SURGICAL INSTRUMENTS
IN GREEK AND ROMAN TIMES

BY
JOHN STEWART MILNE, M.A., M.D. Aberd.
KEITH GOLD MEDALLIST IN CLINICAL SURGERY

WITH ILLUSTRATIONS

OXFORD
AT THE CLARENDON PRESS
1907

HENRY FROWDE, M.A.
PUBLISHER TO THE UNIVERSITY OF OXFORD
LONDON, EDINBURGH
NEW YORK AND TORONTO

PREFACE

The object of this book is to lay before the student of medical history an account of the various instruments with which the ancient Greek and Roman surgeons prosecuted their craft. It is self-evident that no clear conception of a surgical operation, ancient or modern, can be formed from a written description without some previous knowledge of the instruments intended to be used. Many interesting operations described in detail in the classical authors are rendered obscure or quite unintelligible from lack of this knowledge. The learned Adams gives an accurate translation of a long and involved chapter by Paulus Aegineta on the use of the vaginal speculum, but remarks that owing to our want of knowledge of the specula possessed by the ancients the chapter is unintelligible. Daremberg says it is impossible to say what was the shape of any of the cutting instruments mentioned by Hippocrates. The steady progress of archaeological discovery has gradually added find after find of surgical instruments, till now there is scarcely a museum with any considerable number of antique petits bronzes which does not number among its contents a few surgical instruments, and in the Naples Museum alone there are hundreds. In several cases we know even the name of the original possessor of these and the special branch of surgery which he practised. There are thus open to us materials which were not available to the men of learning to whom I have referred above, and the time seems opportune to undertake a systematic review of all the materials at our disposal, and attempt to reconstruct the surgical armamentarium of the ancients. Considering the importance of the subject, it is surprising that no such systematic attempt has previously been made. Indeed, comparatively little attention has been given to this department of archaeology. Literature bearing on it is comparatively scarce. What we have is entirely continental, and consists of a series of reports of different finds with attempts to indicate the uses of the instruments described. In addition to these reports and the actual instruments scattered over various museums, we have at our disposal the writings of the ancient authors themselves. In these a fair number of instruments are minutely described, while many others are named, and here and there points about their shape are mentioned in different places; and by piecing these particulars together and deducing other facts from the nature of the manipulations the instruments are employed in, we can describe in detail, with a tolerable amount of certainty, a surprisingly large number of instruments. It must be confessed that these ancient classics are rather difficult of access, surprisingly so considering that until a few decades ago they were reverenced as works of authority for medical practice; but the fact seems to be that our predecessors were largely content to draw their knowledge of these authors from mediaeval Latin translations. Part of one of the most interesting authors has never been published in the original Greek, and for our knowledge of it we are dependent on a sixteenth-century Latin translation, supplemented, it may be, by fugitive consultations of codices in libraries and museums.

Others of the Greek texts have not been reprinted since the sixteenth century, and bristle with the ingenious but at first perplexing shorthand contractions with which the Renaissance typographer imitated the Compendia of the manuscripts. These difficulties can be got over with patience, however, and the waste of gray matter necessary as a preliminary is not out of proportion to the results to be obtained. Even as a quarry for philological materials the medical classics are far from being worked out, and it is surprising how many words one meets with which are not to be found in the best Greek-English dictionaries.

The method pursued in the present investigation was to make a complete examination of the classical medical, surgical, anatomical, and pharmaceutical writings which have been preserved to us, copying out the portions in which an instrument was mentioned. These extracts were then rearranged in ledger form, each extract being classified under the heading of the instrument it referred to. Out of the enormous number of references thus obtained, those passages were selected which seemed to throw any light on the shape and size of the instrument to which they referred. Next, an examination was made of the reports of finds in various localities; as many specimens in various museums were examined as possible; and annotations of classical texts were searched for any further information they might give. The total information thus gained is so arranged that under the heading of each instrument will be found a series of selected extracts from different authors, with the deductions from them which it is possible to make regarding the appearance of the instrument, and an illustration is given of it from some ancient specimen where such is in existence. Failing actual ancient specimens, I have fallen back on mediaeval or ancient Arabian authors for illustration.

I have omitted a discussion of the many interesting mechanical contrivances for the reduction of deformities due to fracture and dislocation, and also of the splints, pads, and bandages for maintaining these injuries in position. These form such a well-defined group that they might fitly form the subject of a special monograph, and the illustrations required are of a different nature from those in the present volume. The majority of these contrivances will be found described in a chapter by Heliodorus preserved in Oribasius. I have omitted also all reference to the numerous forms of vessels in which the ancients prepared and stored their medicaments, with the exception of those which are intended for carrying on the person. Some of these merge into forms which are common to both drug and instrument cases, and it is impossible to separate them. It has been necessary also to include as far as possible the instruments involved in the preparation and application of medicaments, as most of these are either actually or potentially implements of minor surgery.

The volume opens with a short account of the ancient authors whose writings have any bearing on the subject in hand. At the end of the book will be found a bibliography of reports on finds, and a list of the most interesting instruments to be found in various museums. The latter makes no pretence of being a complete inventory, although it might serve as a skeleton for the construction of a more comprehensive list at some future date. The bibliography, on the other hand, is believed to be fairly complete. The bulk of the book consists of an attempt to reconstruct, in the manner described above, the different instruments used in classical times.

The books from which I have drawn most information are Brunner’s Die Spuren der römischen Ärzte auf dem Boden der Schweiz, Deneffe’s Étude sur la Trousse d’un Chirurgien Gallo-Romain du III^e Siècle, Adams’ translation of Paulus Aegineta, and the papers of Vulpes in the volume for 1851 of the Memorie della Regale Accademia Ercolanese di Archeologia.

During the five or six years which I have spent on this investigation I have unsparingly laid all my friends under contribution whenever opportunity occurred; but among those to whom I am particularly indebted I may mention Mr. M. G. Swallow of Baden, who has given me much assistance in working up the Swiss finds, Professor Alexander Ogston, under whom I spent many happy days as house-surgeon, and who has all along kept a fatherly eye on the progress of the work and encouraged me to proceed to the end with a task which at times seemed inclined to swamp me, Mr. R. C. Bosanquet, late director of the British Archaeological School at Athens, who procured for me photographs of the instruments in the Athens museum, and Mr. H. R. Nielsen of Hartlepool, who has been the companion of my wanderings among the continental museums. I have also to thank my father, John Milne, LL.D., for much help at many different points.

The expense of visiting the museums in the North of France and of obtaining photographs of the instruments in them has been borne by a grant from the Carnegie University Research Fund.

This monograph was presented as the thesis which forms part of the examination for the degree of M.D. of the University of Aberdeen, and it was successful in gaining ‘Highest Honours.’

Hartlepool,
April 19, 1907.

CONTENTS

CHAPTER I

INTRODUCTORY

The earliest classical writer on medical subjects is Hippocrates, who was born in 460 B. C. and who practised in Athens and other parts of Greece. The ‘Hippocratic Collection’ is well known to consist of works which are not all by Hippocrates himself; but as the pseudo-Hippocratic works all belong to the classical period they are all admissible as evidence for our purpose, and for the sake of brevity I shall throughout refer to them as if all were by Hippocrates. Many interesting instruments are named in the comparatively small collection of treatises which make up the admittedly genuine list of Hippocratic works, but, taking these along with the pseudo-Hippocratic works, the number of instruments named in the whole collection is surprisingly large, comprising as it does trephines, bone drills, probes, needles, tooth forceps, uvula forceps, bone elevators, uterine sounds, graduated dilators, cranioclasts, and others. After Hippocrates there is a break in the continuity of the literature, and for some hundreds of years Greek medicine is represented almost entirely by the Alexandrian Schools. The first printed edition of the Hippocratic works was a Latin translation printed at Rome in 1525, followed by the Aldine edition of the Greek text printed at Venice in the following year. Other editions are the edition of Föes (1595), Van der Linden (1665), Kühn (Leipzig, 1821). Later editions are the text with a French translation by Littré (10 vols., 1849-61), a scholarly edition by Ermerins with a Latin rendering (1859-64), and an excellent translation of the genuine works of Hippocrates by the world-famous Dr. Adams of Banchory (Sydenham Soc. Trans., 1849). The best edition, however, is the edition of Kuehlewein, begun in 1894 and at present in course of publication by Teubner, Leipzig. The later volumes have not yet appeared. For the portion of the text which is not contained in the first two volumes of Kuehlewein I have relied on the edition of Kühn for most of the readings, although occasionally those of Van der Linden or Föes are to be preferred. The references given are to the volumes and pages of Kühn’s edition, but in this edition indications are given of the corresponding localities in the other editions so that cross-references to these can easily be made. There seems to be a different arrangement in different editions of Föes, for Liddell and Scott say the references in their Lexicon are to the pages in Föes but they do not correspond in any way to the pagination of the edition before me (Frankfort, 1595).

Aulus Cornelius Celsus is the next writer we have. His system of medicine in eight books is a marvel of lucid arrangement, and his beautiful style makes it a pleasure to read any of his works. The seventh book gives a most interesting review of the surgery of the Alexandrian School. He describes many instruments in detail, although he names fewer special instruments than some of the Greek writers as the Latin language lends itself less well to the formation of compound words than the Greek does. To take one example only, Celsus has practically one word for all varieties of forceps—vulsella, while the Greeks use many compounds like hair forceps (τριχο-λαβίς), flesh forceps (σαρκο-λάβος), tooth forceps (ὀδοντάγρα), stump forceps (ῥιζάγρα). Indeed, in the case of the two latter words Celsus falls back on Greek to express himself. Celsus was first published in 1478. Another edition is that of Targa, 1769. The editions before me are those of Daremberg, published at Leipzig in 1859, and Védrènes (Paris, 1876). The latter contains illustrations of a considerable number of specimens from Italian and French museums.

Rufus of Ephesus (98-117 A. D.) has left little to interest us for our particular purpose, as he merely mentions, without describing, a few instruments, all of which are already known to us from other sources. The best edition is that of Daremberg, Paris, 1879. A Latin translation of his works will be found in Medicae Artis Principes (Stephanus).

Aretaeus of Cappadocia has left us a work on Acute and Chronic Diseases. He has few references to instruments, but such as they are they are interesting, as he names some which are given by no other author. He has a tantalizing allusion to a work by himself on surgery which has not been preserved. There is a fine edition of the text, with an English translation by Adams of Banchory, in the Transactions of the Sydenham Society.

Galen (130-200 A. D.) was a most voluminous writer, much of whose work remains and teems with matter of interest to us. Much information about instruments is to be gained from even his purely anatomical writings. The most accessible edition is that of Kühn (20 vols., Leipzig, 1821), but it is slipshod in the text, and even more so in the translation, which is in Latin.

Oribasius (325 A. D.) wrote an encyclopaedia of medicine, which is called Συναγωγαὶ Ἰατρικαί—Collecta Medicinalia, in seventy books, only about one third of which remain. This is the most interesting of his works from our point of view, but he has left also a synopsis of the encyclopaedia called Σύνοψις, and a sort of first aid manual called Εὐπόριστα. I have used the edition of Daremberg and Bussemaker (1851-76).

Soranus of Ephesus has left us a most valuable treatise on obstetrics and gynaecology, which, though written only for midwives, contains many interesting references to instruments such as the speculum, uterine sound, cephalotribe, decapitator, and embryo hook. He lived in the reign of Trajan. Some of the chapters, of which the Greek is lost, have been preserved to us by his abbreviator Moschion. I have used the edition of Rose published at Leipzig in 1882.

Moschion (fifth century) translated into Latin the gynaecological and obstetrical part of the works of Soranus for the benefit of midwives who could not speak Greek. This version is now lost, but we have a translation of it into Greek, made after the fall of the Western Empire and the development of the Greek-speaking Empire at Constantinople in the sixth century. There is an Edition of this by Gesner (Basle, 1566). Finally, this Greek version of Moschion was translated back into barbarous Latin at some early date, Barbour thinks by some member of the Schola Salernitana. This was published at Venice by Aldus in the sixteenth century, and Rose has prefaced his edition of Soranus with it. This work of Moschion is only of interest to us from the fact that he preserves to us the substance of some chapters of which the original in Soranus is wanting.

Caelius Aurelianus Siccensis, an African of the fourth or fifth century, translated the works of Soranus, both those on gynaecology and those on general diseases, and he preserves some of Soranus which we would not otherwise possess; but he writes in a barbarous Latin which, like the Latin of some other African writers on medical subjects, is calculated to cause great pain to any one not familiar with this particular style.

Aetius lived in the first half of the sixth century, and compiled a voluminous treatise on medicine in sixteen books. He worked entirely with scissors and paste, but the result is the preservation to us of a large number of extracts from writers whose works would otherwise have entirely disappeared, and his work is of great value for the study of instruments. In 1534 an Aldine Edition of the first eight books was published, and, though a translation of the whole work was published by Cornarius in 1533-42 in Latin, six of the last eight books were never published in the original Greek. This is unfortunate for us, as for our purpose the original is the only thing of any great value, Greek being, as I have already pointed out, a language richer in compounds than Latin is, and lending itself better to the coining of special names for special instruments. Not that the sixteenth-century translator is ever at a loss for a turn by which to express himself in Latin, but the turn, as often as not, is by periphrasis just at the very point when we would have liked a very exact equivalent for the Greek. The translation of the part of the work of which we have the Greek shows that we cannot entirely depend on some of these periphrases even where they appear definite, as in some cases an unwarrantable assumption is made about the form of an instrument. Thus λιθουλκῷ is translated ‘forcipe ad id facta’ because in Cornarius’s time the instrument used for extracting stone from the bladder was a forceps, whereas it is doubtful whether there was in the Roman period anything more than a scoop, and, therefore, we are not entitled to translate λιθουλκός by anything more definite than ‘stone extractor’, its etymological equivalent. Although, therefore, I have examined the latter eight books of Aetius in the Latin translation, and although they contain some of the most interesting information to be found in the whole work, I have been very chary about laying stress on any deductions drawn from the Latin translation only. It may be noted that there are two ways of referring to the different books in Aetius, according to whether the Greek text or the translation of Cornarius is meant. Cornarius arranged his version in four tetrabibli of four books each, whereas the Greek text is simply numbered from i-viii. ‘No vii.’ of the Greek text is, therefore, called by Cornarius ‘Tetr. ii. lib. iii.’ The eleventh book was published by Daremberg in his edition of Rufus (1879), and the twelfth book was published by Costomeris at Paris in 1892.

Pliny the Younger. Plinius Secundus (Rose, Leipzig, 1875). The writings of Pliny contain little information of any kind and are absolutely of no use for our purpose.

Scribonius Largus (45 A. D.). The edition I have examined is named ‘Scribonii Largi Compositiones’ and is edited by Helmreich, Leipzig, 1887. The work of Scribonius Largus is entirely pharmaceutical, but he gives many references to appliances by which medicaments were prepared in the surgery.

Marcellus Empiricus (300 A. D.) wrote a work on pharmacy, of large size but little value, and in a poor style. There are a few passages bearing on implements of minor surgery. A good deal is copied from Largus. Aldus published the text by Cornarius at Venice in his collection of Medici Antiqui (1547), republished by Stephanus (Medicae Artis Principes), 1567. The edition I have used is that of Helmreich (Leipzig, 1889).

Theodorus Priscianus, alias Octavius Horatianus, lived in the fourth century and has left a work, in three books, called Euporiston. It is a compilation in African Latin of extracts from Galen, Oribasius, &c. The style of the Latin is so barbarous that it really must be seen to be believed. There is a little information to be gathered about minor instruments. The edition I have used is that of Rose, Leipzig, 1894. To this edition are tacked on the medical remains of Vindicianus Afer, mere fragments without anything to interest us.

The works of Alexander Trallianus (526-605 A. D.) contain practically no surgery at all, although I have managed to extract a few references of minor interest.

The last of the eminent Greek writers is Paulus Aegineta, a writer who probably lived in the sixth and seventh centuries. This is getting rather late in the day, it is true, but to omit the works of Paulus, or Paul, as he is affectionately called by his admirers, would be to omit some of the most valuable knowledge of ancient medicine we possess. Paul, like most of his time, was a compiler, but he was a skilful one, and while he entirely depends on Galen, Archigenes, Soranus, &c. for his information, he has gathered up the best of the medical knowledge of his time in a little encyclopaedia whose artistic completeness and orderly arrangement are not surpassed by any work of a corresponding nature at the present day. The work is divided into seven books, the sixth of which deals with surgery and teems with information about instruments. Aldus published the entire Greek text at Venice in 1527. A fine English translation, with a most valuable commentary, was published by Adams of Banchory for the Sydenham Society in 1846. No one who reads it can wonder that Adams had a worldwide reputation for his knowledge of medical history. The important sixth book was published along with a translation in French by Briau at Paris in 1855.

I have obtained a description of two very important instruments from the works of Hero of Alexandria (285-222 B. C., ed. 1575). There are a few interesting references to instruments in the works of the early Christian fathers. Tertullian is the only one of these I can claim to have systematically searched, but in one of his sermons he refers to no less than four surgical instruments, one of which is not described by any other author.

It were a work of supererogation to recount the names of the other Greek and Roman writers whose works I have run through in a profitless search for references to instruments. Some of these, such as Dioscorides, are of great importance in themselves though valueless for our purpose. Others, such as many of the minor Greek writers contained in the collection by Ideler entitled Physici et Medici Graeci Minores (Berlin, 1841), and the minor Latin writers contained in the collection of Medici Antiqui Omnes (Aldus, 1547), are of little value of any kind.

Before the capture of Alexandria by Omar in 651, many Greek medical writings had been translated into Syrian. At a later date such of these as had escaped destruction were turned into Arabic by the scholars of Bagdad (Honain and his School), in the ninth century. These, introduced into Spain in the Middle Ages by the Moors, were again translated into Latin and supplied for many a day the greater part of the medical knowledge of Europe, until the study of the few Greek texts which had escaped destruction showed the true origin of Arabian medicine. It will thus be seen that there is some information, in fact a great deal, to be had from the study of the works of the Arabs, but the barbarous style of the Latin and the roundabout way in which the works have been preserved, having passed through translations of three different languages, preclude any very exact deductions being drawn from them. Some of these works are profusely illustrated with figures of instruments, but I have been careful not to fall back on any of the Arabs except to support deductions drawn from more direct sources.

The chief Arab writers of interest to us are:—Serapion (800), Rhases (882), and Ali Abbas (after 950), all of Honain’s School at Bagdad. The huge work of Avicenna (born 980), The Canon, was much used by the Arabs. It was published at Cordova, which became the Bagdad of the West after the Arabs crossed to Spain in 811.

The work of Albucasis (ob. 1106) was also published at Cordova, and contains much surgical information and has many illustrations of surgical instruments, but these must be used with due caution. I have used the edition published at Strasburg in 1532.

A word must be said of the later writers such as Paré (1509-90), Scultetus (1650), and Heister (1739). The works of these are profusely illustrated with instruments, some of which can plainly be seen to tally exactly with the descriptions of the classical authors. In other cases, although the names given to the instruments are those of classical times, it is, to say the least, doubtful whether they are of the same form as the ancient instruments whose names they bear. That was an age of great activity in the manufacture of new forms of surgical instruments, and we must accept with caution illustrations professing to indicate ancient forms of instruments. At the same time it is very interesting to note the large number of primitive arrangements which remained in use till nearly 1800. The enema syringe figured by Heister is exactly the same as we find described in the Hippocratic works—the bladder of an animal affixed to a tube—and many practitioners alive at the present day have seen the same simple arrangement in actual use.

CHAPTER II

MATERIAL, EXECUTION, AND ORNAMENTATION

Steel and Iron.

The surgical instruments we meet with are, as a rule, of bronze. Not that the Greeks and Romans did not make many of their instruments of iron and steel, but the iron has mainly perished while more of the bronze has persisted. Long before the date of the earliest medical writings, Greece had passed into the iron age. The Homeric poems picture a civilization in the state of transition from a bronze to an iron period, and weapons such as sword, axe, and spear, are frequently described as made of iron. In the Iliad we even read of implements of agriculture made of iron, but it is ‘hard to work’ (πολύκμητος, Iliad vi. 48, Od. xxi. 10). However, by the time that Hippocrates wrote, it was in common use, and, if we had only the evidence of the Hippocratic writings to go by, we could see that it was in common use in the time of Hippocrates. Certain instruments, such as the cautery, are always spoken of as made of iron, in fact, the term for cautery is, as a rule, ‘the iron,’ and σίδηρος ὁ ὀξύς is a general term for ‘the knife’. The smelting of iron is even used as a simile by Hippocrates:

‘In the same way iron comes from stones and earth burnt together. In the first exposure to the fire stones and earth mix together with scoria, but at the second and third burning the scoria separate themselves from the iron, and this phenomenon meets the eye, that the iron remains in the fire fallen apart from the scoria, and becomes solid and compact’ (ii. 371).

Again, he uses as a simile a speculative theory as to the way in which heating iron softens it and dipping it in water hardens it. He believes that this comes about by the fire depriving the iron of its nourishing substance, while the addition of water restores it.

Σιδήρου ὄργανα τέχνης· τὸν σίδηρον περιτήκουσι, πνεύματι ἀναγκάζοντες τὸ πῦρ, τὴν ὑπάρχουσαν τροφὴν ἀφαιρέοντες, ἀραιὸν δὲ ποιήσαντες, παίουσι καὶ συνελαύνουσιν. ὕδατος δὲ ἄλλου τροφῇ ἰσχυρὸν γίνεται (ii. 641).

‘The instruments of ironworking soften iron by driving the fire with wind and taking away the supporting substance, and when they have rarefied it they strike and beat it. By the nourishment of water it is again strengthened.’

This is the earliest reference to tempering steel by the Greeks with which I am acquainted. It is a curious commentary on the relative destruction of iron instruments compared with those of bronze, that cauteries, which are always described as made of iron and which must have existed in enormous numbers, are among the rarest surgical instruments found. We have a few cauteries of iron, however, and some knives and knife-blades and other instruments remain. Pots for ointments of certain kinds were made of iron, and we have actually two of these which had been the property of a Roman oculist whose full name is known. I have entered into this discussion because there seems to be a general tendency to underestimate the extent to which iron was employed by the Greeks and Romans. The quantity of scoria left by the primitive founders should alone be sufficient to teach us to how great an extent iron was in use. Wherever there was good iron in any of the Roman provinces, veritable mountains of scoria are found. The heaps of scoria left in the Forest of Dean by the Roman founders contained such a large percentage of iron still remaining that they were smelted over again in later times, and to do this occupied over twenty furnaces for a couple of centuries. Tolouse calculated that similar heaps in Gaul contained over 120,000 tons of scoria. If, however, we tend to underestimate the extent to which iron was in use among the Greeks and Romans, still more, I believe, do we tend to underrate the quantity and the quality of the steel available in those times. This comes about from the fact that in our day we require such enormous quantities of iron and steel that we have to employ iron ores of a very low quality. The greater part of the so-called steel of which battleships are made is got from a ferruginous mud with only 30 per cent. of iron, less than there was left in the scoria after the Roman founder had done with it. To the impurities already existing in this we add others, because the coal we use contains sulphur. It is getting rid of these impurities that makes the production of steel such a roundabout process with us. We forget that, with primitive methods but fine ores and a fuel devoid of sulphur, the production of steel of fine quality is as easy a process as the manufacture of iron, in fact the only difference between the method of procuring iron and steel under these circumstances is the length of time the process is allowed to go on. The ancient founders used the finest ores, often containing 75 per cent. of iron, and, working with charcoal fuel, which was nearly pure carbon, they could produce steel as easily as iron. The difference between steel and iron is that steel contains carbon, and, by allowing the ore to remain longer in contact with the charcoal, steel is formed, so that a founder setting out to make iron with a pure ore and a pure fuel like charcoal, may, if he is not careful, turn out steel of fine quality. This primitive method of making steel is still in vogue in India, Burma, Borneo, China, &c., and very fine qualities of steel are produced. The majority of the tools found in the earliest Greek colonies on the Nile—Naukratis and Daphnae—are of steel or iron, although those of the Egyptians among whom they were living (circa 600 B. C.) were of bronze. The classical medical writings themselves are sufficient evidence of the quality of the steel available in those times. Galen (ii. 683) says that the best quality of steel (which came from Norica) yielded a knife which neither blunted easily nor bent or chipped.

Ἐκ σιδήρου δὲ ἔστω τοῦτο τοῦ καλλίστου, οἷόν περ τὸ Νωρικόν ἐστιν, ἵνα μήτ' ἀμβλύνηται ταχέως, μήτ' ἀνακάμπτηται ἢ θραύηται.

This shows that the Greek surgeon appreciated good steel, and what I have said will show that there was plenty of it to be had. Yet modern writers almost invariably speak of or describe even the cutting instruments of the ancients as made of iron. Greek and Latin have each only one word to indicate both steel and iron, but that is because, as I have shown, they prepared both in the same way. The ancient Hindoo Vedas say that cutting instruments were to be made of steel, well polished and sufficiently keen to divide a hair. For sharpening, a stone was to be used, and they were to be kept clean and wrapt in flannel and laid by in a box of sandalwood. Albucasis in mentioning steel always specifies Indian steel. Many of the Roman shears of steel retain their spring perfectly. As an illustration of the keenness of edge which can be put by simple methods upon steel of primitive manufacture, take the following account of the operations of an African barber of the Hausa tribe, as reported in an account by Professor R. W. Reid, Aberdeen, of a Hausa barber-doctor’s outfit presented to the Anthropological Museum of the University by Sir William MacGregor, Governor of Lagos. The description of the outfit is quoted from Sir William MacGregor, who says:

‘The knife, made by an African bush blacksmith, he uses for shaving. He employs no soap to soften the skin or roughen the hair, only a little water. He sharpens his razor on a black leather strap, turning the knife on the back so deftly that the eye cannot follow the movement; the few last touches he gives to it by turning it with splendid dexterity on the front of the left arm, where the skin is worn and bare by this manipulation. He shaves the whole face, except the nose. He leaves a fine line of eyebrow. The hair is cut short. The outline of the hairy part of the scalp in front is very clearly demarcated by shaving back about a half to an inch and a half. Then he turns the front edge by a marvellous stroke. He holds the knife horizontally, and, with a downward stroke cuts off all the projecting ends of the hair round the forehead. No European barber could do it without burying his razor in the skin. He never draws blood’ (Proc. Anat. and Anthrop. Soc. Univ. Abdn., 1900-2).

Bronze.

Although, as I have shown, iron and steel were largely used in the manufacture of instruments, fortunately for us bronze was the metal usually selected, for thus many instruments have withstood the lapse of time which would otherwise have been oxidized out of existence. Copper is much more easily got from ore than iron, and consequently it was the first to be used by man, and very early the advantage of combining it with tin to form bronze was found out. Bronze was used by the Egyptians 6,000 years ago, and the Phoenicians, who got it from them, passed it on to the whole of Europe. The quantity of tin in the bronze is very constantly about 7½ per cent.

The majority of the instruments which have been preserved to us are of bronze. Hippocrates (i. 58) says:

Χαλκώματι δὲ πλὴν τῶν ὀργάνων, μηδενὶ χρήσθω. καλλωπισμὸς γάρ τις εἶναί μοι δοκεῖ φορτικὸς σκεύεσι τοιουτέοισι χρῆσθαι.

‘Use bronze only for instruments, for it seems laboured ornamentation to use vessels of it.’

We have, however, a good many specimens of vessels which prove that physicians did not adhere to this advice. We know too that certain medicaments were intentionally stored in copper vessels. Scribonius says:

Deinde in patella aeris Cyprii super carbones posita infervescit, donec mellis habeat non nimium liquidi spissitudinem atque ita reponitur puxide aeris Cyprii (Compositiones, xxxvii).

Pure copper was occasionally used for instruments, and of these we have a few remaining, and vessels and instruments of it are frequently mentioned: ‘Oportet autem moveri aquam ipsam rudicula vel spathomela aeris rubri’ (Marcellus, De Medicamentis, xiv. 44). Coins were frequently made of brass (ὀρείχαλκος, orichalcum, aurichalcum), a mixture of copper, tin, and zinc, and in Pompeii there have been found two scalpel handles of brass composed of 25 per cent. of zinc and 75 per cent. of copper. The copper was got mainly from Cyprus and Spain. A small amount, however, came from Africa and Asia.

Tin.

Tin came mainly from Britain. We have no instruments of tin preserved to us, but they are frequently referred to. Hippocrates mentions, over and over again, uterine sounds of tin, and he also speaks of sounds and eyed probes for rectal work, which were made of tin so that they might be flexible. Vessels of tin for storing medicaments in are spoken of by Largus: ‘Reponitur medicamentum fictili vel stagneo vase’ (cclxviii). In the Museum at Chesters (Chollerford) there is a tin weight for medicines.

Lead.

Leaden sounds and tubes for intra-uterine medication are frequently mentioned in the Hippocratic writings, and Celsus and Paul refer to leaden tubes for insertion in the rectum and vagina to prevent cicatricial contractions and adhesions after operations on these parts. The therapists also mention medicament jars of lead. There is one in the Capitoline Museum from the temple of Aesculapius in the forum.

Gold.

There is in the Museum at Stockholm a forceps of gold, but it is more than probable that this is a toilet article. I have a spatula-probe which had been overlaid with gold, and I have met with several others similarly treated. Theodorus Priscianus recommends a cautery of gold for stopping haemorrhage from the throat (Logicus, xxii). Avenzoar speaks of a golden probe for applying salve to the eye and for separating adhesion of the eye to the lid. Avicenna lets out the pustules of small-pox with a golden probe. Albucasis recommends burning the roots of hairs in trichiasis with a probe of gold. Mesue recommends a heated scalpel of gold to excise the tonsil. Hippocrates binds the teeth together in fracture of the jaw with a gold wire (iii. 174): cf. Paul, VI. xcii. In one of his dialogues Lucian satirizes a medical man who sought to conceal his ignorance by a display of a fine library, bleeding-cups of silver, and scalpel handles inlaid with gold—the devices of quacks, Lucian says, who did not know how to use the instruments when necessity arose.

Silver.

There is a forceps of silver in the Athens Museum, and another in the Museum at Kiel. Both are, however, possibly toilet articles. Paul condemns bleeding-cups of silver, as he says they burn, so it is evident that Lucian had grounds for his statement. In the Musée de Cinquantenaire, Brussels, there is in the section of ancient surgery a bronze instrument case from Pompeii which contained a silver spoon and probe combined, a plain probe, and a grooved director, all in silver. I have frequently met with ligulae of silver and also of copper overlaid with silver, and styli, which we shall see were used as implements of minor surgery, were frequently made of silver. Medicament boxes of silver are mentioned by Marcellus. Hippocrates describes a uterine syringe with a tube of silver. Albucasis mentions silver catheters.

A mixture of gold and silver, which was called electrum, was much used for coinage, and I have met with one or two ligulae of this metal. It was found mixed naturally in the mountain districts of Tmolus and Sipylus in Lydia, and it was also artificially produced by alloying the two metals.

Horn.

Hippocrates (iii. 331) speaks of a pessary of horn inserted into the rectum. It would seem that the tube of various syringes was often made of horn, as both Greek and Latin writers speak of the ‘horn’ of the syringe.

Scribonius Largus (Compositiones, vii) says:

Per nares ergo purgatur caput his rebus infusis per cornu, quod rhinenchytes vocatur (cf. Galen, xi. 125).

Wood.

Galen speaks of sounds or directors of wood, and ointment spatulae of wood are very frequently mentioned in the therapeutic works, as are also boxes for storing ointments in.

Bone and Ivory.

Numbers of bone ligulae were found in a Roman hospital lately excavated at Baden.

In the Naples Museum there are two ointment spoons with carved bone handles. Needles such as Hippocrates and Celsus speak of for stitching bandages to fix them were very frequently made of bone and ivory. Knife handles of bone and ivory are common. A carved ivory medicament box with sliding lid will be fully described later. Scribonius Largus describes knives of bone and ivory for preparing plants for pharmaceutical purposes (Compositiones, lxxxiii). An ivory pestle was found with a surgeon’s outfit in Cologne.

Stone.

Medicaments were prepared on stone slabs, and the great majority of oculists’ seals were of stone.

Execution and Ornamentation.

The execution of the instruments is, as a rule, all that could be desired, and the weight and thickness are no more than is consistent with the requisite strength.

Hippocrates points out the necessity for this:—

Τάδ' ὄργανα πάντα εὐήρη πρὸς τὴν χρείαν ὑπάρχειν δεῖ τῷδε μεγέθει, καὶ βάρει, καὶ λεπτότητι.

‘All instruments ought to be well suited for the purpose in hand as regards their size, weight, and delicacy’ (i. 58).

The ornamentation is simple and effective. In the round instruments like the probes it consists usually of raised circular ornamentation, with or without a secondary ornamentation on the raised ringing. In others there are longitudinal or spiral grooves running along the instrument. In some cases the bronze is decorated with an inlay of silver damascening. This is rare in the instruments from Pompeii, though there are two probes with a spiral inlay in the Naples Museum. The majority of the instruments treated in this way have been found in the western provinces, and they are of later date than the Pompeian. The handles of some scalpels belonging to the third century are beautifully inlaid with silver. Lucian, as I have mentioned, speaks of scalpels inlaid with gold. In the Mainz Museum there is a medicament box on the lid of which is inlaid a snake coiled round a tree, the tree and the snake’s body being outlined in copper and the snake’s head in silver. So far no damascened instruments are reported from Greece. Damascening began in Europe apparently in the first century, and reached its height in the time of the Merovingian kings.

Examples of plated instruments are not uncommon. I have a spatula dissector thinly plated with gold, and I have met with several ligulae plated with silver. One of these was so thickly plated that on cutting into it the silver, which was deeply oxidized on the outside and was, therefore, quite black, showed also a layer of metallic silver still bright on section.

All the surgical instruments found in the provinces have an air de famille which would lead one to suppose that they had been manufactured in Italy, but this is not certain. The ointment slabs, however, are rarely of the stone of the country in which they are found. On the other hand, the orthographical faults on the oculists’ seals would indicate that they were cut in the provinces. Wherever possible two instruments are combined into one. Thus very few of the probes are simple instruments but carry a spatula, a scoop or spoon, an eye, or a hook, at the opposite end. Vulsella are more difficult to combine with other instruments, but here again we meet with combinations such as vulsella at one end and scoop, raspatory, or probe, at the other. The typical scalpel handle carries at the end opposite the blade a spatula for blunt dissection. We have needles at one end and probes, scalpel blades, &c., at the other end of a handle. This combination of two instruments in one is still in use in our day. We must notice the fact that the majority of instruments we know were all of metal, not folding into hollow handles of wood, bone, &c., as the instruments of a decade ago did, so that they were easily cleaned. In fact we shall see that where the scalpel and handle were not forged in one piece they were united by something very like our aseptic joint. Hippocrates insists on the importance of keeping everything in the surgery absolutely clean.

A few instruments bear the image of deities connected with medicine, or attributes of these. The figures of Aesculapius and his daughter Hygeia are found on medicament boxes, the former with the serpent entwining his staff, the latter feeding a serpent from a bowl. The serpent is sometimes found on a probe. A uterine dilator from Pompeii also carries it. A probe surmounted by a double serpent (caduceus form) was found in the Roman Hospital at Baden. Two scalpels in the Naples Museum carry on their ends the head of Minerva Medica. The quadrivalve speculum in the Naples Museum has each end of the crossbar tipped with a fine image of a ram’s head. There is also a medicine shovel with the same symbol. Illustrations of these instruments will be found later.

Preservation.

Some of the instruments of silver retain their brightness as when they were made, but under certain circumstances a considerable amount of oxidation takes place, and then they have a thick black coating. Very few bronze articles are found to have retained their colour. In volcanic districts the various sulphur compounds formed give rise to a beautiful patina of varying shades of green and blue, sometimes so evenly distributed as to resemble enamel. This, when fine, much enhances the value of the article.

Articles of iron are sometimes but little destroyed. It is surprising in how good condition the iron or steel may be. The bow of a shears is sometimes quite springy. In some cases a steel or iron article is often represented by a mass of oxide bearing some resemblance to the original. In others only a shapeless mass of oxide remains.

Finds of Instruments.

Finds of ancient surgical instruments, though not by any means common, are still sufficiently numerous for specimens to have found their way into most of our larger museums; and private collectors have here and there acquired considerable numbers. The most prolific source has been the excavations at Herculaneum and Pompeii, which have now been systematically pursued for nearly three hundred years, while the objects found have been deposited in the National Museum at Naples. In 1818 a physician’s house with a large number of surgical instruments was discovered in the Strada del Consulate of Pompeii, and two chemists’ shops have also been found with instruments in them. Besides these there is a large number of instruments from other finds in the two buried cities.

The custom of burying personal effects along with the ashes of a deceased person, which prevailed among the Romans from the second to the fourth century, has preserved to us a number of interesting finds. In 1880 M. Tolouse, a civil engineer in Paris, in executing some alterations in the neighbourhood of the Avenue Choisy, discovered the grave of a surgeon, containing a bronze pot full of surgical instruments. Among these were numerous forceps and vulsella, ointment tubes, bleeding cup, scalpel handles for blades of steel, probes, and spatulae. Sixty-six coins of the reigns of Tetricus I and II showed that the grave belonged to the end of the second or the beginning of the third century. The find was reported by M. Tolouse in a volume entitled Mes fouilles dans le sol du vieux Paris (Paris, 1888). In 1892 the find was fully described by Professor Deneffe of Ghent, in the Revue Archéologique, under the title ‘Notice descriptive sur une trousse de médecin au III^me siècle’, and reprinted, with photogravures, in 1893 in a monograph Étude sur la trousse d’un chirurgien Gallo-Romain du III^me siècle (Antwerp, 1893). It is convenient to refer to this find as that of the ‘Surgeon of Paris’. Another grave containing surgical instruments was found at Wancennes in the canton of Beauraing, Namur, in a cemetery of the first or second century. The instruments are now in the Archaeological Museum at Namur (Deneffe, op. cit., p. 35).

In 1854 there were discovered at Rheims the remnants of a wooden chest containing two little iron jars for ointments, several scalpel handles, a small drill, eight handles for needles, five hooks (two blunt and three sharp), two balances, various probes and spatulae, seven forceps, medicament box, a mortar, and a seal showing that the instruments had belonged to an oculist named Gaius Firmius Severus. The instruments are all of the most beautiful pattern and finish, several being finely inlaid with silver. Some coins of the reigns of Antoninus Pius and Marcus Aurelius showed that the interment belonged to the end of the third century.

These instruments, &c., are now in the Museum of St-Germain-en-Laye. The majority of these will be found described and figured later.

Find of Sextus Polleius Sollemnis, oculist of Fonviel, Saint-Privat-d’Allier. In levelling a heap of earth which had fallen from a cliff above as the result of a landslide, there were found at Fonviel in 1864 a number of bronze surgical instruments. The place where they were found is at the intersection of two old Roman roads, and the instruments had been buried in the grave of a Roman surgeon high up above the valley on the edge of a cliff. Eighteen coins of the reigns of Julia Augusta, Trajan, Hadrian, Commodus, Gordian, Philip, Valerian, and Gallus, showed that the interment had been made at the end of the third century. The instruments found included three scalpel handles, fragments of two forceps, and an oculist’s seal in stone showing that the grave was that of Sextus Polleius Sollemnis. Many more instruments had probably been buried originally. Those enumerated are now in the Museum of Le Puy-en-Velay. An account of this find, with illustrations, is to be found in the Annales de la Société d’Agriculture, Sciences, Arts et Commerce du Puy (tome xxvi. 1864-5). It is also described, along with the find of Gaius Firmius Severus, in a monograph by Deneffe, under the title of Les Oculistes Gallo-Romaine au III^me siècle (Antwerp, 1896).

One of the most prolific finds of late years has been the discovery of a Roman military hospital at Baden, the ancient Roman station of Aquae, or Vicus Aquensis. From time to time isolated discoveries of instruments had been made, including a catheter, a scalpel, and several varieties of probes, and in March, 1893, MM. Kellersberger and Meyer proceeded to excavate systematically the remains of some Roman buildings on their property. A large chamber 10·35 metres by 12·5, with walls 60 cm. thick, was discovered, and later others were discovered varying from 3 to 27 metres in length. There were in all fourteen rooms. Along the side of the building on which a Roman road ran, there were the remains of an imposing façade, running the whole length of the building. It had consisted of a portico with colonnades, the foundations of which were found at regular intervals. It is possible that some of the larger rooms had been subdivided into others by thin walls or partitions, for fragments of partitions of plaster with wood lathing were found.

A large number of objects—tiles, lamps, vases, pots, knives, spearheads, nails, glass, fibulae, beads, weavers’ weights, three amphorae a metre high—were found near the surface. Then, at a depth of two metres, surgical instruments began to be found. These included probes to the number of 120, unguent spoons in bone and bronze, a fragment of a catheter 13 cm. long, bronze boxes for powder, needles, earscoops, unguentaria, spatulae, a fragment of an étui for instruments, and cauteries. Many coins of the reigns of Claudius, Nero, Domitian, Vespasian, and Hadrian were found, showing that the hospital had been in use between 100 and 200 A. D. The objects mentioned are still the private property of MM. Kellersberger and Meyer. In 1905, by the kindness of these gentlemen, I was allowed to make a complete examination of the collection.

A case containing a surgeon’s outfit was found in the Luxemburgerstrasse, Cologne. It contained a phlebotome, a chisel, and some fragments of other instruments of steel, two forceps and two sharp hooks in bronze, and a small ivory pestle-like instrument. These are now in the Cologne Museum. This is a most interesting and important little find. The phlebotome is by far the best preserved and best authenticated example which we possess of this instrument. Probably the same may be said of the chisel as a purely surgical instrument.

CHAPTER III

KNIVES

The surgical knife had, as a rule, the blade of steel and the handle of bronze. We find specimens all of steel or all of bronze but these are exceptional forms; and hence it happens that many more handles than blades have been preserved to us, as usually the blade has oxidized away leaving no trace of its shape. It will be well, therefore, to commence with the study of the handle.

The scalpel handle consists, as a rule, of a bar of bronze, which may be round, square, hexagonal, or trapezoidal in section. At one end there is a slot to receive the steel blade, varying in depth from 2 cm. in the larger, to 1 cm. in the smaller, instruments. The other end of the handle carried a leaf-shaped spatula to act as a blunt dissector. A groove is often formed near the end of the handle, or the end is raised into a cylindrical roll on each side, and this roll again is sometimes perforated with a hole.

It is generally believed that the blades were fixed in the handle by a binding thread or wire, and that the rolls and perforations were to give security to the mounting used. This detachable arrangement would allow of removal for cleaning, and also permit one handle to be used with several varieties of blade. A consideration of the slots in a large number of handles leads me to believe, however, that this was, to say the least, not the usual arrangement. The proportion of the depth of the slot to the size of the blade to be supported is in most cases not large enough to allow of a temporary mounting to fix the blade firmly, and I believe that most blades were either luted or brazed in permanently. These processes were well known to the ancients, and in fact we have them in evidence in other surgical instruments. Those bleeding-cups from Pompeii which carry rings on their summits have the top part brazed or soldered on. Galen (ii. 717) alludes to the blowpipe which goldsmiths used, and Paulus Aegineta has a chapter on the fluxes used by these artists. We frequently meet with ornaments fixed on boxes by means of solder.

On the other hand, the slot in some handles expands at its termination into a wider portion which would carry a cylindrical expansion on the other end of the blade. This form of blade could not be pulled outwards, and might well be fixed with a temporary mounting.

Different varieties of handles are shown in [Plates I-III]. Some are beautifully damascened with silver. These are mostly of the third century, but Sambon reports some damascened handles of the first century. A rare form is seen in a specimen in the Museum at Le Puy-en-Velay, where the handle is round and decorated with a spiral band of silver inlaid round it. It is from the find of the oculist Sollemnis ([Pl. II, fig. 6]).

A few variations from the characteristic combination of handle and spatula-shaped dissector occur. Thus we have a handle ending in a conical point ([Pl. II, fig. 7]), which Deneffe regards as a drill for perforating the nasal septum in cases of fistula lachrymalis. Archigenes describes this operation, and the handle was found in the grave of the oculist Severus. Along with it were found two other handles, which, instead of a spatula, had carried a steel needle ([Pl. II, figs. 1, 2]). The needles have disappeared of course, but there are the holes to receive them. In other cases the handle was round, and either quite plain or ornamented with raised rings. Some of these ended in a small round knob ([Pl. V, fig. 2]). Others carry the head of Minerva Medica like the spoon in [Pl. XX, fig. 5]. There are three of these handles in the Naples Museum. Rufus of Ephesus describes a lithotomy knife which had a scoop at the end of the handle with which to extract the stone. An example of this is seen in the box of scalpels from Athens ([Pl. IV]).

The Blade.

For the study of the different varieties of blade we have at our disposal first of all the specimens that have actually survived. Of these the largest number are to be seen in the Naples Museum, but a considerable number are to be found scattered over various museums. An ex voto tablet found on the site of the temple of Aesculapius on the Acropolis at Athens shows a box of scalpels, among which are some interesting forms ([Pl. IV]). The scalpels, it will be noted, are arranged head and tail alternately. A few varieties are actually described in detail in the classical authors, and, by piecing together other references to particular instruments and drawing inferences from the various uses to which we find them put, we are able to describe a surprisingly large number of forms. The sixteenth-century writers, such as Paré, and seventeenth-century writers, such as Scultetus, illustrate with great confidence many of the cutting instruments mentioned by ancient writers, but it is easy to show that in several instances they are wrong, and, therefore, I have drawn on them as little as possible.

As a basis of classification we may select the following points about the blade. The form may be straight or curved. There may be only one cutting edge or there may be two, and the point may be sharp or blunt. We shall examine combinations of these in the following order:

Ordinary Scalpel.

The ordinary scalpel had apparently a straight, sharp-pointed blade. The word which Galen, Aetius, and Paulus Aegineta use to denote scalpel is σμίλη. Latin authors use scalpellus, the diminutive of scalper. From the etymology of these terms we can learn nothing as to the shape of the blade; they are merely general terms denoting a cutting blade of any kind—chisel, graving tool, knife, &c. The word Hippocrates uses, μάχαιρα or μαχαίριον, has a more definite meaning. It is from μάχαιρα, the old Lacedaemonian sword, a broad blade cutting on one edge, sharp-pointed, and straight or with the tip turned slightly backwards. Thus, even in Hippocratic times the scalpel was apparently much of the same shape as it is now. Good examples of the ordinary scalpel may be seen in [Pl. V, figs. 1 and 2] from the British Museum. They are all of steel. A variety with the point turned back at the tip is seen in one of the scalpels in the scalpel box from the Acropolis ([Pl. IV]).

A more bellied form is seen in [Pl. V, fig. 5], which is from the Naples Museum, and is all of bronze, handle and blade. At the Scientific Congress held at Naples in 1845 Vulpes showed this specimen, and described it as the lithotomy knife invented by Meges and mentioned by Celsus (VII. xxvi).

Later I shall discuss in detail the instrument of Meges, but I believe the instrument shown by Vulpes is only an ordinary scalpel with a somewhat bellied shape.

Hippocrates refers to a bellied scalpel in a well-known passage on empyema (ii. 258):

Ὅκως σοι ἡ ἔξοδος τοῦ πύους εὐρὺς ᾖ τάμνειν δεῖ μεταξὺ τῶν πλευρῶν στηθοειδεῖ μαχαιρίδι τὸ πρῶτον δέρμα.

‘Incise the outer integument between the ribs with a bellied scalpel.’

Στηθοειδής means rounded like the breast of a woman. Galen translates it in his lexicon τῷ σμιλίῳ ἰατρικῷ γαστρωδεῖ, ‘the bellied surgical knife.’ It is quite a serviceable instrument for several kinds of work, and it seems to have been a common form. Three out of the six scalpels depicted in the votive tablet from the Acropolis are of this form, and there are now in the Naples Museum four others of the same shape as the one described by Vulpes. These have blades of steel and handles of bronze. The figures of three of these ([Pl. V, figs. 3-6]), show the gradual evolution from a common scalpel into the bellied form. I have seen a scalpel with a blade similar to [Pl. V, fig. 3] in use in Scotland for castrating piglings and calves.

Scarificator for wet cupping.

Paul (VI. xli) says that some have conceived for the purpose of scarifying before wet cupping an instrument compounded of three blades joined together in such a way that at one stroke three scarifications are made:

Τινὲς οὖν ἐπενόησαν ὄργανον πρὸς τοῦτο, τρία σμιλία ἴσα ζεύξαντες ὁμοῦ, ὅπως τῇ μιᾷ ἐπιβολῇ τρεῖς γίνοιντο διαιρέσεις.

Paul says he prefers a single scalpel.

What the precise shape of scalpel used was we cannot say, but it would most likely be one of the bellied forms. Hippocrates, in his treatise De Medico, says that the lancets used in wet cupping should be rounded and not too narrow at the tip (καμπύλοις ἐξ ἄκρου μὴ λίην στενοῖς). Even if καμπύλος meant curved and not bellied it would not be certain that it was meant to cut on the convex side of the blade. The words of Hippocrates imply at any rate a blade with a rounded, not sharp point (i. 62).

Straight sharp-pointed bistoury.

Greek, σκολοπομαχαίριον, σκολόπιον; Latin, scalpellus.

The etymology of the term σκολοπομαχαίριον as applied to a cutting instrument sufficiently indicates its shape. It takes its name from its similarity to the beak of a snipe, which is long and slender[1]. We find it used by Galen (xi. 1011) for dissecting out warts, excising caruncles from the inner canthus, puncturing the foetal cranium in obstructed labour, &c.

In Aetius (IV. iv. 23) and Paulus Aegineta (VI. lxxiv) it is used for opening not only the foetal cranium but also the thorax and abdomen of the foetus in transverse presentations. Paul refers to it for opening the thorax in empyema (VI. xliv) and the abdomen in ascites (VI. l). In both cases the outer integument was incised with a scalpel and the deeper layer punctured with the bistoury. In opening the abdomen for ascites, by sliding the outer skin upwards before the peritoneal cut was made, a valvular opening was secured. Although many other interesting applications of this instrument are to be found, these instances will suffice to show that the uses to which the instrument was put agree with the supposition that it was of the shape indicated by the etymology of its name. A variant form of the same name is σκολόπιον which also occurs pretty often.

A large variety of this instrument is mentioned by Galen as devised by him for the dissection of the spinal cord. He says he uses a knife of the same shape as the scolopomachaerion, but larger and stouter and made of the best Norican steel, so as to neither blunt, bend, nor break easily (ii. 682).

Razor.

Shaving and cutting the hair were looked upon as important means of treatment in several diseases. Oribasius (Med. Coll. xxv) has a chapter on this entitled περὶ κουρᾶς καὶ ξυρήσεως. ‘These things,’ he says, ‘have been introduced into medicine as a means of evacuation and as remedies in chronic diseases.’

Celsus makes frequent mention of shaving as a means of treatment. Of alopecia he says:

Sed nihil melius est quam novacula quotidie radere—quia, cum paulatim summa pellicula excisa est, adaperiuntur piloram radiculae. Neque ante oportet desistere quam frequentem pilum nasci apparuerit (VI. iv).

A large scalpel of this form from the Naples Museum is shown in [Pl. VI, fig. 1]. The handle is of the usual shape and is made of bronze. The blade is of steel. It measures 15 cm. all over, the blade being 2 cm. broad at the heel. The cutting border slopes backward to the back of the blade, which is in a straight line with the border of the handle. At the point the blade is 1·5 cm. broad. It may be noted that this instrument had much the same shape as the culter, but culter is not a term applied by any Latin author to a surgical instrument, nor is cultellus, although the sixteenth-century translators of Aetius and Paulus Aegineta very frequently use the latter term. Scultetus figures a scalpel of this form and sums up its uses well:

La fig. est un rasoir ou scalpel droit ne tranchant que d’un coste et de l’autre mousse, dont les chirurgiens se servent lorsqu’il ne faut avoir aucun égard aux parties sujettes, scavoir lorsqu’il s’agit de faire des incisions au cuir de la teste jusqu’au crane, &c.

Another specimen also of this class, but with the blade so long in proportion to its width as to deserve the name of a blunt-pointed bistoury was excavated in a third-century graveyard at Stree, and is now in the Charleroi Museum. It is 14 cm. long by 1 cm. broad at the heel, widening gradually towards the point where it is 2 mm. broader than at the heel. The end of the blade is square ([Pl. VI, fig. 2]). An example of the domestic culter or cultellus is shown in [Pl. VII, fig. 4]. It is from a Roman camp at Sandy in Bedfordshire.

In the curious pseudo-Hippocratic treatise (i. 463) a knife to fix on the thumb and dismember a foetus in utero is mentioned:

Ἔχειν δὲ χρὴ πρὸς τὰ τοιαῦτα καὶ ὄνυχα ἐπὶ τῷ δακτύλῳ τῷ μεγάλῳ. καὶ διελόντα ἐξενεγκεῖν τὰς χεῖρας κτλ.

‘If, however, the foetus be dead and remain, and cannot either spontaneously or with the aid of drugs come away in the natural manner, having liberally anointed the hand with cerate and inserted it in the uterus endeavour to separate the shoulders from the neck with the thumb. It is necessary to have for this a ‘claw’ upon the thumb and, the amputation having been performed, to extract the arms and, again inserting the hand, to open the abdomen and, having done so to remove the intestines, &c.’

An instrument answering to this description is still in use by veterinary surgeons ([Pl. VII, fig. 1]), but the forefinger, and not the thumb, is used. A scalpel blade is mounted on a ring and the forefinger is passed through the ring. Foals and calves are in this way easily dismembered in exactly the same way as is described by Hippocrates. The name of the instrument of Hippocrates would rather indicate that its blade was curved, but as the modern instrument has a probe point I have included it in this class. It is called by Tertullian the ‘ring knife’—‘cum annulo cultrato (var. lect. anulocultro) quo intus membra caeduntur anxio arbitrio’ (De Anima, 26).

Galen’s knife for opening the vertebral canal.

In his description of the dissection of the spine Galen describes a large straight two-edged knife (ii. 682):

Καθίημι τὸ πρόμηκες μαχαίριον, οὕτω γὰρ αὐτὸ καλῶ δύο πλευρὰς ὀξείας ἔχον ἐπὶ τοῦ πέρατος εἰς μίαν κορυφὴν ἀνηκοῦσας.

‘I push in the ‘long scalpel’, for thus I describe the one with two cutting edges meeting in one at the tip.’

What Galen means by πρόμηκες when applied to an instrument he has himself explained in a note on the chapter by Hippocrates on the treatment of dislocation of the shoulder. He applies it to instruments long in proportion to their breadth (see [p. 118]). The knife referred to here is a large strong instrument, for it is intended for cutting through the lateral processes of the vertebrae.

Phlebotome.

Greek, φλεβοτόμον, τὸ (sc. σμιλίον), also φλεβοτόμος, ὁ (Galen). ὀξυβελές (sc. ὄργανον); Latin, phlebotomum (late), scalpellus.

Although venesection is one of the most frequently mentioned operations, and although the phlebotome is one of the most frequently named instruments, we have no passage giving even the most meagre description of this instrument. It is assumed that its appearance would be familiar to every one, since phlebotomy was so common. Celsus tells us that every one old and young was bled.

Sanguinem, incisa vena, mitti, novum non est, sed nullum paene morbum esse in quo non mittatur novum est (II. x).

The operation continued just as frequent all through the Roman period, and the writings on venesection are very voluminous. Galen has three treatises on the subject. The operation was performed in exactly the same way as at the present day, and the lancet was apparently the same as that figured in modern instrument catalogues, viz. sharp-pointed, double-edged, and straight. A consideration of all the various operations to which the phlebotome was put bears this out. The following passage from Hippocrates shows that there were various sizes of the phlebotome:

Τοῖς γε μαχαιρίοις ὀξέσι δεῖ χρῆσθαι καὶ πλάτεσι, οὐκ ἐπὶ πάντων ὁμοίως παραγγέλλομεν, κτλ. (i. 60).

‘We do not recommend that the lancets narrow and broad should be used indiscriminately in all cases, for there are certain parts of the body which have a swift current of blood which it is not easy to stop. Such are varices and certain other veins. Therefore, it is necessary in these to make narrow openings, for otherwise it is not possible to stop the flow. Yet it is sometimes necessary to let blood from them. But in places not dangerous, and about which the blood is not thin, we use the lancets broader (πλατυτέροις χρῆσθαι τοῖς μαχαιρίοις), for thus and not otherwise will the blood flow.’

The phlebotome appears to have been a convenient instrument for all sorts of operations besides phlebotomy, especially for the opening of abscesses and the puncture of cavities containing fluid, and for fine dissecting work. Paulus Aegineta mentions its application for the excision of fistula lachrymalis (VI. xxii), the removal of warts (VI. lxxxvii), slitting the prepuce in phimosis (VI. lv), incising the tunica vaginalis in excision of hydrocele sac (VI. lxii), opening abscesses (VI. xxvii), dissection of sebaceous cysts (VI. xiv). Galen (xiv. 787) mentions its use in dissecting open an imperforate vagina. Celsus has no special word for phlebotome. He always refers to it by the general term scalpellus. Theodorus Priscianus, whose Latin takes curious forms, gives us a transliteration of the Greek term:

Convenit interea prae omnibus etiam his flebotomum adhibere, convenit etiam eos ventris purgatione iuvari (Euporiston, xxi. 66).

Hippocrates in the famous passage on the surgical treatment of empyema (ii. 258) says:

‘Incise the skin between the ribs with a bellied scalpel, then let a phlebotome (ὀξυβελεῖ) which has been wound round with a rag, leaving the breadth of the thumb nail at the point, be pushed in.’

Ὀξυβελής literally means sharp-pointed. The term occurs in the Iliad, e. g. applied to an arrow (iv. 126), but Galen in his Lexicon expressly states that Hippocrates by it means the phlebotome. In his treatment of empyema Paulus Aegineta uses not the phlebotome but a sharp curved bistoury; however, in opening the abdomen for ascites it is the phlebotome he recommends:

‘We take a curved bistoury or a phlebotome and, having with the point of the instrument dissected the skin that lies over the peritoneum, we divide the peritoneum a little higher up than the first incision, and insert a tube of bronze.’

All these various applications of the phlebotome are consistent with the supposition that the phlebotome was the same as that figured in the catalogues of the present day. Heister says:

Spectant huc primo loco ea quae Tab. 1 sub litt. A & B ([Pl. VII, figs. 6, 7]) exhibentur, scalpellum nempe minus et maius; vulgus lancettas eadem nominant. Serviunt eadem, praesertim minora, venis incidendis, quare phlebotoma Graecis vocantur; sed et abscessibus aperiendis, imprimis maiora; ideoque Gallis etiam lancettes a l’absces appellari consueverunt.

A bronze blade of this shape is shown in [Pl. VII, fig. 3]. It was found near Rome.

The identity in shape of the abscess knife and the phlebotome holds good to-day. The best example of the phlebotome is in the Cologne Museum. It was found in the Luxemburgerstrasse along with the other contents of a surgeon’s case. It is all of steel, with a square handle and blade of myrtle leaf shape ([Pl. VII, fig. 2]). There is in the Naples Museum an instrument which is of this shape, and Vulpes (Tav. VI, fig. 1) has described it as a lancet for bleeding. The instrument, however, is formed of a blade of silver set in a handle of bronze, so that it can scarcely be regarded as a cutting instrument (see [Pl. XIX, fig. 2]). I look upon it as an unguent spatula. There is, however, an instrument of bronze of phlebotome shape in the Naples Museum. It was found in the house of the physician in the Strada del Consulare of Pompeii, and it was described by Vulpes as an instrument for removing the eschar formed by a cautery, as it was found lying alongside a small trident-shaped cautery. It is doubtful whether the eschar formed by a cautery was removed at all, and it is still more doubtful whether Vulpes is justified in postulating a special instrument for doing so, and as this instrument is of phlebotome shape it is more likely to have been a phlebotome than anything else. It is of bronze, 8 cm. long and 9 mm. in the broadest part of the blade. The handle is neatly decorated with raised ring ornamentation.

The following account of the discovery of a phlebotome in excavating some graves along the line of the old Watling Street Road, in the neighbourhood of Wroxeter, is given by C. Roach Smith in the Gentleman’s Magazine (1862, pt. ii. p. 677):

‘Several sepulchral interments have been met with of a character similar to those usually found in Roman cemeteries. In some of them objects of particular interest were found, with urns and other earthen vessels; as, for instance, the fragments of a circular mirror in the bright, shining, mixed metal commonly known as ‘speculum’ metal; and what appears to be a surgeon’s lancet, contrived in a very ingenious manner. The point for penetrating the flesh is of steel, not unlike that in use at the present day. It is surmounted by a guard to hinder it from cutting too deeply, and above this is a handle, which is bow-shaped, and of bronze.’

J. Corbet Anderson, in The Roman City at Wroxeter, p. 92, says it was embedded in the remains of a case in which it had been carried, and he gives an illustration of it ([Pl. VII, fig. 5]). A similar object is classified as a surgical instrument in the Louvre, but both these articles are I believe detached mirror handles. The passage quoted from Hippocrates shows that the ordinary phlebotome was not guarded in this way. A phlebotome of the principle of the fleam is figured by Albucasis and the method of using it in dividing the frontal vein by striking it with a comb is described. There is also a similar instrument in the Naples Museum, from Pompeii, which is classed as a veterinary instrument ([Pl. VIII, fig. 3]). It is probable, however, that such an instrument was used by Roman physicians, as the offices of surgeon and veterinarian were often held by the same individual in Roman times. It is not unlikely that the method is referred to by Antyllus in the passage beginning—ποτὲ μὲν καταπείροντες ποτὲ δὲ ἀναπείροντες φλεβοτοῦμεν (Oribasius, Collect. VII. x).

This passage describing the technique of phlebotomy has given rise to great and voluminous discussion (see Daremberg’s Oribas. vol. ii. p. 776) from the fact that Antyllus goes on to state that we operate καταπείροντες—cutting inwards—in cases where the vessels are deep, and ἀναπείροντες—cutting outwards—where the vessels are superficial, and the advice has seemed to most commentators to be the reverse of what one would expect. The explanation seems to me to be simple. Superficial vessels are those which could be seen standing out on applying the fillet, and were to be divided by the method in vogue at the present day by transfixing the vessel through its middle and bringing the lancet outwards. The reason of this is that the danger of injuring important structures lying deep to the vein was well understood by the ancients. Thus Galen warns against wounding the nerve in phlebotomy of the median, the tendon of the biceps in phlebotomy of the scapulo-cephalic, the artery in dividing the basilic, and so on. But in opening deep-lying veins the method of transfixing was inapplicable, and the bone was cut boldly down upon till the issue of blood showed that the vein was opened. The deep vessels which were divided were those about the scalp, and as they had no important relations they were divided by cutting through everything overlying the bone, often with razor-shaped knives. Thus Paulus Aegineta (VI. vii) says: ‘When many deep vessels send a copious defluxion to the eyes we have recourse to the operation called Periscyphismus.’ This consisted in making a transverse incision down to the bone over the vertex from one temple to the other.

The ‘Katias.’

Κατιάς -ιάδος (ἡ) (Soranus, II. xviii); καθιάς (Paul, VI. lxxiv); κατιάδιον (τό) (Aetius, II. iii. 2); κατειάδιον (τό) (Aretaeus, Cur. Morb. Diut. i. 2).

In Soranus (Bib. II. xviii. par. 59, p. 359, ed. Rose) there occurs mention of an instrument for puncturing the membranes where they do not rupture spontaneously:

Χόριον δὲ μὴ ἀναστομούμενον κατιάδι προσεχόντως διαιρεῖν τῷ δακτύλῳ προκοιλάναντα τι μέρος.

The Latin version of Moschion has:

Folliculum verum non ruptum ante digito impresso formantes locum phlebotomo sollicite dividimus omnibus praedictis post encymatismis utimur (xviii. 10, p. 83, ed. Rose).

However, we cannot accept this as conclusive evidence that the katias was the same as the phlebotome, as I have already pointed out that this version of Moschion is a late retranslation into Latin of a Greek translation of the original Moschion. While the meagre references to the katias point to its having been a similar instrument to the phlebotome, it is by no means certain that the instruments were identical. The next writer who notices the instrument is Aretaeus, who mentions it in the cure of headaches (Cur. Morb. Diut. i. 2):

‘We abstract blood from the nostrils, and for this purpose push into them a long instrument named κατειάδιον, or the one called the scoop’ (τορύνη).

In a note to his edition of Celsus, Lee says Aretaeus ‘invented an instrument having at the end a blade of grass, or made like a blade of grass, which was thrust into the nostrils to excite an haemorrhage in some affections of the head. This instrument is named κατειάδιον, from κατά and εἴα a blade of grass’.

I have shown, however, that Soranus, who wrote a century before Aretaeus, used the term, and a comparison of the various forms in which the word appears seems to me to point rather to a connexion with καθίημι, one meaning of which is ‘to let blood’. The next writer who mentions it is Aetius (II. iii. 2, and again II. iv. 14), where he refers to its use in opening quinsy, in a chapter copied from Leonidas:

‘If the patient be adult make him sit down, and, opening his mouth, depress the tongue with a spatula or a tongue depressor, and open the abscess with a scalpel or katias’ (σμιλαρίῳ ἢ κατιάδι).

Paul says that abscess of the womb is to be exposed with a speculum and opened with a scalpel or katias (σπαθίῳ ἢ κατιάδι). Paul also refers to it in perforating the foetal cranium in delivery obstructed through hydrocephaly (πολυπικῷ σπαθίῳ ἢ καθιάδι ἢ σκολοπομαχαιρίῳ) (VI. lxxiv).

These somewhat scanty materials, summed up, give us the following results. We find the instrument used for opening the chorion, opening abscess of the womb, perforating the foetal cranium, drawing blood from the inside of the nose, and opening abscess of the tonsil. It cannot have been a needle, as Adams and Cornarius translate it, as some of these applications (e. g. perforating the foetal cranium) could not have been performed with a needle. The uses to which the instrument was put correspond very closely to the uses of the phlebotome, and from this and from the etymological significance of the word I am inclined to think that if it is not identical with the phlebotome it is at least only a variety of that instrument, with a handle longer than usual in order to adapt it for uterine and intranasal operations.

Spathion and Hemispathion.

Greek, σπαθίον (diminutive of σπάθη), ἡμισπάθιον; Latin, spatha.

On several occasions a knife called σπαθίον is mentioned. Paul (VI. lxxiii) says of abscess of the womb:

‘When the abscess is explored, if it is soft (and this may be ascertained by touching it with the finger) it is to be opened with a spathion or a needle knife’ (σπαθίῳ ἢ κατιάδι).

Again, Paul (VI. lxxviii) says:

Find the orifice of the fistula, pass an ear probe through it and cut down upon it. Divide the whole fistula with a hemispathion or a fistula-knife (ἡμισπαθίῳ ἢ σπαθίῳ συριγγοτόμῳ).

What the nature of the σπαθίον was, if indeed it was a distinct instrument and not a term for scalpels in general, we cannot definitely say. The etymology of the word would indicate a blade of the shape of a weaver’s spattle, the two edges running into one at the point. Heister (i. 651) and Rhodius (Commentar. in Scrib. Larg. p. 46) agree in making the spathion a large two-edged scalpel, as also does Scultetus, who says of it:

Scalpellum ancipitem esse utrimque acutum et in superiore parte paulo latum, qui in extremitate sua in unam cuspidem coiret (Arm. Chir. Tab. II, fig. 1).

We shall see that one variety of spathion—that for detaching nasal polypus—was certainly of this shape.

Rhodius (loc. cit.) says the hemispathion is a small variety of the spathion.

An instrument in the Louvre has two blades of this shape at either end of a round handle ornamented with rolling grooves ([Pl. VIII, fig. 8]).

Polypus Knife.

Greek, πολυπικὸν σπαθίον, πολυποδικὸν σπαθίον; Latin, ferramentum acutum modo spathae factum.

Paulus Aegineta (VI. xxv) thus describes the excision of nasal polypus:

‘Holding in his right hand the polypus scalpel, which is shaped like a myrtle leaf and sharp pointed (πολυπικῷ σπαθίῳ τῷ μυρσινοειδεῖ ἀκμαίῳ), we cut round the polypus or fleshy tumour, applying the point of the steel blade (τὴν ἀκμὴν τοῦ σιδήρου) to the part where it adheres to the nose. Afterwards turning the instrument end for end (ἀντιστρέψαντες) we bring out the separated fleshy body with the scoop’ (τῷ κυαθίσκῳ).

This description reminds us very forcibly of Celsus’s account of the operation:

Ferramento acuto modo spathae facto, resolvere ab osse oportet. Ubi abscissus est unco ferramento extrahendus est (VII. x).

These passages, especially that from Paul, show that like the majority of Roman instruments the polypus scalpel was a double instrument, with a sharp-pointed leaf-shaped blade at one end and a scoop at the other. The fact that it was able to work inside the nose shows that it could not have been of any great breadth. Paul says it was able to be used in the auditory canal.

‘If there be a fleshy excrescence it may be excised with a pterygium knife or the polypus scalpel’ (VI. xxiv).

This shows that it was less than a quarter of an inch broad at the most. It was used for several other purposes. Soranus refers to it for opening the foetal head in cranioclasis:—

Εἰ δὲ μείζονος τοῦ κεφαλίου ὑπάρχοντος ἡ σφήνωσις ἀποτελοῖτο, διὰ τοῦ ἐμβρυοτόμου ἢ τοῦ πολυπικοῦ σπαθίου κρυπτομένου μεταξὺ λιχανοῦ καὶ τοῦ μακροῦ δακτύλου κατὰ τὴν ἔνθεσιν (xviii. 63).

Paul copies this (VI. lxxiv). Soranus also says it may be used for dividing the membranes where they delay in rupturing.

There are two instruments of steel which are of the form indicated above. One is in the Museum of Montauban (Tarne-et-Garonne). The other was found at Vieille-Toulouse and is shown in [Pl. VIII, fig. 1].

Lithotomy Knife.

Greek, λιθοτόμον (τό); Latin, scalpellus.

In describing lithotomy Paul says:

‘We take the instrument called the lithotomy knife (τὸ καλούμενον λιθοτόμον), and between the anus and the testicles, not however in the middle of the perinaeum, but on one side, towards the left buttock, we make an oblique incision cutting down straight on the stone where it projects’ (VI. lx).

Celsus, whose description of the operation is famous, gives us no more hint of the shape of the lithotomy knife than Paul does. He only says ‘multi hic scalpello usi sunt’, and as he uses ‘scalpellus’ to denote all sorts of different knives, we can draw no information from that term. We may note, however, that both Celsus and Paul describe the operation as being performed by fixing the stone by means of the left index finger inserted in the anus, and cutting down directly upon it with one stroke as in opening an abscess. Now this sort of incision was always performed by early surgeons with a two-edged scalpel sharp at the point, and a knife of this sort was used for lithotomy by the Arabian surgeons, and after them by European surgeons down to comparatively recent times. Heister, for instance, shows as a lithotomy knife a large knife, like a phlebotome in shape. It is most likely, therefore, that the Greeks and Romans used a knife of this shape also.

A passage in Rufus of Ephesus shows that in his time the lithotomy knife had the handle shaped like a hook to extract the stone after the perineal incision was made:

Καὶ εἰ μὲν πρόχειρος εἴη, τῇ λαβῇ τοῦ μαχαιρίου ἐκβάλλειν, πεπιεσμένον δὲ τῇ λαβῇ τραχείᾳ τε καὶ καμπύλῃ ἐξ ἄκρου, ὡς ἂν μάλιστα συμφέροι τῷ ἔργῳ.

‘And if it (the stone) be at hand we must eject it with the handle of the knife, made with the handle roughened and curved at the tip, as best suited for the operation’ (ed. cit. p. 52).

One of the knives in the scalpel box shown in [Pl. IV] has the handle of this curved shape.

Although Celsus gives us no information about the shape of the ordinary lithotomy knife, he goes on to describe in detail a special variety of lithotomy knife invented by Meges, a surgeon of whom he had a very high opinion. As this passage has given rise to much discussion I shall quote Celsus’s description in full:

Multi hic quoque scalpello usi sunt. Meges (quoniam is infirmior est potestque in aliquam prominentiam incidere, incisoque super illam corpore qua cavum subest, non secare sed relinquere quod iterum incidi necesse sit) ferramentum fecit rectum, in summa parte labrosum, in ima semicirculatum acutumque. Id receptum inter duos digitos, indicem ac medium, super pollice imposito, sic deprimebat ut simul cum carne si quid ex calculo prominebat incideret, quo consequabatur ut semel quantum satis esset aperiret (VII. xxvi).

‘Here many have used the scalpel. Meges (since it is rather weak and may cut down upon some projecting part, and while the tissues overlying that are divided it may not divide those where there is a hollow underneath, but may leave a portion which requires to be divided afterwards) made an instrument straight, with a projecting lip at the heel and rounded and cutting at the tip. This, held between the two fingers, index and middle, the thumb being placed on the top, he pushed down so as to divide not only tissues but any projecting portion of the calculus, and as a consequence at one stroke he made a sufficient opening.’

Etangs in his edition of Celsus gives as his idea of the instrument described an instrument of the shape indicated in the accompanying diagram ([Pl. VIII, fig. 6]). Thus he makes the cutting edge a concave semicircle, and therefore we may dismiss his conjecture, for a cutting edge on this principle would never cut its way into the bladder in the manner described by Celsus.

Daremberg (Gaz. Med. de Paris, 1847, p. 163, &c.) conjectures an instrument which seems to me to be nearer the true interpretation ([Pl. VIII, fig. 4]). This instrument, with some modification, I would accept. The lunated handle figured by Daremberg is not strictly speaking what is meant by labrosum, and summa parte I take to refer to the back part of the blade, and not to the back part of the instrument as a whole. Rectum I take to indicate that the instrument was straight and not a curved bistoury. I conceive that the lithotomy knife of Meges was only a modification of the one in general use, and that in order to enable it to be held more firmly in the manner described by Celsus, Meges raised a lip on the handle at the heel of the blade, and in order to allow it to cut its way into the stone itself to some extent (which was his avowed object) he rounded the end of the blade, so that it might be rocked upon the stone without chipping as a pointed blade would do. I think the above explanation provides an instrument corresponding to a legitimate interpretation of the text and at the same time suited for the operation indicated ([Pl. VIII, fig. 5]).

Perforator for the foetal cranium.

Greek, ἐμβρυοτόμον.

A special instrument for perforating the foetal cranium is mentioned by Soranus (II. viii. p. 366):

Εἰ δὲ μείζονος τοῦ κεφαλίου ὑπάρχοντος ἡ σφήνωσις ἀποτελοῖτο, διὰ τοῦ ἐμβρυοτόμου ἢ τοῦ πολυπικοῦ σπαθίου κρυπτομένου μεταξὺ λιχανοῦ καὶ τοῦ μακροῦ δακτύλου κατὰ τὴν ἔνθεσιν.

‘If the head be too big, the obstruction may be removed by the embryotome, or the polypus knife, concealed between the index finger and the thumb during its introduction.’

The other authors who recommend this unpleasant operation use mostly the polypus-scalpel or the phlebotome, and hence we may conjecture that a straight two-edged blade was considered the most suitable. The embryotome figured by Albucasis is of this shape ([Pl. VIII, fig. 7]), as is also the cutting part of the perforators of more modern times—fortunately now obsolete.

Probe pointed blade with two cutting edges.

There is in the Orfila Museum, Paris, a fine little two-edged bistoury of bronze with a probe point ([Pl. VIII, fig. 2]). It is a relic of the Roman occupation of Egypt. Its use must remain a matter of conjecture as we have no written description of such an instrument. It is perhaps a fistula knife.

II A. (a) Curved bistoury—‘Crow Bill.’

Greek, ὀξυκόρακον σμίλιον.

In extirpating warts Paul (VI. lxxxvii) says we put them on the stretch with a vulsella and extirpate them radically with a scalpel shaped like a crow’s beak or a phlebotome (ὀξυκοράκῳ σμιλίῳ ἢ φλεβοτόμῳ ἐκ ιζῶν ἐξελεῖν). This undoubtedly refers to a curved scalpel, for the grappling hook was called κόραξ.

In Celsus the instrument appears under the term corvus. In describing the opening of the scrotal sac in the operation for the radical cure of hernia he says:

Deinde eam ferramento, quod a similitudine corvum vocant, incidere sic ut intrare duo digiti, index et medius, possint (VII. xix).

Vulpes (Tav. VII, 3 and 4) figures two curved bistouries from the Naples Museum. They have lost their tips. Both are of the same shape, but one has the blade slightly larger than the other. The handles are of bronze, the blades of steel. A good example is seen in the Athens scalpel box ([Pl. IV]).

A powerful variety so strongly curved as to resemble a small billhook was found in the Roman hospital at Baden ([Pl. IX, fig. 5]). The handle is of ivory, the blade is of steel, and there is a mounting of bronze.

Pterygium Knife.

Greek, πτερυγοτόμος, ὁ; Latin, scalpellus.

Paul (VI. xviii), quoting Aetius, II. iii. 60, says that there were two methods of curing pterygium. In the first the pterygium was raised by a small sharp hook, and a needle carrying a horsehair and a strong flaxen thread was passed under it. Tension being made on the thread by an assistant, the operator sawed off the pterygium towards the apex by means of the horsehair. The base of the pterygium was then severed with the scalpel for the plastic operation on entropion. The second method consisted in dissecting away the pterygium (stretched as aforesaid with a thread) with the instrument called the pterygotome (πτερυγοτόμῳ) care being taken not to injure the lids.

Aetius (II. iii. 74) says that adhesion of the sclerotic to the lid may be separated by means of the pterygotome. Paul (VI. xxii) in empyema of the lachrymal sac dissects out the part between the sac and the canthus with the pterygotome, and again in excision of polypus aurium he says it may be employed. These uses of the pterygotome point to its having been a sharp-pointed knife of a small size. Albucasis, who conveys entire the passage on pterygium from Paul, gives figures of both these instruments. The pterygotome which Albucasis depicts is a small, narrow, sharp-pointed scalpel ([Pl. IX, fig. 2]).

Knife for plastic operation on the eyelid.

Greek, ἀναρραφικὸν σμιλίον.

I have in describing the pterygotome given one instance of the use of the ‘scalpel for the plastic operation’, viz. to dissect away the base of a pterygium the rest of which had been separated off by means of sawing with a horsehair. The plastic operation for entropion seems to have been one which was very frequently required. We know that granular ophthalmia with trichiasis as a sequela was very rife. Aetius (quoting from Leonidas) and Paul give very nearly the same account of the operation to remedy the trichiasis. Paul says:

‘Having placed the patient on a seat either before us or on the left hand, we turn the upper eyelid outwards, and if it has long hairs we take hold of them between the index finger and thumb of the left hand; but if they are very short we push a needle having a thread through the middle of the tarsus from within outwards. Then stretching the eyelid with the left hand by means of this thread, with the point of the scalpel held in the right hand, having everted the eyelid, behind the thread we make the inferior incision inside the hairs which irritate the eye, extending from the larger canthus to the smaller along the tarsus. After the inferior incision, having extracted the thread and having put a small compress under the thumb of the left hand, we stretch the eyelid upwards. Then arranging other small compresses on the canthi at their extremities we direct the assistant, who stands behind, to stretch the eyelid by means of them. Then by means of the ‘scalpel for the plastic operation’ (ἀναρραφικοῦ σμιλίου) we make the first incision called the ‘arrow-shaped’ a little above the hairs which are normal, extending from canthus to canthus and penetrating only the depth of the skin. Afterwards we make the incision called the crescent-shaped, beginning at the same place as the former and carrying it upwards to such a height as to enclose the whole superabundant skin and ending in like manner as it did. Thus the whole skin within the incision will have the shape of a myrtle leaf. Having perforated the angle of this portion with a hook we dissect away the whole skin. Then washing away the clots with a sponge we unite the lips of the incision with three or four sutures’ (VII. viii).

The use of the scalpel for the plastic operation, therefore, was to make an incision in the eyelid in such a way as to enclose a leaf-shaped area and to dissect off the skin surrounded by the incision. Albucasis figures it as a small but fairly broad blade with a rounded cutting tip ([Pl. IX, fig. 3]).

It must have been a small scalpel to suit the operation described, and to make the dissection indicated it must have been sharp-pointed. It is contrasted to some extent with the pterygotome by Paul, and we saw that the pterygotome was narrow and sharp-pointed. These various references to its use are in agreement with the supposition that it was of the shape figured by Albucasis. I have considered it here because the question of its shape is rather hypothetical, and therefore it seemed best to consider it close by its confrere the pterygotome. We may recall the fact that in the grave of the third-century oculist Severus several tiny scalpel handles were found. These were probably handles for these two ophthalmic scalpels, but unfortunately only a trace of the steel remains. Védrènes, in his edition of Celsus, figures an instrument from Pompeii of a shape which we are accustomed to associate with eye work ([Pl. IX, fig. 6]).

Uvula Knife.

Greek, σταφυλοτόμον.

This is a special scalpel for throat work, of whose shape we know nothing. It is mentioned by Paul as a special scalpel for excision of the uvula:

‘Wherefore, having seated the patient in the sunlight and directed him to gape wide, we seize with the uvula forceps or a common tenaculum upon the elongated part and drag it downwards and excise it with the instrument called the uvula knife (σταφυλοτόμῳ), or the scalpel used for the plastic operation on the eyelid’ (VI. xxxi).

The knife figured by Albucasis as used for the purpose is a small curved bistoury ([Pl. IX, fig. 4]). We have no other means of determining its shape. I have placed it here because it was mentioned along with the ‘scalpel for the operation on the eyelid’.

Blade curved on the flat.—Tonsil Knife.

Greek, ἀγκυλοτόμον (ἀγκύλη, ‘bend of elbow,’ or ἀγκύλος, ‘crooked’).

This instrument is described by Paul (VI. xxx) in the operation for removing the tonsils:

‘Wherefore, having seated the patient in the sunlight, and directed him to open his mouth, one assistant holds his head and another presses down the tongue with a tongue depressor. We take a hook and perforate the tonsil with it and drag it outwards as much as we can without dragging the capsule out along with it, and then we cut it off by the root with the tonsillotome (ἀγκυλοτόμον) suited to that hand, for there are two such instruments having opposite curvatures. After the excision of one we may operate on the other in the same way.’

This passage clearly proves that there were two scalpels of a set, each having opposite curvatures after the manner of our right and left vesicovaginal fistula knives.

Curved blade cutting on one side, blunt-pointed.—Fistula Knife.

Greek, συριγγοτόμον, from σῦριγξ, ‘a fistula.’

This was a falciform blade whose end was blunt, but the handle end was prolonged into a slender, rounded sound-like portion with a sharp point ([Pl. IX, fig. 1]). The narrow point was passed into a fistula, caught, and the whole instrument pulled outwards by means of it, thus dividing the overlying tissues with the falciform blade. This instrument remained in use till comparatively recent times. Heister figures a large number of varieties, and from him I have taken the figure shown, although it is also described and figured by Fabricius. The two following passages, taken in conjunction with each other, show that the classical instrument was of the form I have indicated. The first passage, from Galen, shows that the end of the blade was blunt, and that there was only one cutting side. The second, from Paul, shows that the blade was falciform and was operated in the manner I have stated. Galen (x. 415) says that in enlarging an abdominal wound we use a fistula knife (συριγγοτόμῳ). ‘But the scalpels which are two-edged or have a point are distinctly to be avoided’ (τὰ δ' ἀμφήκη τῶν μαχαιρίων ἢ κατὰ τὸ πέρας ὀξέα παντὶ τρόπῳ φευκτέα).

Secondly, Paul (VI. lxxviii) says:

‘Having perforated the bottom of the fistula with the point of the falciform part of the syringotome (τοῦ δρεπάνου τοῦ συριγγοτόμου) bring the instrument out of the anus and so divide all the intervening space with the edge of the falciform part’ (τῇ ἀκμῇ τοῦ δρεπάνου).

Another passage in the same chapter indicates that some of the syringotomes had an eye in the instrument:

Τινὲς δὲ ἐν τῷ τρήματι τοῦ συριγγιακοῦ δρεπάνου τὸ λίνον ἐνείραντες.

There was also a straight variety of the instrument (τὰ καλούμενα ὀρθὰ συριγγοτόμα, Paul, VI. lii).

Curved blade cutting on two edges.

A curved blade of a somewhat unusual type is described by Galen in discussing the dissection of the thorax (ii. 673). However, the description is unmistakably clear. He says:

Χρῆσθαι δ' αὐτῆς μάλιστα τῷ κυρτῷ μέρει κεχαλκευμένης ὁμοίως ἑκατέρωθεν, ὥστε ἀμφικύρτους ἔχειν ἀμφότερας τὰς τεμνούσας γραμμὰς ἀλλὰ κατὰ μὲν τὴν ἑτέραν σιμῆς, κατὰ δὲ τὴν ἀντικειμένην ταύτῃ κυρτῆς.

‘It is best to have the curved part forged alike on both sides so that the cutting edges are curved in two ways, viz. one concave and the other convex.’

A smaller variety for fine dissection is referred to in the same book (εἰς ὅπερ ἐστὶν ἐπιτηδειοτάτη μυρσίνη κυρτή, ii. 674).

Shears.

Greek, ψαλίς; Latin, forfex.

Oribasius treats of cutting the hair as a regular medical procedure, in a special chapter, περὶ κουρᾶς καὶ ξυρήσεως. Celsus also frequently refers to cutting the hair as a therapeutic measure. Possibly the ancients found difficulty in putting an edge sufficiently smooth for surgical purposes on their shears. We have a few references to the use of the shears for cutting tissues. Celsus, in the treatment of abdominal injury with protusion of omentum, says:

Omentum quoque considerandum est: ex quo, si quid iam nigri et emortui est, forfice excidi debet: si integrum est, leniter super intestina deduci (VII. xvi).

Again in the operation for the radical cure of hernia he says:

Fuerunt etiam qui omentum forfice praeciderent: quod in parvulo non est necessarium; si maius est, potest profusionem sanguinis facere, siquidem omentum quoque venis quibusdam etiam maioribus illigatum est. Neque vero, si discisso ventre id prolapsum forfice praeciditur, quum et emortuum sit et aliter tutius avelli non possit, inde huc exemplum transferendum est (VII. xxi):

‘There have been others who cut away the omentum with scissors, which is unnecessary if the portion is small; and if very great it may occasion a profuse haemorrhage, since the omentum is connected with some of even the largest veins. But this objection cannot be applied in cases where, the belly being cut open, the prolapsed omentum is removed with shears, since it may be both gangrenous and unable to be removed in any other way with safety.’

We have also two references in Paulus Aegineta. He says some of the moderns effect a cure of warty excrescences on the penis by a pair of shears (ψαλίδι, VI. lviii), and dealing with relaxation of the scrotum he says that Antyllus, having first transfixed the superfluous skin with three or four ligatures, cut off what was external to them with a pair of sharp-pointed shears or a scalpel (ψαλίδι ἐπάκμῳ ἢ σμίλῃ), and having secured the parts with sutures he effected healing with the treatment for recent wounds.

Shears are very common objects in museums. Some are of bronze and some are of steel. Judging from the relative numbers in which they have been preserved it would seem that the steel shears far outnumbered the bronze. In [Pl. X, fig. 5] is shown a bronze pair from the Naples Museum, found in Pompeii.

CHAPTER IV

PROBES

Greek, μήλη, κοπάριον, ὑπάλειπτρον, ὑπαλειπτρίς; Latin, specillum.