var.  /

lat. teredo, caries, os vitiatum

Cognates of medical relevance: τερηδονίζομαι (V); τερηδονισμός (N); ἀτερηδόνιστος (Adj) 

Caries of the bones caused by internal action of corroding acrid humours. This medical condition entails rarefaction or absorption of bone-tissue attended by suppuration and can also affect the bones of the head. The result is the removal of portions of carious bone leaving a cavity with a worm-eaten appearance, the surface of which is covered with granulations and pus. The τερηδών has been identified and described by ancient physicians since the time of Hippocrates with investigation into its etiology, symptomatology, diagnosis, treatment and surgery. Among medical papyri, the term is attested in just one catechism of the late II-beginning of the III century CE (GMP I 6), which is paralleled by the so called ‘continental’ tradition of the Latin Pseudo-Soranian Quaestiones medicinales (as is preserved in MS Carnot. 62, fol. 13r-v).

1-2.    Etymology – General linguistic commentary

Metaphorical noun named after the worm which bores holes through wood and leaves it porous.[1] The reason of this designation could be the morphological analogy between the worm-eaten wood and the carious bone, or even the ‘functional’ comparison between the animal that eats up wood and the malady that assaults the body.[2] But it is not excluded the trace of an archaic theory of the etiology of the disease.[3] The Greek technical term is borrowed in Latin as 'teredo'[4] and corresponds to 'caries'.[5]

Neither diminutives nor graphic variants are attested.

Three derivatives of the term, documented in medical texts since the I century CE, belong to the technical language. The most attested one is the verb τερηδονίζομαι, that means «to be worm-eaten» when applied to trees and plants,[6] and «to be carious» when applied to bones (LSJ⁹ 1776 s.v.).[7] The adjective ἀτερηδόνιστος, «not worm-eaten» (LSJ⁹ 269 s.v.), appears only in medical writers and is always referred to the roots and wood of plants and trees.[8] Finally, the noun τερηδονισμός has a single attestation in [9] expressing the «carious condition» (LSJ⁹ 1776 s.v.) of bones, particularly of the skull.

The word τερηδών is etymologically connected to the core semantic idea of “piercing”, “perforating”,[9] and derives from the IE disyllabic root *terh- («bore») that is also found in other Greek words, such as the verbs τείρω («oppress, distress»),[10] τετραίνω («bore through, pierce, perforating»),[11] τιτρώσκω («wound, damage»),[12] and the nouns τέρετρον («borer, gimlet»)[13] and τρῆμα («perforation, aperture, orifice»),[14] see also Lat. tero and Sk. tṛṇatti, «bore through». The term is formed by the expressive suffix -ηδών that is quite common in names of insects (see e.g. ἀνθηδών, «bee», ἀνθρηδών, «hornet», πεμφρηδών, «wasp», τενθρηδών, «a kind of wasp»).[15] This etymological connection was already perceived by the Greeks, since Galen relates τερηδών to τρῆμα, i.e. the physical effect of the disease, and even supposes that τερηδών has the ε added, so that the correct form of the word should be τρηδών (see [5] and [6]).

The noun τερηδών (in form τερηδόνα) and its cognates τερηδονίζομαι and τερηδονισμός live on in medical technical terminology of modern Greek, especially referred to the caries of teeth.[16]

3. Abbreviation(s) in the papyri

No abbreviated form had appeared, as yet.

1. Hp. Morb. II 7 (X/2 138,9-15 Jouanna) – V-IV BCE

ὅταν τερηδὼν γένηται ἐν τῷ ὀστέῳ, ὀδύνη λαμβάνει ἐκ τοῦ ὀστέου· χρόνῳ δ’ ἀφίσταται τὸ δέρμα ἀπὸ τῆς κεφαλῆς ἄλλῃ καὶ ἄλλῃ. οὗτος ταῦτα πάσχει ὅταν ἐν τῇ διπλόῃ τοῦ ὀστέου ὑπογενόμενον φλέγμα ἐναποξηρανθῇ· ταύτῃ ἀραιὸν γίνεται καὶ ἐκλείπει ἐξ αὐτοῦ ἡ ἰκμὰς πᾶσα καὶ ἅτε ξηροῦ ἐόντος ἀφίσταται ἀπ’ αὐτοῦ τὸ δέρμα. αὕτη ἡ νοῦσος οὐ θανάσιμός ἐστιν.

When a teredo forms in the skull, a pain originating in the bone arises, and, as time passes, skin separates from the head in one place after another. The patient suffers these things when phlegm that has formed in the diploe of the bone becomes dried up inside it; where this happens, the bone becomes loose in texture, all the moisture leaves it, and, because it is dry, the skin separates from it. This disease is usually[1] mortal.

(Transl. P. Potter [London 1988] 201)

2. Id. Morb. II 24 (X/2 188,1-9 Jouanna)

ὅταν τερηδὼν γένηται ἐν τῷ ὀστέῳ, ὀδύνη λαμβάνει ἀπὸ [τούτου] τοῦ ὀστέου· τῷ δὲ χρόνῳ τὸ δέρμα λεπτὸν γίνεται καὶ ἀναφυσᾶται καὶ γίνεται ἐν αὐτῷ κάτηγμα καὶ ἢν τοῦτο ἀνατάμῃς, εὑρήσεις ἀνατεῖνον ὀστέον καὶ τρηχὺ καὶ πυρρόν, ἐνίοισι δὲ καὶ διαβεβρωμένον πρὸς τὸν ἐγκέφαλον. ὅταν οὕτως ἔχοντι ἐπιτύχῃς, ἢν μὲν ᾖ πέρην διαβεβρωμένον, ἐᾶν ἄριστον, καὶ ἰᾶσθαι ὡς τάχιστα τὸ ἕλκος· ἢν δὲ βεβρωμένον μὲν μὴ ᾖ, τρηχὺ δὲ, ξύσας ἐς τὴν διπλοΐδα, ἰᾶσθαι ὥσπερ τὴν πρόσθεν.

When a teredo forms in the skull, a pain originating in the substance of the bone arises; in time, the skin over the teredo becomes thin and puffed up, and a break develops in it; if you cut this open, you will discover the bone to be raised, jagged, reddish and, in some cases, eroded through to the brain. When you happen upon a patient like this, if the bone is eroded right through, it is best to leave it alone, and to heal up the ulcer as fast as possible; however, if the bone is not perforated,[2] but only jagged, scrape into the diploe, and treat as in the preceding disease.

(Transl. P. Potter [London 1988] 233)

3. Id. Epid. VII 35 (V 402,17-404,13 L.)

τῷ Φιλίας παιδίῳ, ψιλώματος ἐν τῷ μετώπῳ γενομένου, ἐναταίῳ πυρετός· εἶτα ἐπελιάνθη τὸ ὀστέον· ἐτελεύτησεν. καὶ τῷ Φανίου καὶ τῷ Εὐέργου· πελιαινομένων δὲ τῶν ὀστέων καὶ πυρεταινόντων, ἀφίστατο τὸ δέρμα ἀπὸ τοῦ ὀστέου, καὶ πῦον ὑπεμένετο· τούτοισι τρυπωμένοισιν ἐξ αὐτοῦ τοῦ ὀστέου ἀνήρχετο ἰχὼρ λεπτὸς, ὀῤῥώδης, ὕπωχρος, κάκοδμος, θανάσιμος. ξυμβαίνει δὲ τοῖσι τοιούτοισι, καὶ ἐμέτους ἐπιγίνεσθαι καὶ τὰ σπασμώδεα ἐπὶ τελευτῇ, καὶ ἐνίους κλαγγώδεας εἶναι, καὶ ἐνίους ἀκρατέας, καὶ ἢν μὲν ἐν τοῖσι δεξιοῖσι τὸ τρῶμα ᾖ, τὰ ἀριστερά· ἢν δ' ἐν τοῖσιν ἀριστεροῖσι, τὰ δεξιά. τῷ Θεοδώρου ἐναταίῳ ἡλιωθέντι, πυρετὸς ἐπῄει δεκαταίῳ ἐκ ψιλώματος, οὐδενὸς ἀξίου, ὡς εἰπεῖν, κατὰ τὸ ὀστέον· ἐν δὲ τῷ πυρετῷ ἐμελάνθη, ἀπέστη τὸ δέρμα· ἐπὶ πουλὺ κλαγγώδης· δευτέρῃ καὶ εἰκοστῇ, ἡ γαστὴρ ἐπήρθη, μάλιστα δὲ κατὰ τὰ ὑποχόνδρια· τρίτῃ καὶ εἰκοστῇ ἐτελεύτησεν. οἷσι δ' ἂν ὀστέα κατεαγῇ, τούτοισιν ἑβδομαίοισιν οἱ πυρετοί· ἢν δὲ θερμοτέρη ἡ ὥρη, καὶ θᾶσσον· ἢν δὲ μᾶλλον κλασθῇ, καὶ παραχρῆμα. καὶ ὁ Ἐξαρμόδου παιδίσκος παραπλησίως, καὶ ἄλγημα ἐς μηρὸν οὐ κατ' ἴξιν τοῦ τρώματος, καὶ ἐγεγόνει κλαγγώδης, καὶ τραχήλου ὀδύνη. καὶ ὁ Ποσειδοκρέων, τρίτῃ σπασμός· θέρμη οὐκ ἔλιπεν· ἐτελεύτησεν ὀκτωκαιδεκαταῖος. ὁ τοῦ Ἰσαγόρα ὄπισθεν ἐπλήγη τῆς κεφαλῆς, φλασθέντος τοῦ ὀστέου καὶ μελανθέντος πεμπταίῳ, περιεγένετο, ὀστέον δὲ οὐκ ἀπέστη.

The child of Philia, whose skull was laid bare on his forehead, had fever on the ninth day. The bone became livid. The child died. Also the children of Phanias and Euergus: when their bones became livid and they became feverish, the skin stood away from the bone and pus gathered below. When they were trephined a thin serum came out of the bone itself, like fig juice, slightly yellow, foul-smelling, deathly. And it occurs in such cases that there are vomiting and convulsions at the end, and some cry shrilly; some are paralyzed: if the wound is on the right side paralysis on the left, if on the left, the right. Theodorus’ child, having been exposed to the sun on the ninth day, got an insignificant fever on the tenth day from the exposed bone. But in the fever it turned black, the skin fell away. Much shrill crying. On the twenty-second day the child’s belly swelled up, especially at the hypochondria. On the twenty-third death. Those whose bones are broken have fever on the seventh day. If the weather is warm, even earlier. The more the bones are shattered the quicker it comes. Exarmodus’ young slave had it immediately, and the pain in the thigh, not on the side of the wound, and he cried shrilly, and had pain in the neck. Poseidocreon had convulsions on the third day. The fever did not leave him; he died on the eighteenth day. Isagoras’ son was struck behind the head, the bone was shattered and grew black on the fifth day. He survived, and the bone did not come away.

(Transl. W.D. Smith [London 1994] 339)

4. Cels. Med. VIII 2-3 [CML I 373,9-377,13 Marx] – I BCE-I CE

Omne autem os, ubi iniuria accessit, aut uitiatur aut finditur aut frangitur aut foratur aut conliditur aut loco mouetur. Id quod VITIATVM est, primo fere pingue fit, deinde uel nigrum uel cariosum; quae supernatis grauibus ulceribus aut fistulis, hisque uel longa uetustate uel etiam cancro occupatis, eueniunt. – Oportet autem ante omnia os nudare ulcere exciso, et, si latius est eius uitium quam ulcus fuit, carnem subsecare, donec undique os integrum pateat; tum id, quod pingue est, semel iterumue satis est admoto ferramento adurere, ut ex eo squama secedat; aut radere, donec iam aliquid cruoris ostendatur, quae integri ossis nota est: nam necessum est aridum sit id, quod uitiatum est. […] deinde siue os siue cartilago rasa est, nitro bene trito respergendum est: neque alia facienda sunt, ubi caries nigritiesue in summo osse est: siquidem id uel paulo diutius eodem ferramento adurendum, uel radendum est. Qui radit haec, audacter inprimere ferramentum debet, ut et agat aliquid et maturius desinat. Finis est, cum uel ad album os uel ad solidum uentum est. Albo finiri ex nigritie uitium, soliditate quadam ex carie manifestum est […]. Si quando autem an altius descenderit utrumlibet, dubium est, in carie quidem expedita cognitio est. Specillum tenue in foramina demittitur, quod magis minusue intrando uel in summo cariem esse uel altius descendisse testatur. Nigrities colligi quidem potest etiam ex dolore et ex febre; quae ubi mediocria sunt, illa alte descendisse non potest. Manifestior tamen adacta terebra fit: nam finis uitii est, ubi scobis nigra esse desit. Igitur si caries alte descendit, per terebram os pungendum crebris foraminibus est, quae altitudine uitium aequent; tum in ea foramina demittenda candentia ferramenta sunt, donec id siccum os ex toto fiat. Simul enim post haec et soluetur ab inferiore osse, quodcumque uitiatum est, et is sinus carne replebitur, et umor aut nullus postea feretur aut mediocris. Sin autem nigrities [est] aut si caries ad alteram quoque partem ossis transit, oportet excidi; atque idem in †carie quoque ad alteram partem ossis penetrante fieri potest. Sed quod totum uitiatum est, totum eximendum est: si inferior pars integra est, eatenus, quod corruptum est, excidi debet. Item, siue capitis siue pectoris os siue costa cariosa est, inutilis ustio est, et excidendi necessitas est. […] Exciditur uero os duobus modis: si paruulum est, quod laesum est, modiolo, quam ΧΟΙΝΕΙΚΙΔΑ Graeci uocant; si spatiosius, terebris. […] si caries subest, medius clauus in foramen demittitur; si nigrities, angulo scalpri sinus exiguus fit, qui clauom recipiat, ut eo insistente circumactus modiolus delabi non possit; deinde is habena quasi terebra conuertitur. […] Vix umquam nigrities, interdum caries per totum os perrumpit, maximeque ubi uitiata caluaria est. Id quoque signi specillo significatur, quod depressum in id foramen, quod infra solidam sedem habet, [et] ob id renitens aliquid inuenit, et madens sius, terebris. Vtriusque rationem proponam. Modiolus ferramentum concauum, teres est, imis oris serratum, per quod medium clauus ipse quoque interiore orbe cinctus demittitur. Terebrarum autem duo genera sunt: alterum simile ei, quo fabri utuntur, alterum capituli longioris; quod ab acuto mucrone incipit, dein subito latius fit, atque iterum ab alio principio paulo minus quam aequaliter sursum procedit. Si uitium in angusto est, quod conprehendere modiolus possit, ille potius aptatur; et, si caries subest, medius clauus in foramen demittitur; si nigrities, angulo scalpri sinus exiguus fit, qui clauom recipiat, ut eo insistente circumactus modiolus delabi non possit; deinde is habena quasi terebra conuertitur. Estque quidam premendi modus, ut et foretur et circumagatur; quia si leuiter inprimitur, parum proficit; si grauiter, non mouetur. Neque alienum est instillare paulum rosae uel lactis, quo magis lubrico circumagatur; quod ipsum tamen, si copiosius est, aciem ferramenti hebetat. Vbi iam iter modiolo pressum est, medius clauus educitur, et ille per se agitur; dein cum sanitas inferioris partis scobe cognita est, modiolus remouetur. At si latius uitium est quam ut illo conprehendatur, terebra res agenda est. Ea foramen fit in ipso fine uitiosi ossis atque integri; deinde alterum non ita longe, tertiumque; donec totus is locus, qui excidendus est, his cauis cinctus sit; atque ibi quoque quatenus terebra agenda sit, scobis significat. Tum excissorius scalper ab altero foramine ad alterum malleolo adactus id, quod inter utrumque medium est, excidit; ac sic ambitus similis ei fit, qui in angustiorem orbem modiolo inprimitur. Vtro modo uero id circumductum est, idem excissorius scalper in osse corrupto planissumam quamque testam laesit, donec integrum os relinquatur. Vix umquam nigrities, interdum caries per totum os perrumpit, maximeque ubi uitiata caluaria est. Id quoque signi specillo significatur, quod depressum in id foramen, quod infra solidam sedem habet, [et] ob id renitens aliquid inuenit, et madens exit. Si peruium inuenit, altius descendens inter os et membranam nihil oppositum inuenit, educiturque siccum: non quo non subsit aliqua uitiosa sanies, sed quo[niam] ibi ut in latiore sede diffusa sit. Siue autem nigrities, quam terebra detexit, siue caries, quam specillum ostendit, os transit, modioli quidem usus fere superuacuus est, quia latius pateat necesse est, quod tam alte processit. Terebra uero ea, quam secundo loco posui, utendum […]. Vbi tempus processit, ab ipso osse caro increscit, eaque factum manu sinum complet. Si quod etiam os adustum est, a parte sana recedit, subitque inter integram atque emortuam partem caruncula, quae quod apscessit expellat […]. Haec quamuis maxime fiunt in capite, tamen ceteris quoque ossibus communia sunt, ut ubicumque idem incidit, eodem remedio sit utendum.

Now when any bone has been injured, it either becomes diseased or splits or is broken or perforated or crushed or displaced. A diseased bone generally first becomes fatty, next either blackened or rotten; and this occurs in cases of severe ulceration or fistula, when these have become chronic or even gangrenous. And it is necessary in the first place to expose the diseased bone by cutting out the ulcer, and if the bone disease extends beyond the margins of the ulcer to cut away the flesh until sound bone is exposed all round. Then if the diseased bone appears merely fatty, it is enough to apply a cautery once or twice until a scale of bone comes away; or to scrape it away until there is bleeding, which is a sign of sound bone; for diseased bone is necessarily dry. […] Then, whether bone or cartilage has been scraped, finely powdered soda must be dusted on; and nothing different is to be done when the surface of the bone is black or carious, except that the treatment by cautery or scraping must be continued for a longer time. In these cases if the surgeon scrapes he should press boldly upon the instrument that he may effect more and finish sooner. The end is when white or hard bone is reached. White bone instead of black, or hard bone instead of carious clearly indicates the end of the diseased part. […] But if in either case it is doubtful how deep the disease has reached, in the case of carious bone, this is readily ascertained. A fine probe is introduced into the hole, and according as it enters to a less or greater extent, it shows either that the caries is superficial or that it has penetrated more deeply, With black bone it is possible to form some opinion also from the pain and fever; when these are moderate in degree, the disease cannot have penetrated deeply. This becomes more obvious, however, when a trepan is used; for the limit of disease is reached when the bone dust ceases to be black. Therefore, if caries has penetrated deeply, by means of the trepan holes are bored in the bone at frequent intervals, equal in depth to the extent of the disease; next cautery points are passed into these holes, until the bone becomes entirely dry. For after such applications, simultaneously the diseased part separates off from the bone underneath, and the cavity will make flesh, and no humour or very little will be subsequently discharged. If on the other hand the disease, whether blackness or caries, has extended to the other side of the bone as well, excision is required; and the same can be done when caries has penetrated right through a bone. But whatever is wholly diseased is to be wholly removed; if the lower part is sound, only that which is corrupt should be excised. Further, if there is caries of the skull or breast-bone or rib, the cautery is useless, and excision is necessary. […] Now bone is excised in two ways; if the damaged part is very small, with the modiolus, which the Greeks call χοινεικίς; if more extensive by means of trepans. […] if the bone is carious, the central pin (of the modiolus) is inserted into the hole; if there is black bone, a small pit is made with the angle of a chisel for the reception of the pin, so that, the pin being fixed, the modiolus when rotated cannot slip; it is then rotated like a trepan by means of a strap. […] Black bone hardly ever penetrates the whole thickness of the bone, but caries sometimes does so, and especially when the cranium is diseased. A test of this is also made by means of the probe, which when inserted into a cavity which has solid bone underneath finds some resistance because of this and is wet when it comes up. If it finds a clear way, as it goes deeper between bone and membrane, it encounters no resistance and comes up dry; not because there is no harmful sanies within, but because this is spread over a wider area. If bone is diseased right through, whether it be black bone exposed by the trepan, or caries discovered by a probe, the use of the modiolus is generally out of place, because what goes down so deep must be more widely opened up. Then the trepan which I described second is to be used […]. In course of time flesh grows up from the bone and fills up the hollow made by the surgery. Also if any bone has been cauterized it separates from the healthy part, and between the sound and dead bone granulations form to throw off what has separated […]. These conditions, although mostly occurring in the head, are found also in the other bones, so that whenever the same thing happens the same procedure is to be followed.

(Transl. W.G. Spencer [Cambridge-London 1961] 493-503)

5. Ps.-Gal. Def. med. 395 (XIX 443,11-3 K.) – end of the I CE[3]

τερηδών ἐστιν ὀστοῦ κατάτρησις ἀπὸ φθορᾶς. τὸ δὲ ὄνομα τῷ πάθει ἀπὸ τῶν συμβεβηκότων τρημάτων, οἱονεί τις τρηδὼν οὖσα.

The teredo is the cavity of the bone due to deterioration. The name of the disease derives from the perforations which occur, as if it was ‘tredo’.

6. Gal. De morb. caus. 11 (VII 37,13-38,12 K.) – II CE

οὐδὲν γὰρ ὄνομα κατ' αὐτοῦ κείμενον ὑπὸ τῶν ἔμπροσθεν παρελάβομεν, ὥσπερ ἐπί τινων εἰδῶν αὐτοῦ κάταγμα μὲν καὶ τερηδόνα τῆς ἐν ὀστῷ συνεχείας διαιρουμένης, ἕλκος δὲ καὶ τραῦμα τῆς ἐν σαρκί […]. τὸ δὲ τῆς τερηδόνος ὄνομα πλεονάζειν δοκεῖ τῷ ε στοιχείῳ· παρὰ γὰρ τὸ τρῆμα συγκεῖσθαι πεπίστευται, καθάπερ τερηδών τις οὖσα. καὶ γίνεται μὲν ὑπὸ δριμέων χυμῶν διαβιβρωσκόντων, ὑποπίπτει δὲ κατ' ἀρχὰς μὲν ἑτέρῳ γένει νοσήματος. ὀστοῦ γοῦν τραχύτης μᾶλλον ἢ τερηδὼν ὀνομάζεται. μείζονος δὲ τοῦ τρήματος γενομένου καὶ οἷον ὀπῆς τινος ἤδη φαινομένης, τερηδὼν ὀνομάζεται.

I do not admit any name formulated by my predecessors, since in some cases they designated as fracture and caries the breaking of continuity in the bone, but in other cases ulcer or wound the breaking of continuity in the flesh […]. The name of the teredo seems to have had a letter ε added, for it is believed to be derived from the word τρῆμα which means a ‘perforation’, exactly as a teredo looks like. It is the result of acrid and corroding humours, yet at its onset it falls under another class of disease, when it is then called a roughness rather than caries of the bone. When the perforation has grown larger, and looks already like a hole, it is called caries.

7. Ps.-Sor. Quaest. med. 236 (as in MS Carnot. 62, fol. 13r-v, transcription by K.D. Fischer)[4]

236  Quid est theredom? Corruptela et asperitas ossi facta circa testam uel cetera ossa.

236  What is the teredo? Decay and roughness of the bone in the skull or other bones.

8. GMP I 6,19-20 (LDAB 10278, MP³ 2340.01, SoSOL 2011 454) – late II-beginning of the III CE

] τ̣ερηδών (vac.) | ] τερηδών̣ [

‘[What is] terêdôn? … terêdôn’.

(Transl. HANSON-MATTERN 2001, 81)

9. Orib. Coll. XLVI 22 (CMG VI 2,1, 232,18-234,17 Raeder) – IV CE

Ἐκ τῶν Ἡλιοδώρου. Περὶ τερηδονισμοῦ κρανίου.

τὴν τοῦ κρανίου φθορὰν καὶ τῶν ἄλλων ὀστέων συνήθως οἱ ἰατροὶ τερηδόνα προσηγόρευσαν. διαφοραὶ δὲ τερηδόνων εἰσὶν αἵδε· ἢ γὰρ χαυνοῦται ἢ ἀραιοῦται μελαινόμενον τὸ φθειρόμενον ὀστέον ἢ ἀναβιβρωσκόμενον βοθροῦται· ἱστόρησα γὰρ καὶ κυκλοτερῆ τερηδόνα […]. ὅλου δὲ δι' ὅλου τοῦ πάχους τοῦ κρανίου τερηδονισθέντος, ἡ μῆνιγξ ἀφίσταται ὑγροῦ ὑποσυλλεγομένου […]. σημεῖα δὲ τερηδόνων τάδε· ἐπὶ πάσης τερηδόνος τὸ ἕλκος γίνεται πλαδαρόν, σομφόν, ἀκάθαρτον, ῥευματιζόμενον ἰχῶρι λεπτῷ […]· τερηδόνος δ' οὔσης ἐπιπολαίου, χαῦνον τῇ ἐπερείσει ὑποπεσεῖται τὸ ὀστέον, καὶ μᾶλλον ἰχωρροοῦν τὸ ἕλκος φανήσεται, ἰχῶρι λεπτῷ ὑγραινόμενον· βαθυτέρας δ' οὔσης τῆς τερηδόνος, ἕως τῆς σήραγγος κεχαυνωμένου τοῦ ὀστέου […] τραχύτερον ὑποπεσεῖται τὸ ἐφθαρμένον ὀστέον.

From Heliodorus. On the carious condition of the skull.

The physicians have commonly called teredo the deterioration of the skull and of the other bones. These are the different kinds of teredo / caries: either it makes the bone porous, or it rarefies the bone that is blackened and deteriorated, or it digs the corroded bone. I observed also a circular teredo [...]. Being entirely carious the thickness of the skull, the meninx separates when the fluid collects gradually [...]. These are the signs of the caries: in every kind of caries the ulcer becomes loose, spongy, uncleaned, suffering from a slight flux [...]. When the caries is superficial, the bone is porous because of the pressure, and the ulcer will appear rather suppurating and moistened by a slight flux. But when the caries is deeper, the corrupted bone will be more rough [...] until the cavity of the porous bone.

1. τερηδών and its medical sources

The medical condition called τερηδών, that has been identified with a kind of osteomyelitis in modern terminology (vd. infra), was quite a common illness in antiquity, as confirmed by paleopathological analysis of human skeletal remains from the Neolithic onwards.[1] An example is the skeleton of a Bronze Age man from Argos (123 Arg.), which suffered of what seems to have been such a disease: the external surface of the occipital bone, to the left of the inion, is deeply corroded and the wall has become very thin.[2]

The earliest scientific description of τερηδών in Greek medical literature is found in chapters 7 and 24 of the Hippocratic treatise De morbis II (see [1] and [2]).[3] The nosological description of these passages is similar but not identical in structure, since both consist of the identification of the disease in form of a temporal clause (ὅταν τερηδὼν γένηται ἐν τῷ ὀστέῳ) and of a list of ‘signs’, but only the last one comprises the treatment.[4] In [1] the author first describes some symptoms – the pain arising when a teredo forms in the bone and the separation of the skin from the skull –, then he outlines the etiology stating that τερηδών is due to desiccation of phlegm inside the diploe. Finally the author expresses his opinion on the mortality of the disease, but the manuscript tradition of the text makes difficult to understand whether the author considered it lethal or not (Μ has οὐ but θ omitts the negation: vd. supra, B 1 n. 1). The second chapter ([2]), after a more detailed description of the perceptible ‘signs’, focuses on treatment and surgery (vd. infra, C 2). Concrete case-histories of young patients affected by this kind of disorder, though never mentioning the name τερηδών, are significantly presented in the Hippocratic Epidemiae (see [3]).[5] The most relevant symptoms described are: bone is laid bare of flesh and becomes livid, the skin comes away from it and pus shows from beneath; the patient has an acute fever, sometimes accompanied with vomiting, convulsions and even paralysis, and very often he/she dies (ἐτελεύτησεν). This last aspect strongly supports the possibility that the correct text in [1] is the one in the manuscript Μ, thus affirming that τερηδών is usually mortal. According to GRMEK 1983, 193, «l’importance que les texts hippocratiques accordant à la carie de la tête nous fait croire que chez les Grecs le siege de predilection de l’ostéomyélite était le crâne. La raison en est probablement la fréquence très élevée des infections de la region stomato-rhino-otologique, notamment chez les enfants». The impression that the head was one of the preferred sites of this malady seems to be confirmed by Poll. IV192,3 τερηδὼν ὀστῶν φθορὰ ἀπροφάσιστος, μάλιστα περὶ τὴν κεφαλήν.

Dioscorides (I CE), which never mentions τερηδών, provides the first extant attestations of the derivatives ἀτερηδόνιστος[6] and τερηδονίζομαι[7] but, since the author always applies these words to plants and trees, they are not medical technical terms, but belong to the language of botany.

The Latin transliteration ‘teredo’ has just a few attestations with medical meaning. One can particularly recall the definition given in the Pseudo-Soranian ‘Questiones medicinales’ ([7]) as preserved in MS Carnot. 62, fol. 13 r-v (X cent.), from Chartre, as well as the very similar item 227 (An. II 270,28-9 Rose), that is drawn from MS Cottonianus Galba E IV (early XIII cent.) quid est teredon? corruptibilitas et asperitas ossium facta circa testam vel cetera ossa (see also item 313 in MS Lincoloniensis 220, fol. 38r): teredon is placed among the maladies of the head, and it is also specified within the definition that it is often localized in the skull.[8] By contrast, Cass. Fel. De Med. XXXII 14 cancri dentis genus […] qui ipsam buccam perforet, quod Graeci teredona uocant evidently applies the transliteration ‘teredo’ to tooth decay, about which see also, e.g., Cels. V 28,12D (CML I 243,25-6 Marx). Celsus refers to the carious bone as 'os vitiatum' and focuses in details on its treatment ([4]).

The author of the pseudo-Galenic Definitiones medicae ([5]) provides the first definition of τερηδών,[9] as well as a sort of ‘medical’ etymology of its name (vd. supra, A 1-2). Great attention is paid to this supposed derivation from τρῆμα, so that the same etymological attempt is found in [6]. In this passage, Galen tracks down the cause of the disorder in the action of acrid humours corroding the bone and states that at the beginning it is a roughness rather than an actual caries, but it becomes a caries when the perforation (τρῆμα) has grown larger and looks complete: only at this stage the proper designation is τερηδών. Furthermore, Ps.-Gal. Introd. s. medic. 18 (XIV 780,7 K.) sets τερηδών in the category of bone diseases afflicting the whole body and juxtaposes it to conditions such as fractures with or without wound.[10]

Oribasius ([9]) preserves the extensive account by the Greek surgeon Heliodorus (second half of the I cent. CE),[11] that contains in the title the only attestation of the derivative noun τερηδονισμός (vd. supra, A 1-2) meaning the «cranial caries», the «carious condition» of the skull. Heliodorus' account proceeds from definition to signs and symptoms interspersed with treatment. After the short definition, where emphasis is on «deterioration (φθορά) of the skull and other bones», the author formulates the only extant classification of τερηδών depending on its physical effect on bones, and also includes a «circular caries» (κυκλοτερὴς τερηδών), i.e. a circular perforation in the middle part of the bone (τοῦ μέσου ὀστέου κατὰ φύσιν ἔχοντος φθείρεται ὁ κύκλος). A further distinction is introduced (see ibid. 22, 4,4-9 [CMG VI 2,1, 233,6-11 Raeder]) between a superficial caries (ἐπιπόλαιος τερηδών), characterized by pitted roughness and fatty texture, and one that has penetrated deeply (βαθυτέρη τερηδών), enveloping the entire dura in suppuration. The author does not give an actual etiological explanation of the disease, but he especially focuses on its dynamics and signs (σημεῖα: ibid. 22, 3,1-12,2 [CMG VI 2,1, 232,31-233,33 Raeder]). It is also said that the τερηδών, at least the circular type, can lead to death.[12] Finally, a detailed report on therapy and surgery ends the discussion (vd. infra, C2). Except in the extract from Heliodorus, Oribasius does not mention τερηδών anywhere. Neverthless, he employs both the verb τερηδονίζομαι[13] and the adjective ἀτερηδόνιστος[14] in several passages.

No other relevant information on τερηδών is found in late antique compendiasts. Paulus Aegineta just mentions it in a list of disorders of the head[15] and uses τερηδονίζομαι saying that, if a fistula (σῦριγξ) finishes with a bone and this is carious (τερηδονισμένον) or otherwise corrupted, the whole diseased portion is to be cut out.[16] Thus, given the occasional appearance of τερηδών in the compendiasts, medical interest in the disease may be declining in that period.

The only papyrological evidence for τερηδών is [8],[17] a papyrus scrap containing a fragment of medical catechism copied on the back of a roll previously used perhaps for accounts. After the discussion on hydrocephalus in ll.3-18 (see s.v. ὑδροκέφαλον), τερηδών is the new topic introduced in l.19, very likely in form of the question "what is teredon?", but the papyrus breaks off just after another mention of τερηδών in l.20, the beginning of its definition. The text of this erôtapokrisison papyrus displays close affinities with the ‘continental version’ of the Pseudo-Soranian ‘Questiones medicinales’ ([7]) as preserved in MS Carnot. 62, fol. 13 r-v (vd. supra). Indeed, only in these two copies of medical questions discussions of hydrocephalus and τερηδών are directly juxtaposed.This leads one to suppose that, at least in the section on hydrocephalus and perhaps τερηδών, the source of the Pseudo-Soranian Latin translation was the Greek erôtapokrisis of which the papyrus is a lacunose copy.[18] Furthermore, since the question-answer set (item 233) that precedes consideration of hydrocephalus (items 234-5) and τερηδών along with its treatment (items 236-7) in MS Carnot. 62, fol. 13 r-v concerns calcification (oporeis cod., l. porosis, i.e. Greek πώρωσις), maybe this was the topic lost in the upper lacuna of the papyrus.[19] Differently, both in MS Cottonianus Galba E IV (early XIII cent.) and in MS Lincoloniensis 220 (XII cent.), which represent the ‘insular’ tradition of the Ps.-Sor. ‘Quaestiones medicinales’, the discussion of τερηδών sits at some distance prior to hydrocephalus.[20]

In modern terms, as already pointed out before, τερηδών has been identified with a kind of osteomyelitis that affected particularly the skull (see GRMEK 1983, 193, quoted above). But it is not easy to understand whether this identification is appropriate. This is due in part to the difficulties in determining exactly what an ancient disease may have been and to what can correspond in modern medicine. The technical term ostemyelitis, derived from the Greek ὀστέον, «bone», and μυελός, «marrow», is believed to have been introduced in 1844 by Auguste Nélaton (1807-1873), one of the leading surgeons of Paris.[21] Ostomyelitis[22] is an inflammatory condition of bone and/or bone marrow due to infection, usually by pyogenic microorganisms. Over time, one of the most common results can be destruction or necrosis of portions of bones. Thus, in late stage of bone infection, the pathologic process in the bone involves sequestration, that is the formation of a sequestrum, a piece of dead or necrotic bone, devoid of circulation, that has become separated from healthy and sound bone. In 1930s Staphylococcus aureus was recognized as the primary causative agent in osteomyelitis. Infecting bacteria reach bone through direct inoculation from traumatic wounds, or through hematogenous seeding, i.e. via the bloodstream, but no real distinction between bone infections resulting from open fractures and those arising from hematogenous osteomyelitis was made until the end of the XVIII century. Although several systems exist for classifying osteomyelitis, it is generally categorized as acute or chronic (evolving over months or even years), and can involve four different areas of bone, so that there are four anatomic types (medullary, superficial, localized, diffuse). As a consequence, «osteomyelitis is a complex, multifaceted disease with highly varied presentation» (WARE-BROWNER et al. 2015⁵, 619). Signs and symptoms of osteomyelitis include fever or chills, irritability, bony tenderness, pain, soft tissue swelling around the affected bone, warmth and redness over the area of infection. Any bone may be affected, but skull-based osteomyelitis is more difficult to treat than that of other bones of the body, given the complex craniofacial skeletal anatomy.[23] According to PELTIER 1993, 101, «before the nature of the infectious processes was understood completely, osteomyelitis was sometimes simply called necrosis». Thus, before the introduction of the term ‘osteomyelitis’, XVIII century physicians used various terms for bone infections, among which ‘caries of the bone’.[24] During the XVIII-XIX centuries quite accurate descriptions of the characteristics and management of caries of the bones were provided, even if it seems that the term has not always been employed in the most proper way.[25] Caries of the bone has been described as a kind of ulceration of the bone, preceded by inflammation, with absorption of bone-tissue attended by suppuration or formation of matter.[26] Thus, a caries occurs when the bone is deprived of its covering, the periosteum, and, having lost its natural color, it becomes oily, yellow, brown, and at length black. This state is said to be the first degree of the disorder, and corresponds to the ‘os vitiatum’ in the passage by Celsus ([4]); but when the disease advances, the bone is eroded and eaten, and becomes uneven because of the small halls which form in it.[27] It is sometimes specified that τερηδών was the Greek name for this caries.[28] On the one hand, at least in some cases, it seems that caries of the bone and osteomyelitis were considered and interpreted as the same disease.[29] On the other hand, caries may rather represent a pathological sequela of osteomyelitis, that is the external manifestation of osteomyelitis, and one of its most visible and destructive phenomena.[30] Anyway, despite the inner difficulties of comparing the ancient forms of the diseases with their possible contemporary equivalents, it would seem that the symptoms of the caries that Greek authors called τερηδών do not contradict at least some symptoms of osteomyelitis. 

2. τερηδών in practice

Apart from surgery, other kinds of treatments are prescribed for τερηδών by ancient authors. Galen, in particular, provides us some examples of such therapeutic procedures. In De comp. med. per gen. V 11 (XIII 824,14 K.) τερηδόνες are numbered among the various diseases for which a kind of τροχίσκοι made with myrrh, saffron, flower of the pomegranate, copper sulphate, aloe, alum and wine, and significantly defined as πολύχρηστοι, «useful for many purposes», are effective. Galen also claims that a plaster made with turpentine, incense, wax, litharge and other ingredients heals abscesses, scrofulous swellings and τερηδόνες (De comp. med. per gen. VI 14 [XIII 925,16 K.]). Elsewhere, the author prescribes a remedy with the consistency of honey that medicates both τερηδόνες and suppurations, and is made with alum, vinegar and sweet wine (De remed. parab. II 3,6 [404,5-7 K.]). Finally, Oribasius in the extract from Heliodorus ([9]) three times recommends a drying treatment by the use of dry powders or plasters after surgery, especially scraping (ξῦσις).[31]

Some detailed accounts of surgery for τερηδών / caries have been preserved. The earliest information on the surgical treatment of τερηδών is found in chapter 24 of the Hippocratic treatise De morbis II ([2]). The author eschews surgery if the bone is eroded through to the brain and recommends healing only the ulcer, leaving it alone, whereas, if the bone is not perforated, but only rough, it is necessary to scrape into the diploe and treat like a fracture.

Celsus ([4]) provides a long description of the various steps involved in surgery of carious bones. Basically, he recommends cutting out the ulcer until sound bone is exposed or even scraping the diseased bone until bleeding, since this is a sign of healthy bone, whereas carious bone is inevitably dry. In order to understand whether the caries is superficial or deeper, a fine probe is introduced into the hole. Otherwise, a trepan named terebra is used to known where the disease reaches its end and the bone dust starts to be white. On the other hand, excision is required when caries extends to the other side of the bone, so that the whole bone seems to be corrupted, and it must be taken entirely out. But, if the lower part remains sound, one must remove only as much as is corrupted. Excision is necessary also in cases particularly difficult, such as if there is caries of the skull and it penetrates the whole thickness of the cranium. According to Celsus’ words, excision is made in two ways corresponding to two different instruments: with the modiolus, i.e. the Greek χοινικίς, when the damaged part is small, but the operation is carried out by the trepan if the diseased portion is more extensive (see PENSO 1985, 467-8). Thus, if the disease is limited and the bone is carious (caries), the central pin of the modiolus is inserted into the hole, whereas, if there is black bone (nigrities) a small pit is made with the angle of the chisel to receive the pin, so that the modiolus can be rotated like a trepan by means of a strap. The trepan is used, for instance, when a caries goes down deep and it must be widely opened up. Then, in course of time, flesh growing from the bone fills up the hollow made by surgery.

In Ps.-Sor. Quaest. med. 228 (An. II 270,30-3 Rose) surgical treatment for teredon follows directly after definition and it is said to eliminate the 'vitium' if the bone is wholly diseased (totum os vitiatum).

Oribasius, in the final part of the account by Heliodorus (Coll. XLVI 22, 12,2-19,4 [CMG VI 2,1, 233,33-234,17 Raeder]), focuses on surgery. The main surgical option for the various kinds of τερηδών consists in the removal by scraping (ξύσις) of a portion of the diseased bone. Scraping is used, for instance, in case of fatty ulceration (λίπασμα) and superficial decay (ἐπιπόλαιος φθορά), in order to eliminate even the dense surface of the skull (ἵνα τῇ ἐπιμόνῳ ξύσει καὶ ἡ πυκνὴ ἐπιφάνεια τοῦ κρανίου δαπανηθῇ). Further, in case of decay with erosion of bone, when the skull is pitted, after removal of intervening tissues, is stated to perform a scraping operation with scalpel-shaped chisels (ibid. 22, 16,3 [CMG VI 2,1, 234,3-5 Raeder] ἐπὶ δὲ τῆς κατ' ἀνάβρωσιν τερηδόνος, βεβοθρισμένου τοῦ κρανίου, πάλιν δεῖ μετὰ τὴν τῶν σωμάτων ἀναστολὴν ὅμοιόν τι ξύσει δρᾶσαι διὰ τῶν σμιλιωτῶν ἐκκοπέων). After these procedures, as pointed out above, drying treatments with powders for the head and plasters are recommended.

In sum, according to ancient medical sources, excision and scraping were the surgical operations of choice to treat τερηδών / caries.       

The surgical instrument mentioned by Heliodorus ap. Oribasius to perform scraping is a specific subtype of ἐκκοπεύς, the «chisel»,[32] called σμιλιωτὸς ἐκκοπεύς. This scalpel-shaped chisel was probably specialized both for its shape and its function and it is always employed in bone surgery.[33] Its use is also documented in a medical text on papyrus from the I-II cent. CE, P.Strasb. inv. G 1187,11 (MP3 2374; LDAB 1085; SoSOL 2014 46). Other implements are referred to by Celsus. As an important tool in diagnosis, a specillum tenue, a «fine probe»,[34] is introduced into the hole of the caries in order to know, according as it enters more or less, whether the caries is superficial or deeper. Elsewhere Celsus claims that if the probe does not slip but meets with en even surface, there is a caries although still slight, whereas, if what underlies is uneven and rough, the bone has become seriously eroded (Med. V 28,12D [CML I, 243,24-7 Marx] ibi deinde si labitur specillum, nondum caries est: si non labitur, sed aequali innititur, caries quidem, uerum adhuc leuis est: si inaequale quoque et asperum subest, uehementius os exessum est). The Latin terebra, corresponding to Greek τρύπανον,means the «trepan» which perforates for subsequent chiseling out. According to Celsus, trepans or drills are of two kinds: the first like that used by smiths and driven by a thong, the second is longer in the blade, which begins in a sharp point, and has a guard to prevent the implement from sinking too deeply into the bone (see ibid. VIII 3,1 [CML I, 374,27-375,3 Marx]). Trepans were employed in excising circular sections of bone, especially from the skull, where the diseased portion was too extensive for the modiolus to comprehend. Perforations with the trepan ringed round the area to be removed and the intervening spaces were cut out with an excising chisel until sound bone was left (see ibid. VIII 3,4-5 [CML I, 375,15-23 Marx]).[35] The other implement used in excising bone, in case the damaged portion is smaller, is the modiolus, that is the Greek χοινικίς, as already recollected. Celsus describes both the shape of the modiolus and the method of its application. It was a hollow and cylindrical ferramentum with the lower edges serrated and driven by a thong; in the middle of the instrument is fixed a pin surrounded by a disc (ibid. VIII 3,1 [CML I, 374,25-7 Marx] modiolus ferramentum concauum, teres est, imis oris serratum, per quod medium clauus ipse quoque interiore orbe cinctus demittitur).[36] Among the other implements employed in operating carious or diseased skull also the membranae custos, i.e. Greek μηνιγγοφύλαξ, literally the "guard of the membrane", is numbered. The membranae custos is described as a small plate-like instrument of bronze with the end slightly concave and smooth on the outer side (Med. VIII 3,8 [CML I, 376,17-8 Marx] lammina aenea est, prima paulum resima, ab exteriore parte leuis). This plate was inserted with the smooth side next the brain, then it was gradually pushed in under the bone which was being cut by the chisel in order to protect underlying structures. Thus, the surgeon was able to strike the chisel with the mallet more safely, until the bone, having been divided all around, was lifted by the membranae custos, and could be removed without any injury to the brain (see ibid. VIII 3,8-9 [CML I, 376,18-23 Marx]).[37]

As to the treatment of caries of the bone, many methods have been attempted and described by surgeons until the XIX century. The mildest method is applied to the slightest degree of a caries and consists in the application of remedies more or less corrosive, powders, balsamics and plasters. The method for a greater degree of this disorder involves the perforation of the bone with a trepan after it is laid bare. A third method is performed by scraping away with a raspatory or a chisel the diseased and discolored portion of bone till the removal of the corrupted part. Another method, used in the most serious degrees of caries, is performed by burning down the vitiated portion of bone with a cautery, but this is not recommended in case of carious cranium, because of the risk of injuring the membranes of the brain or the brain itself. Further, when the caries penetrates to the marrow of the larger bones, it is advised to make one or more perforations with the trepan.[38] So, the main steps generally indicated are: the exfoliation of the carious laminae of the bone; the debridement and removal of all the corrupted parts of the bone by rasping, chiseling or trepanning, according to the surgical implements employed; sometimes, especially when caries is accompanied by an acrid discharge, the use of dry powders to absorb the fluid and dry the diseased part, as already suggested by ancient authors (see [9]); other times, when the bones affected are so situated as to admit such an invasive treatment, the application of the cautery, heated to the highest degree, to the portion of bone, in order to separate it, brought into a state of necrosis and deprived of its vitality; finally, when the internal surface of the bone is entirely eroded as well as the external, the whole bone is to be removed by amputation to prevent the death of the patient.[39] Similar in part is the surgery of osteomyelitis in more recent times.[40] Management of osteomyelitis focuses on eradicating infection. Treatment involves a broad-spectrum antibiotic therapy and often requires the removal of infected tissue, that is debrided surgically. Surgical debridement of devitalized tissue is indeed the only definitive cure for osteomyelitis. Also cranial osteomyelitis is treated in this way, even if, in advanced cases, where the underlying bone is grossly eroded, a partial craniectomy may be required.[41] Finally, if amputation was, in the past, the ultimate treatment of bone infection, amputation as an option to treat osteomyelitis has dramatically decreased with current methods, and it remains a viable alternative only as intervention of last resort.[42]   

1. Lexicon entries

ThGL VIII 2031D-2032C s.v.; TLL III 455,78-456,75 s.v. caries; FORCELLINI, LTL I 537 s.v. caries and IV 699 s.v. teredo; LSJ⁹ 1776 s.v.; CHANTRAINE, DELG II 1106 s.v.; FRISK, GEW II 879 s.v. τέρετρον; BEEKES, EDG II 1468 s.v. τέρετρον; DURLING 1993, 310 s.v. 

2. Secondary literature

GRMEK 1983, 193; SKODA 1988, 301-4; LANGHOLF 1990, 55; HANSON-MATTERN 2001, 73-7 and 83; HANSON 2003, 208-11

GMP I 6,19-20 – SoSOL 2011 454

Isabella Bonati