nd–4th century AD [18].

All these techniques were joined together to retrace the evolution from wire fixed single tooth to full dentures, none of them were perfect. George Washington suffered from poor dental health throughout his adulthood, with recurrent toothaches, decay, and tooth loss from his twenties on. These problems were likely due to common problems during Washington’s era, including a poorly balanced diet and disease, as well as genetics. As a result, he spent his life in frequent pain and employed a variety of tooth cleaners, dental medicines, and dentures [18].

His dentures represented the latest advancements in contemporary dental technology. Contrary to popular myth, his false teeth were not made of wood but of human and cow teeth as well as natural ivory from elephant, hippopotamus and walrus. Dr. John Baker, the first dentist to fashion false teeth for Washington, fabricated a partial denture with ivory that was wired to Washington’s remaining teeth (Figure 25).

Washington’s dentures represented the latest advancements in dental technology. Contrary to popular myth, his false teeth were not made of wood but of human and cow teeth as well as elephant, hippopotamus and walrus ivory.
Figure 25

Washington’s dentures represented the latest advancements in dental technology. Contrary to popular myth, his false teeth were not made of wood but of human and cow teeth as well as elephant, hippopotamus and walrus ivory.

When Washington was inaugurated as President in 1789, only one natural tooth remained in his mouth. Dr. John Greenwood – a New York dentist, former soldier in the Revolution, and a true pioneer in American dentistry – fashioned a technologically advanced set of dentures carved out of hippopotamus ivory and employing gold wire springs and brass screws holding human teeth. Greenwood even left a hole in the dentures to accommodate Washington’s single tooth as he believed a dentist should “never extract a tooth…[when] there is a possibility of saving it.” When Washington finally lost his last tooth, he gave it to Greenwood, who saved this cherished item in a special case [19].

All of Washington’s dentures caused him pain and produced facial disfigurement, described by George Washington Parke Custis as “a marked change – in the appearance – more especially in the projection of the under lip.”

Dental decorations

The pre-Columbian Maya, Moche and Inca civilisations had also a special sense for shaped and decorated teeth, the signification of which is still unknown. The Maya culture flourished from about 300 AD. to about 900 AD. They were accomplished smelters and forgers of gold, silver, and bronze in addition to being highly skilled in cutting, polishing, and engraving precious/semiprecious stones. Despite these skills, they did not perform restorative or corrective dental procedures. The skills they developed for working on teeth were for ritual or religious purposes. The Mayas were skilled in the fabrication and placement of beautifully carved stone inlays in precisely prepared cavities in the front teeth. These inlays were made of various minerals, including jade, emeralds, rubies, iron pyrites, hematite, turquoise, quartz, serpentine, and cinnabar (Figure 26) [20]. A round, hard tube was spun between the hands or in a rope drill, with slurry of powdered quartz as abrasive, to cut a perfectly round hole through the tooth enamel. The inlay was then cemented in place. The stone inlay was ground to fit the cavity so precisely that many of them remained in the teeth through thousands of years. This technique is still applied currently with little diamonds giving a brilliant shining to a beautiful smile.

In many Maya communities, dental inlays and filled teeth were symbols of elite status.
Figure 26

In many Maya communities, dental inlays and filled teeth were symbols of elite status.

Conclusions

Amputation was often feared more than death in some ancient cultures, which was believed to affect the amputee not only in their lifetime but also afterlife. Reasons for amputation in ancient times varied: congenital deformities have always been present; war was often the cause of traumatic amputation; it was used as a punishment for theft. This promotes the early attempt to provide the artificial limbs in ancient cultures, which began from simple crutches or wooden and leather cups (shown in Mochica pottery) to a modified type of crutch or peg leg to free the hands for function.

The fabrication of implants and prostheses date back more than 7000 years and is as old as the beginning of the invention of instruments and tools, as old as the beginning of material science in ceramics and metallurgy. All great civilisations are barrier of these techniques, which issued certainly to a lot of failures, but brought great successes when related to the surgical tools used. Interestingly, a lot of similarities have been found among civilisations as far from each other as South- and Mesoamerica from Rome, Athens or Luxor, as Ireland from India, as Mexico from Shandong province. An astonishing resemblance has also been reported for the surgical tools used in the various, often very different cultures at all ages. This may be one more example that human beings invent what they need simultaneously.

From the history of prosthetics and the surgical techniques employed, albeit very basic, they began at the dawning of human medical thought, the historical twists and turns paralleled with the development of medical science. The improvements have been made possible with new surgical techniques, the advancement of components for making prosthetics, and creative engineering ideas.

My first thanks go to Luis Castillo, professor of archeology at the Universidad Catholica Pontifica of Lima and scientific supervisor of Peruvian archeology and the Museo Nacional de Arqueología, Antropología e Historia del Perú, the Museo del Oro and the Museo Lorca in Lima. He opened the doors for me and allowed me to take the photos I needed. I still remember our multiple discussions enriching my knowledge about pre-Columbian cultures. I also want to express my many thanks to Google and Wikipedia who allowed me to complete my own collection of documents on prostheses and implants in ancient cultures.

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About the article

Corresponding author: Hartmut F. Hildebrand, Biomaterials Research Group, U 1008 INSERM “Medicaments and Biomaterials with controlled delivery”, Faculty of Medicine, Lille 2 University Law & Health, F – 59045 LILLE cedex, France, E-mail:


Received: 2013-07-30

Accepted: 2013-10-29

Published Online: 2013-12-05

Published in Print: 2013-12-01


Citation Information: BioNanoMaterials, Volume 14, Issue 3-4, Pages 119–133, ISSN (Online) 2193-066X, ISSN (Print) 2193-0651, DOI: https://doi.org/10.1515/bnm-2013-0014.

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