HISTORICAL REVIEW

The evolution of carpal nomenclature: A short review

Roger Paul Johnson, MS, MD, Milwuukee, Wis.

M cMurrich’s paper in 1914 on carpal nomenclature is not well known and the topic has re- ceived little attention. Therefore, I thought it of interest to briefly review the evolution of carpal nomenclature.

Galen, in the second century, knew of the carpals but no drawings, if ever made, are available. It was not until the Renaissance (1300 to 1600) that multiple por- trayals of the carpals emerged. The most notable were those of Leonardo de Vinci (1452 to 15 19), exquisite in detail and beauty, unpublished, and seen only by a few contemporaries, and the somewhat crude, by com- parison, Helain skeleton (Nuremberg, 1493). However, it was the anatomical woodcuts of the Flemish Andreas Vesalius (15 14 to 1564), and a talented illustrator Jan Stephen van Calcar’ (1499 to 1546), published as the first book of De Fabrica, that put the carpals in front of the medical world, each identified with a number. This precise identification was of relatively recent origin compared with the tarsals (except the cunei- forms), which were known and named in classical times. 3

Michael Lyser of Denmark first named the carpals in 1653, and such anatomical luminaries as the Scotsman Alexander Monro primus, the German Henle, the Dutchman Albinus, and Winslow of Denmark modi- fied, changed, and in the case of the trapezium and trapezoid, transposed them. The tendency to retrans- pose them persists to the present.

From The Medical College of Wisconsin, and the Musculoskeletal

Center, St. Francis Hospital, Milwaukee, Wis.

Received for publication Dec. 19, 1989; accepted in revised form

Feb. 8, 1990.

No benefits in any form have been received or will be received from

a commercial party related directly or indirectly to the subject of this article.

Reprint requests: Roger Paul Johnson, MS, MD, Milwaukee Clinic of Orthopedic Surgery, 5233 W. Morgan Ave., Milwaukee, WI 53220.

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834 THE JOURNAL OF HAND SURGERY

In response to Lyser’s names, Laurentius (Lorenz) Heister (1683 to 1758), a German anatomist and sur- geon, jeered in his 1727 Compendium, “There are some who give names to the ossicles of the carpus, a thing which I regard as unnecessary and useless.“’

Alexander MONO primus (1697 to 1767), of the Uni- versity of Edinburgh, questioned even the wisdom of numbering them, stating that:

the method of arranging them by Numbers, leaves Anat- omists too much Liberty to debate very idly, which ought to be preferred to the first Number: or which is worse, several,

without explaining the order they observe, differently apply the same Numbers, and so confound their Readers’ ideas.’

Almost all of the skeletons before (and many after) the De Fubrica (1543) show the metacarpals attached directly to the distal radius (Fig. 1). The recognition of the individual carpal bones containing marrow and a numbering system (Fig. 2) beginning with the scaph- oid and proximal row and ending with the hamate are found in Plate Sixteen of the First Book of Vesalius De Humani Corporis Fabrica Libri Septum (1543).5 This plate portrays multiple views of the carpals and their relationship to each other with a high degree of graph- ical clarity and anatomical accuracy.

The medical theories and principles of Claudius Galen (AD 138 to 201) had held sway for thirteen centuries. They were sanctioned by emperors, endorsed by the Church, and embraced by practitioners of rupute. Although not by design, De Fabrica represented the first bold affront to Galen’s teachings. Considering the youthfulness of its author, Vesalius, age 28, it is little wonder that Sylvius (Jacques Dubois), a true blue Ga- lenist and former teacher of Vesalius wailed, “Any dif- ference in human anatomy from the second century to the sixteenth was due to the decadence and degeneration in mankind and not a result of any deficiency in Galen’s observational or rational powers.” (Many of Galen’s drawings described structures in the pig and Barbary ape.) Vesalius’ response:

Vol. 15A, No. 5 September 1990 Historical review 835

Fig. 1. A Pre-Vesalian hand and distal forearm.

Fig. 2. Vesalius’ numbering of the carpal bones.

MICHAEL LYSER - 1653

Fig. 3. Lyser’s nomenclature system.

I hear that many are hostile to me because I have held in contempt the authority of Galen, the prince of physicians and preceptor of all; because I have not indiscriminately accepted all his opinions; and, in short, because I have demonstrated that some fault is actually discernible in his books. Surely scant justice to me and to our studies, and indeed, to our generation!5

So fierce was the pestilence of disbelief, that Vesalius

threw his drawings and notes into the fireplace and retired from anatomic medicine. He entered the royal service of Emperor Charles V of Spain, and Philip II,

Charles’ son, until 1564. He then took a brief pilgrim-

age to the Holy Land, perhaps for the forgiveness of his “scientific sins,” one of which was dissecting a “corpse” that still had a heart&at.* On his way back to his beloved Padua, apparently to assume his old chair of anatomy left vacant by the death of his friend and

former student, Gabriele Fallopio (1523 to 1562), he was shipwrecked on the Ionian Isle of Zante (Zakinthos) off the western coast of Greece where he died.5

For the next century Vesalius’ carpal numbering stood without challenge. It is not clear what prompted Mi-

836 Johnson The Journal of

HAND SURGERY

ALEXANDER MONRO - 1726

Cuneiforme (Lyser I

Fig. 4. Monro’s deviations from Lyser.

BERNARD SIEGFRIED ALBINUS - 1726

Copitatum

Cuneiform

Triquetrum

Subrotundum

Fig. 5. Albinus’ introduction of the terms “navicular” and “greater” and “lesser multangular.”

chael Lyser, prosector in anatomy to Thomas Bartholin at Copenhagen, to give proper names to the carpals. His first edition of Culter Anatomicus (1653) became a popular work consisting of five books. The last was devoted to the preparation and mounting of skeletons. In it can be found the first known proper naming of the carpals (Fig. 3).

The next 75 years saw a slow acceptance of Lyser’s terminology. Alexander Monro primus (1697 to 1767), the first of the three Monros, who between them held the chair of anatomy at Edinburgh for 126 years, was noted for his work in comparative anatomy. He pro- fessed to follow Lyser’s terminology but deviated from it considerably (Fig. 4). Of note is the transposition of

the terms trapezium and trapezoid. The tendency to retranspose these terms persists to the present.

Simultaneously, Bernard Siegfried Albinus (1697 to 1770) of the famous school of Leiden (Leyden, Neth- erlands) unveiled his proposal for carpal nomenclature in his De ossibus corporis humani (1726). Note the introduction of the terms “navicular” and “greater and lesser multangular”-the ghosts of carpal terminology that continue to haunt us (Fig. 5).

Jacques Benigne Winslow (1669 to 1760) of Den- mark, later professor of anatomy at the Parisian Jardin du Roi, published his Exposition anatomique de la structure du corps humuin in 1732. He also claimed to follow Lyser’s terminology but in fact used Monro’s

Vol. 15A, No. 5 September 1990 Historical review 837

JACOB HENLE - 1871

Trapezoid nc tmn~*n;rl~e

OS scaphoideum

0s lunatum

Fig. 6. Henle’s addition of the hamate.

NOMINA ANATOMICA - 1955

,Os capitatum

Fig. 7. Nomina Anatomica establishes the official nomenclature.

with minor variations. The most notable change was unfortunate that the Commission did not adopt Henle’s the use of the term semilunare (for lunare) a popular nomenclature with the exception of triquetrum for term in Europe and England at that time. Henle’s pyramidal.

Frederich Gustav Jacob Henle (1809 to 1885), one of Germany’s most celebrated anatomists, “the father of histology,” selected names of carpals used by his predecessors and added one of his own-hamate, “the hooked one” (Fig. 6). Although Henle did no original work with the carpus, his academic stature carried his preferences to the forefront.

Forty-one years after McMurrich’s suggestion, the Nomina Anatomica in 1955 established the “official nomenclature of the carpus” (Fig. 7). Fig. 8 is a com- posite with the common names, their authors, and the year of their coining.

McMurrich expressed dissatisfaction with the accep- tance of the terms multangulum majus and multangulum minus by the Anatomical Commission (circa 1900). He labeled them “cumbersome binomials.” He thought it

In the future, medical students will continue to con- jure up mnemonics to recall the carpals in their proper sequence. Practitioners will favor terms best suited for compound derivatives, e.g., scapho-trapezia1 versus the cumbersome naviculo-greater multangular. Anatomists will be driven by a powerful historical compulsion to

838 Johnson

The Journal of HAND SURGERY

CARPAL NOMENCLATURE WITH COMMON NAMES:

Copitote (Albinus-1726)

Homo te (Henle - 18711

Triquetrum (Albinus-1726)

Pisiform transposed -2- tropez hlonro-1726)

Lunate (Lyser - 1653)

Fig. 8. A historical composite of the systems.

Latinize the terms. Together they agree the carpals de- serve naming, though the question remains as to how. It may be this diversity of perspective that causes the carpal bones to defy attempts at uniformity and sim- plicity. Perhaps it is fitting that the wrist, the most complicated and potentially unstable joint in the body, poses a complicated and unstable resolution to its no- menclature .

REFERENCES

1. Garrison FM. An introduction to the history of medicine. 4th ed. Philadelphia: WB Saunders, 1929.

Lyons AS, Petrucelli II RJ. Medicine--an illustrated his- tory. New York: Abrams, 1978. McMurrich JP. The nomenclature of the carpal bones. The anatomical record 1914;8(3):173-83. Mettler CC, Mettler FA. History of medicine. Philadel- phia: Blakiston, 1947. O’Malley CD. Andreas Vesalius of Brussels. Berkley, Los Angeles: University of California Press, 1964.

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