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diff --git a/40424.txt b/40424.txt deleted file mode 100644 index fad69db..0000000 --- a/40424.txt +++ /dev/null @@ -1,9343 +0,0 @@ -The Project Gutenberg EBook of Surgical Instruments in Greek and Roman -Times, by John Stewart Milne - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: Surgical Instruments in Greek and Roman Times - -Author: John Stewart Milne - -Release Date: August 6, 2012 [EBook #40424] - -Language: English - -Character set encoding: ASCII - -*** START OF THIS PROJECT GUTENBERG EBOOK SURGICAL INSTRUMENTS, GREEK/ROMAN TIMES *** - - - - -Produced by Bryan Ness and the Online Distributed -Proofreading Team at http://www.pgdp.net (This file was -produced from images generously made available by The -Internet Archive/American Libraries.) - - - - - - - - - - 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 roemischen Aerzte auf dem Boden der Schweiz_, Deneffe's _Etude -sur la Trousse d'un Chirurgien Gallo-Romain du III{e} Siecle_, 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 - - - PAGES - - CHAPTER I - - INTRODUCTORY 1-9 - - Hippocrates--Celsus--Rufus of Ephesus--Aretaeus of - Cappadocia--Galen--Oribasius--Soranus of Ephesus--Moschion-- - Caelius Aurelianus--Aetius--Pliny the Younger--Scribonius - Largus--Marcellus Empiricus--Theodorus Priscianus--Alexander - Trallianus--Paulus Aegineta--Hero of Alexandria--Christian - Fathers--The Arabs--Pare--Scultetus--Heister. - - - CHAPTER II - - MATERIAL, EXECUTION, AND ORNAMENTATION 10-23 - - Steel and Iron--Bronze--Copper--Brass--Tin--Lead--Gold-- - Silver--Horn--Wood--Bone--Ivory--Stone--Execution and - Ornamentation--Ringed Ornamentation--Inlaying--Plating-- - Patina--Finds of Instruments--Herculaneum and Pompeii--Find - of Surgeon of Paris--Oculist Severus of Rheims--Oculist - Sollemnis of Fonviel--Military Hospital at Baden--Surgeon - of Cologne. - - - CHAPTER III - - KNIVES 24-50 - - Cutting instruments--The scalpel handle--Typical form - rectangular, with blunt dissector--Round--Octagonal--Mounting - the blade--Varieties of blade--Classification--Straight - blades with one cutting edge--Scalpel--Bistoury--Scarificator - single or multiple--Razor type--Blunt-pointed bistoury--Ring - knife for dismembering the foetus--Straight two-edged - knives--Galen's long dissecting knife--Phlebotome--Fleams-- - Katias--Spathion--Hemispathion--Polypus knife--Lithotomy - knife--Knife for lithotomy invented by Meges--Perforator for - foetal cranium--Probe-pointed bistoury with two edges--Curved - bistoury--Crow-bill--Pterygium knife--Knife for plastic - operation for entropion--Uvula knife--Tonsil knife--Fistula - knife--Curved two-edged blades--Galen's cartilage knife-- - Curved myrtle-leaf-shaped blade--Shears. - - - CHAPTER IV - - PROBES 51-89 - - Specilla or probe-like instruments--Definition of specillum-- - [Greek: koparion--mele--hypaleiptron]--Materials--Bronze-- - Silver--Gold--Tin--Wood--Bristle--Flower-stalk--Specillum as - sound--Combination of instruments on one shaft--Plain rods-- - Double olive--Spathomele or spatula-probe--Cyathiscomele or - spoon-probe--Ear specillum--Probe with screw thread-- - Specillum vulnerarium--Handled needle--Ophthalmic probe-- - Rasping specillum--Trachoma curette (Blepharoxyston)--Styli - and styloid specilla--Grooved director--Surgical needle-- - Dressing needle--Bodkin--Eyed probes--Ligula--Spoons for - warming and pouring salves--Tongue depressor--Uterine - sounds--Uterine dilators--Bifurcated probe--Y probe--Blunt - dissector--Curved dissectors--Sharp hooks--Blunt hooks-- - Aneurism needle--Strigil--Spoon for applying liquid to uvula. - - - CHAPTER V - - FORCEPS 90-100 - - Epilation--Polypus--Tumour vulsellum--Eyelid fixation - forceps--Uvula (Staphylagra)--Forceps for applying caustic to - uvula--Pharyngeal. - - - CHAPTER VI - - BLEEDING CUPS, CLYSTERS, ETC. 101-115 - - Bleeding cups--Materials--Glass--Silver-Bronze--Shapes-- - Syringes--Principles--Rectal--Vaginal and uterine--Bladder-- - Nose--Sinus--Ear--Insufflator--Cannula for ascites and - empyema--Leaden tubes to prevent contraction and adhesion-- - Calamus scriptorius--Quill. - - - CHAPTER VII - - CAUTERIES 116-120 - - Cautery knife--Trident--Olivary--Gamma-shaped--Obol-- - Lunated--Nail--Tile--Button--Wedge--Needle--Cautery with - tube--Wood--Moxa. - - - CHAPTER VIII - - BONE AND TOOTH INSTRUMENTS 121-142 - - Raspatory--Chisel--Gouge--Lenticular--Hammer--Block-- - Meningophylax--Drill--Drill with guard (Abaptista)--Saw-- - Trephine--Perforator for fistula lachrymalis--Bone elevator-- - Sequestrum forceps--Varix extractor--Blacksmith's tongs-- - Tooth forceps--stump forceps--Tooth elevator--Tooth scalers-- - File--Forceps for extracting weapons--Periosteal elevator for - the pericranium--Impellent--Arrow scoop. - - - CHAPTER IX - - BLADDER AND GYNAECOLOGICAL INSTRUMENTS 143-160 - - Catheter--Male--Female--Child--Bladder sounds--Lithotomy - scoop--Forceps--Lithotrite--Speculum--Rectal--Vaginal-- - Trivalve--Quadrivalve--Traction hook--Decapitator-- - Cranioclast--Cephalotribe--Midwifery forceps--Uterine - curette--Instrument for destroying foetus in utero-- - Apparatus for fumigating uterus and vagina--Vaginal - pessaries. - - - CHAPTER X - - SUTURES, ETC. 161-167 - - Sponge--Sutures--Serres fines--Band of Antyllus--Sieves and - strainers--Mortar--Pestle--Whetstone. - - - CHAPTER XI - - ETUI, ETC. 168-173 - - Portable outfit--Probe cases--Scalpel box--Ointment box-- - Boxes for collyrium sticks--Ointment slabs--Boxes for drugs. - - - APPENDIX - - I. INVENTORY OF CHIEF INSTRUMENTS IN VARIOUS MUSEUMS 174-177 - - II. BIBLIOGRAPHY 177-178 - - - - -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 Foees (1595), Van der Linden (1665), Kuehn -(Leipzig, 1821). Later editions are the text with a French translation by -Littre (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 Kuehn for most of the readings, although occasionally those -of Van der Linden or Foees are to be preferred. The references given are to -the volumes and pages of Kuehn'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 Foees, for Liddell and Scott -say the references in their Lexicon are to the pages in Foees 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 ([Greek: tricho-labis]), flesh forceps ([Greek: -sarko-labos]), tooth forceps ([Greek: odontagra]), stump forceps ([Greek: -rhizagra]). 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 Vedrenes (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 Kuehn (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 -[Greek: Synagogai Iatrikai]--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 [Greek: Synopsis], and a sort of first aid manual -called [Greek: Euporista]. 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 [Greek: lithoulko] 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 [Greek: lithoulkos] 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 Pare (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' ([Greek: polykmetos], _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 [Greek: sideros -ho oxys] 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. - - [Greek: Siderou organa technes; ton sideron peritekousi, pneumati - anankazontes to pyr, ten hyparchousan trophen aphaireontes, araion de - poiesantes, paiousi kai synelaunousin. hydatos de allou trophe - ischyron ginetai] (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. - - [Greek: Ek siderou de esto touto tou kallistou, hoion per to Norikon - estin, hina met' amblynetai tacheos, met' anakamptetai e thrauetai.] - -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 -7-1/2 per cent. - -The majority of the instruments which have been preserved to us are of -bronze. Hippocrates (i. 58) says: - - [Greek: Chalkomati de plen ton organon, medeni chrestho. kallopismos - gar tis einai moi dokei phortikos skeuesi toiouteoisi chresthai.] - - '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 ([Greek: oreichalkos], _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 Musee 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:-- - - [Greek: Tad' organa panta euere pros ten chreian hyparchein dei tode - megethei, kai barei, kai leptoteti.] - - '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 Archeologique_, under the title 'Notice -descriptive sur une trousse de medecin au III{me} siecle', and reprinted, -with photogravures, in 1893 in a monograph _Etude sur la trousse d'un -chirurgien Gallo-Romain du III{me} siecle_ (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 Societe 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} siecle_ (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 -facade, 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 etui 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 Pare, 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: - - I. Blade straight-- - (A) Cutting on one side only (_a_) sharp-pointed, - (_b_) blunt-pointed. - (B) Cutting on two edges (_a_) sharp-pointed, (_b_) blunt-pointed. - II. Blade curved-- - (A) Cutting on one edge (_a_) sharp-pointed, (_b_) blunt-pointed. - (B) Cutting on two edges, sharp-pointed. - - - I. A (_a_) _Straight blade cutting on one edge, sharp-pointed._ - - 1. Ordinary scalpel. - 2. Scalpel with tip turned back. - 3. Bellied scalpel. - 4. Scolopomachaerion. - - -_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 -[Greek: smile]. 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, [Greek: machaira] or [Greek: machairion], has a more definite -meaning. It is from [Greek: machaira], 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): - - [Greek: Hokos soi he exodos tou pyous eurys e tamnein dei metaxy ton - pleuron stethoeidei machairidi to proton derma.] - - 'Incise the outer integument between the ribs with a bellied scalpel.' - -[Greek: Stethoeides] means rounded like the breast of a woman. Galen -translates it in his lexicon [Greek: to smilio iatriko gastrodei], '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: - - [Greek: Tines oun epenoesan organon pros touto, tria smilia isa - zeuxantes homou, hopos te mia epibole treis ginointo diaireseis.] - -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 ([Greek: kampylois ex akrou me lien stenois]). -Even if [Greek: kampylos] 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, [Greek: skolopomachairion, skolopion]; Latin, _scalpellus_. - -The etymology of the term [Greek: skolopomachairion] 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. - - [1] So says Briau (_Paul D'Egine_, p. 97), but it seems more likely to - be derived from [Greek: skolops] 'a spike'. - -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 [Greek: skolopion] 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). - - - I. A (_b_) _Straight blade cutting on one side, blunt-pointed._ - - ([Greek: a]) Novacula or razor (Greek [Greek: xyron], diminutive - [Greek: xyrion]). - ([Greek: b]) Blunt-pointed bistoury. - ([Greek: g]) Ring knife for dismembering foetus. - - -_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 [Greek: peri kouras kai xyreseos]. '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 egard 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: - - [Greek: Echein de chre pros ta toiauta kai onycha epi to daktylo to - megalo. kai dielonta exenenkein tas cheiras ktl.] - - '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). - - - I. B (_a_) _Straight blade cutting on two edges, sharp-pointed._ - - (1) Galen's 'long' dissecting knife. - (2) Phlebotome. - (3) Lithotome. - (4) Polypus knife. - - -_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): - - [Greek: Kathiemi to promekes machairion, houto gar auto kalo dyo - pleuras oxeias echon epi tou peratos eis mian koryphen anekousas.] - - '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 [Greek: promekes] 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, [Greek: phlebotomon, to] (sc. [Greek: smilion]), also [Greek: -phlebotomos, ho] (Galen). [Greek: oxybeles] (sc. [Greek: organon]); 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: - - [Greek: Tois ge machairiois oxesi dei chresthai kai platesi, ouk epi - panton homoios parangellomen, ktl.] (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 ([Greek: platyterois chresthai tois - machairiois]), 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 ([Greek: oxybelei]) which has been wound round with a rag, - leaving the breadth of the thumb nail at the point, be pushed in.' - -[Greek: Oxybeles] 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--[Greek: pote men -katapeirontes pote de anapeirontes phlebotoumen] (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 [Greek: -katapeirontes]--cutting inwards--in cases where the vessels are deep, and -[Greek: anapeirontes]--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.'_ - -[Greek: Katias -iados (he)] (Soranus, II. xviii); [Greek: kathias] (Paul, -VI. lxxiv); [Greek: katiadion (to)] (Aetius, II. iii. 2); [Greek: -kateiadion (to)] (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: - - [Greek: Chorion de me anastomoumenon katiadi prosechontos diairein to - daktylo prokoilananta ti meros.] - -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 [Greek: kateiadion], or the one called - the scoop' ([Greek: toryne]). - -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 [Greek: kateiadion], from -[Greek: kata] and [Greek: eia] 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 [Greek: kathiemi], -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' ([Greek: smilario e katiadi]). - -Paul says that abscess of the womb is to be exposed with a speculum and -opened with a scalpel or katias ([Greek: spathio e katiadi]). Paul also -refers to it in perforating the foetal cranium in delivery obstructed -through hydrocephaly ([Greek: polypiko spathio e kathiadi e -skolopomachairio]) (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, [Greek: spathion] (diminutive of [Greek: spathe]), [Greek: -hemispathion]; Latin, _spatha_. - -On several occasions a knife called [Greek: spathion] 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' ([Greek: spathio e katiadi]). - -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 ([Greek: hemispathio e spathio syringotomo]). - -What the nature of the [Greek: spathion] 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, [Greek: polypikon spathion, polypodikon spathion]; 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 ([Greek: polypiko spathio to - myrsinoeidei akmaio]), we cut round the polypus or fleshy tumour, - applying the point of the steel blade ([Greek: ten akmen tou siderou]) - to the part where it adheres to the nose. Afterwards turning the - instrument end for end ([Greek: antistrepsantes]) we bring out the - separated fleshy body with the scoop' ([Greek: to kyathisko]). - -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:-- - - [Greek: Ei de meizonos tou kephaliou hyparchontos he sphenosis - apoteloito, dia tou embryotomou e tou polypikou spathiou kryptomenou - metaxy lichanou kai tou makrou daktylou kata ten enthesin] (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, [Greek: lithotomon (to)]; Latin, _scalpellus_. - -In describing lithotomy Paul says: - - 'We take the instrument called the lithotomy knife ([Greek: to - kaloumenon lithotomon]), 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: - - [Greek: Kai ei men procheiros eie, te labe tou machairiou ekballein, - pepiesmenon de te labe tracheia te kai kampyle ex akrou, hos an - malista sympheroi to ergo.] - - '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, [Greek: embryotomon]. - -A special instrument for perforating the foetal cranium is mentioned by -Soranus (II. viii. p. 366): - - [Greek: Ei de meizonos tou kephaliou hyparchontos he sphenosis - apoteloito, dia tou embryotomou e tou polypikou spathiou kryptomenou - metaxy lichanou kai tou makrou daktylou kata ten enthesin.] - - '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, [Greek: oxykorakon smilion]. - -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 ([Greek: oxykorako smilio e phlebotomo ek -rhizon exelein]). This undoubtedly refers to a curved scalpel, for the -grappling hook was called [Greek: korax]. - -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, [Greek: pterygotomos, ho]; 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 ([Greek: pterygotomo]) -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, [Greek: anarrhaphikon smilion]. - -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' ([Greek: anarrhaphikou - smiliou]) 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. Vedrenes, -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, [Greek: staphylotomon]. - -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 ([Greek: staphylotomo]), 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, [Greek: ankylotomon] ([Greek: ankyle], 'bend of elbow,' _or_ -[Greek: ankylos], '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 ([Greek: ankylotomon]) 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, [Greek: syringotomon], from [Greek: syrinx], '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 ([Greek: syringotomo]). 'But the -scalpels which are two-edged or have a point are distinctly to be avoided' -([Greek: ta d' ampheke ton machairion e kata to peras oxea panti tropo -pheuktea]). - -Secondly, Paul (VI. lxxviii) says: - - 'Having perforated the bottom of the fistula with the point of the - falciform part of the syringotome ([Greek: tou drepanou tou - syringotomou]) bring the instrument out of the anus and so divide all - the intervening space with the edge of the falciform part' ([Greek: te - akme tou drepanou]). - -Another passage in the same chapter indicates that some of the -syringotomes had an eye in the instrument: - - [Greek: Tines de en to tremati tou syringiakou drepanou to linon - eneirantes.] - -There was also a straight variety of the instrument ([Greek: ta kaloumena -ortha syringotoma], 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: - - [Greek: Chresthai d' autes malista to kyrto merei kechalkeumenes - homoios hekaterothen, hoste amphikyrtous echein amphoteras tas - temnousas grammas alla kata men ten heteran simes, kata de ten - antikeimenen taute kyrtes.] - - '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 -([Greek: eis hoper estin epitedeiotate myrsine kyrte], ii. 674). - - -_Shears._ - -Greek, [Greek: psalis]; Latin, _forfex_. - -Oribasius treats of cutting the hair as a regular medical procedure, in a -special chapter, [Greek: peri kouras kai xyreseos]. 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 ([Greek: psalidi], 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 ([Greek: psalidi epakmo e -smile]), 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, [Greek: mele, koparion, hypaleiptron, hypaleiptris]; Latin, -_specillum_. - -This is a very comprehensive class. The original specillum was no doubt a -simple sound. Varro thus defines the specillum: 'Quo oculos inunguimus -quibus specimus specillum est. Graecis [Greek: mele] dicitur.' Thus it -meant a probe or sound. - -[Greek: mele] is probably derived from [Greek: melon], an apple or fruit, -from the olivary enlargement at the end of a sound. - -The term [Greek: hypaleiptron], which is frequently used by Hippocrates, -originally meant an ointment spatula, being derived from [Greek: -hypaleipho], to spread ointment. But the custom of combining two -instruments on one shaft gradually led to the application of these terms, -especially the term specillum, to denote a large variety of instruments. - -The name [Greek: koparion] is evidently derived from the resemblance of -the probe to the pestle, which was such a frequent utensil in Greek homes. -It is connected with [Greek: kopanon], 'pestle,' [Greek: kopanisterion], -'mortar,' and [Greek: kopanizo], 'bray,' and [Greek: koptarion], a -medicament pounded in a mortar (Dioscorides, iv. 190). The exact -significance of the term [Greek: koparion] is sometimes difficult to -determine. It is easy to prove that in general it is merely a sound. Thus -Paul (VI. lxxviii), in quoting a passage from Hippocrates, substitutes -[Greek: koparion] for the word [Greek: mele], which Hippocrates uses to -denote the sound used for exploring a fistula. Throughout this chapter, in -which the word occurs ten times in all, Briau translates it by 'manche du -scalpel', although the whole context shows that a probe is meant. Even -where it is spoken of as an eyed probe ([Greek: dia tetremenou kopariou]) -Briau translates it by 'au moyen du manche perce d'un scalpel', an -expression which is meaningless to a surgeon. Briau evidently thinks it is -derived from [Greek: kopto], and at times it seems as if it might denote a -cutting instrument. Thus Adams, in a note to Paul, VI. lxxvii, says, 'if -the [Greek: koparion], however, was the same as the [Greek: mele] or -specillum it was evidently used for cutting with, as well as for cutting -upon', and on one occasion (Paul, VI. lxxx) he translates [Greek: -koparion] by 'knife'. Liddell and Scott translate it as 'a small knife'. A -careful examination of those passages where it seems to indicate a cutting -instrument will show, however, that only blunt dissection, which was -frequently performed with the spatula end of a probe, is meant. I am quite -convinced that the word [Greek: koparion] is only a late Greek term for -the earlier [Greek: mele], and means essentially a sound, and not a knife. -While on this subject we may note that throughout the codices and texts -there is great confusion between words meaning probe and words meaning -scalpel. The proper forms [Greek: smile], 'scalpel,' and [Greek: mele], -'probe,' are distinct, but the inferior reading [Greek: smele] is frequent -in both codices and texts as a bastard, for [Greek: smile] is often -written [Greek: smele] incorrectly, and [Greek: mele] often becomes -[Greek: smele], just as [Greek: mikros] is written [Greek: smikros]. Thus -in Paul (VI. viii), where the author is describing the eversion of the -eyelid by means of the olivary point of a probe ([Greek: to pyreni tes -meles]), four codices and the Aldine and Basle texts read [Greek: smeles], -two codices read [Greek: smyles], one reads [Greek: meles], four [Greek: -miles], and Briau reads [Greek: smiles]. In a case like this only a -knowledge of surgery can tell us whether a probe or scalpel is meant. - - -_The Specillum as a Sound._ - -The ancients were fully aware of the value of the information to be gained -by searching the recesses of a lesion with a rod of metal. Celsus (v. 28) -says regarding fistulae: - - Ante omnia autem demitti specillum in fistulam convenit, ut quo tendat - et quam alte perveniat scire possimus; simul etiam protinus humida an - siccior sit: quod extracto specillo patet. Si vero os in vicino est - id quoque disci potest si iam necne eo fistula penetraverit et - quatenus nocuerit; nam si molle est quod ultimo specillo contingitur, - intra carnem adhuc vitium est, si magis id renititur, ad os ventum - est. Ibi deinde si labitur specillum, nondum caries est: si non - labitur sed aequali innititur, caries quidem, verum adhuc levis est: - si inaequale quoque et asperum subest, vehementius os exesum est. At - cartilago ubi subsit, ipsa sedes docet; perventumque esse ad eam ex - renisu patet. - - 'But first it is well to put a probe into the fistula to learn where - it goes and how deeply it reaches, also whether it is moist or rather - dry as is evident when the probe is withdrawn. Further, if there be - bone adjacent, it is possible to learn whether the fistula has entered - it or not and how deeply it has caused disease. For if the part is - soft which is reached by the end of the probe the disease is still - intermuscular; if the resistance be greater it has reached the bone: - if there the probe slip there is as yet no caries. If it does not slip - but meets with a uniform resistance there is indeed caries, but it is - as yet slight. If what is below is uneven and rough the bone is - seriously eroded, and whether there is cartilage below will be known - by the situation, and if the disease has reached it will be evident - from the resistance.' - -These remarks show that with the probe the ancients had cultivated the -tactus eruditus to a high degree, and the remarks of Aetius and Paul are -equally to the point. - -The tips of the probes which have survived vary considerably in size and -shape. Some have a point which is almost sharp like a stylet; in others -the natural thickness of the shaft is kept right to the tip, which is -simply rounded off or there is an oval enlargement like that on our -olivary probes and sounds. In rare cases the enlargement is globular. The -oval enlargement was named by the Greeks [Greek: pyren], which means -'olive-kernel'. The sixteenth-century translators uniformly render this by -'nucleus', which is a convenient term to use, but it has no classical -Latin authority. Indeed, there is no classical Latin equivalent used by -medical authors. Theodorus Priscianus uses _baca_ (_sic_), a berry, and -_bacula_, little berry, and in the _Additamenta_ (I. viii. 21, ed. Rose) -he uses the transliteration _pyrena meles_. But this is African Latin. - -A probe without enlargement at the tip was called [Greek: apyrenomele] or -[Greek: apyromele]. The ear probe is frequently referred to as belonging -to this class. These probes without nuclei were specially adapted for -wrapping round with wool to apply medicaments, or wipe away discharge. - -The size of the nucleus varied in different varieties of probe, but was -pretty constant in each particular. It was largest in the probe known as -the spathomele--a combination of spatula and probe which was in extremely -common use for pharmaceutical purposes. The nucleus of this probe was such -a well-known object that it is frequently referred to as a standard of -size and shape. Galen (ii. 898) says: - - 'In the cervix uteri is the foramen by which the woman both passes the - monthly flux and receives the semen of the husband. By it also the - foetus leaves the womb. It is marvellous how it varies in size - according to circumstances. When the woman is not pregnant it admits - the nucleus of a probe or something slightly larger' ([Greek: pyrena - men meles epidechetai e brachy ti toutou pachyteron]). - -Here Kuehn translates [Greek: pyrena] by 'acuminatum capitulum specilli', -which is incorrect. It is an olivary enlargement, not sharp point. In Paul -(VI. xc), we have the nucleus given at the measure of distance between the -perforations by which a bone was surrounded preparatory to its excision by -means of chisels: 'the space between the perforations made by the drills -should be the breadth of the nucleus of a probe' ([Greek: to mekos -pyrenos]). - -Aetius (III. i. 16) says in volvulus the sphincter ani is so contracted -that the nucleus of a probe cannot be got in. - -Paul (VI. xxi) says that in couching a cataract we must enter the couching -needle a nucleus breadth from the iris. - -Besides its use as a sound the nucleus was frequently used as a means of -applying medicaments, either in the form of ointments or dry powder, to -affected parts. - -Paul (VI. ix) says that in the cases of entropion, where the ordinary -plastic operation is objected to, an elliptical piece may be burnt out of -the eyelid with caustic applied on the nucleus of a probe ([Greek: -pyrenosmeles]), and similarly after removal of sebaceous cysts from the -lid, levigated salts may be applied on the nucleus ([Greek: ton pyrena tes -meles]). - -Aetius (II. iv. 23), quoting from Galen, says that in caries of the teeth -some wax may be warmed on the nucleus of a probe ([Greek: pyrenos meles]), -and again (II. iv. 14) he directs us to use it for application of pomade -to the face ([Greek: pyreni meles]). It would seem that this, and not the -exploration of wounds, was the original use to which the olivary-pointed -probe was put, for in early Egyptian tombs small pestle-like probes are, -as a rule, found accompanying the toilet pigment boxes which are so -common. They are mostly made of wood (Pl. X, fig. 2). The kohl-stick was -not unknown to Greek ladies. (See Eustathius, _Comment. in Iliad_.) - -Hitherto I have spoken of the probe as if it were a single instrument; -but, as a matter of fact, the ends of the shaft are usually fashioned to -serve different purposes. Thus at one end there will be a probe, at the -other a spatula, a spoon, or a hook. Some of these combinations have names -of their own, and others are so frequently met with that they too seem to -have been constant types. - -It may simplify matters if we anticipate a little and remark that while -the uses of the probes in actual surgery were the same as at the present -day, in the minor surgery, consisting of the application of medicaments -and toilet preparations, they were used in a slightly different manner. -Semi-solids, like eyebrow pigment and eye ointments, were applied on -olivary-pointed probes. Liquids, like ear and eye drops, were usually -instilled by squeezing a ball of wool dipped in the liquid and placed -round the middle of a probe, and letting it run off the point. Thus a -common form of toilet instruments consists of a probe-like instrument with -an olive at one end and a sharp stylet at the other. Ligulae with scoops -were used to withdraw drops of fluid essences, &c. from unguentaria. Some -of these ligulae run up to a foot and a half in length. - -The specilla which remain to us are mostly made of bronze. A few are -overlaid with gold and silver, and a few are solid gold or solid silver. -We read, however, of specilla of lead, tin, copper, and wood, and of the -use of a boar's bristle or a stalk of garlic for searching fistulae. - -I shall now proceed to classify and discuss these different varieties, -premising, however, that no hard and fast line can be drawn between -different types. They shade off into each other by imperceptible -gradations, so that whatever system of classification we adopt bastard -forms are sure to occur. - - -_Double Simple Probe._ - -Greek, [Greek: apyrenomele, apyromele]; Latin, _specillum_. - -The simplest form of specillum is a plain rod of metal rounded off at -either end. These are not infrequently met with. I figure one from my -collection. Its length is 14.5 cm., its diameter 2 mm. At either end it -tapers rapidly off to a blunt point. At a distance of 3 cm. from one end -is a raised ring (Pl. X, fig. 4). A similar probe in silver may be seen in -the Musee de Cinquantenaire, Brussels. It was found with other probes in -an etui. Pl. X, Fig. 3 shows a rather longer specimen from the Naples -Museum. A variety with non-tapered ends is seen in Pl. X, fig. 1. It is -also from the Naples Museum. Pl. XI, fig. 4 shows a probe, from my own -collection, which carries the snake of Aesculapius at one end. One with a -double snake (caduceus form) was found in the Roman Hospital at Baden (Pl. -XI, fig. 2). - - -_Specilla with two olivary ends._ - -Greek, [Greek: dipyrenos mele, amphismilos]. - -A slender sound with slight olivary enlargement at either end is very -frequently mentioned under the name [Greek: dipyrenos mele] by Galen. He -also calls it [Greek: amphismilos]. Thus he says: - - [Greek: Kai soi dichothen esti diemballein autou ti ton - paraskeuasmenon lepton eite amphismilon, eite dipyrenon onomazein - etheleis, ei de ti leptoteron dee kai melotida] (ii. 581). - - 'And in the double passage you must insert some one of the slender - instruments you have at hand, either a double-ended probe (a 'double - olive' if you prefer to call it so), or if something finer be - necessary, even an ear probe.' - -In dealing with fistulae Paul (VI. lxxvii) says: - - 'We must first examine them with a sound if they be straight, or with - a very flexible 'double olive' ([Greek: dipyreno eukampei]), such as - those made of tin or the smallest of those made of bronze, if they be - crooked.' - -Paul refers to its use as a cautery to destroy the roots of hairs after -epilation (VI. xiv): - - 'Some, preferring cauterizing to the operation of transplantation, - evert the eyelid, and with a cilia forceps dragging out the offending - hair, or two or even three hairs, apply a heated double-olive probe or - an ear probe, or some such slender instrument, to the place from which - the hair or hairs were removed' ([Greek: Diapyrinon e melotida e ti - toiouton lepton organon pepyromenon eirousi to topo hothen he thrix e - hai triches ekomisthesan]). - -Here Briau reads [Greek: pyrena] (an olivary point), but the balance of -the evidence of the codices is in favour of [Greek: diapyrinon], and the -parallel to the passage quoted from Galen is so complete that I have no -hesitation in adopting the reading given above. - -I give an example of the dipyrene from my own collection. It is 11.2 cm. -long. The shaft is unequally divided by a ringed fluting into two -portions; 4.5 cm. and 6.7 cm. long respectively. The shorter portion of -the shaft is plain, the longer is grooved longitudinally by eight grooves -(Pl. XI, fig. 1). In many instances the dipyrene carried an eye in one of -its olives. This variety is frequently mentioned. Thus Paul (VI. xxv) -says, under treatment of nasal polypus: - - 'Taking then a thread moderately thick like a cord, and having tied - knots on it at the distance of two or three finger-breadths, we - introduce it into the eye of a dipyrene ([Greek: dipyrenou tremati]), - and we push the other end of the probe ([Greek: to heteron peras tou - dipyrenou]) upwards to the ethmoid openings, withdrawing it by the - palate and the mouth, and then pulling with both hands we, as it were, - saw the fleshy bodies away by means of the knots.' - -Pl. XI, figs. 5 and 3 show single olive probes for the application of -semi-solid medicaments. The former is from the outfit of the oculist of -Rheims, in the Museum at St-Germain-en-Laye; the latter, more highly -ornamented by spirally twisting the stem, is from my own collection. - - -_Spathomele or Spatula probe._ - -Greek, [Greek: hypaleiptron, spathomele]; Latin, _spathomele_ (Theodorus -Priscianus), _spathomela_ (Marcellus); German, _Spatelsonde_. - -Almost every medical writer mentions the spathomele. It consists of a long -shaft with an olivary point at one end and a spatula at the other. Galen -(_Lex._) calls the one [Greek: strongylon melen], the other [Greek: mele -plateia]. It was a pharmaceutical rather than a strictly surgical -instrument. The olive end was used for stirring medicaments, the spatula -for spreading them on the affected part or on lint. Galen (xiii. 466) says -that certain applications are to be softened in the hand with rosaceum by -means of the spathomele ([Greek: malaxas epi tes cheiros dia -spathomeles]). - -Marcellus frequently refers to it as used for stirring liquids in a -vessel: - - Immo manu vel digitis moderantibus paulatim insperges et adsidue - spathomela commovebis et permiscebis, post haec omnia mittes oleum - chamaemelinum, et iterum igni non nimio adposita olla lente et - paulatim decoques medicamen, ita ut illud manu non contingas, sed - spathomela agites (vii. 19). - -In xiv. 44 he mentions a spathomele of copper: - - Oportet autem moveri aquam ipsam rudicula vel spathomela aeris rubri. - -The following passage from Theodorus Priscianus refers to its use for -applying ointment to an affected part: - - Si veluti carbunculus innatus fuerit, lycium cum melle contritum - suppono frequenter per diem et spathomela temptante (_Euporiston_, - xxvii). - -Aetius (II. iv. 16) directs a particular medicament to be rubbed in and to -be scraped off after a moderate space of time with a spathomele ([Greek: -te spathomele]). - -The spathomele was used by painters for preparing and mixing their -colours. The very large numbers in which they are found would indicate -that their use was not confined to medical men. - -Although the nucleus of the spathomele was too large to admit of its use -as a probe for small lesions, it is evident that in exploring large -cavities it must have been a valuable instrument. Galen (ii. 712) says: - - 'In small bodies the opening into the torcular Herophili may not be - large enough to admit a spathomele nucleus, and therefore we must try - some of the other olivary probes or even an ear probe, and cut - alongside it.' - -Priscianus alludes to plugging the nares with it: - - Prius spathomeles extremo in baca molli lana obvoluto glebas sanguinis - e naribus frequentius purgare nos convenit, post lana identidem - obturando perclaudere (xiv). - - 'First of all we must frequently wipe away the clots of blood from the - nose with the end of a spathomele wrapped on the 'berry' with soft - wool, and then occlude it by plugging with wool in the same way.' - -From Leonidas (Aetius, VI) we learn that it was used as a tongue -depressor. He says: - - 'In inflammation of the throat in adults seat the patient, open his - mouth and depress the tongue with a tongue depressor or a spathomele, - and open the abscess with a scalpel or a needle-knife.' - -The following passage from Galen shows that it was used as a substitute -for the meningophylax (_q. v._): - - 'Having separated the pleura from the rib and placed a thin - meningophylax or a flat spathomele ([Greek: spathomelen plateian]) - between the ribs, and taking care that you neither tear nor perforate - the membrane, which being properly accomplished, cut the bone of the - rib with two chisels placed opposed to each other' (ii. 686). - -Soranus (xxvii) refers to its use as a cautery: - - 'After cutting off the umbilical cord, cauterize the umbilicus with a - heated reed, or the flat of a probe' ([Greek: tou plateos tes meles]). - -An interesting passage in Aetius shows that it was used as a dissector in -opening up an occluded vagina: - - 'Pass a sound into the cervix, and dissect with the spathomele below - the spot marked out by the sound' (Aet. IV. iv. 96). - -This probably means blunt dissection only, as none of the spathomeles -found have edges sharp enough to be actually cutting. Large numbers of -this instrument have been found. It is the commonest surgical instrument -in museums. It must be remembered, however, that not every spathomele is a -surgical instrument strictly speaking, as pharmacopolists and even artists -used exactly similar instruments. - -The average length of twenty specimens measured by me was 16 cm. Of this -the nucleus occupies 1.5 cm., the spatula 6 cm. The average diameter of -the nucleus is 7.5 mm. The width of the spatula averages 15 mm., but the -size and shape of the spatula both vary considerably. - -The different varieties of shape will be better understood by a reference -to the accompanying figures of actual specimens than from a written -description. Pl. XII shows neatly formed specimens from various sources; -the specimen shown in fig. 3 having ornamental grooves along the length of -the shaft. Figs. 3 and 4, Pl. XIII show coarse, thick specimens, which are -most likely to have been used for non-medical purposes. All have the -characteristic oar-blade shape, though the outline varies greatly. In some -the blade widens out at the end, so that the tip is broad and rounded. In -others the blade slopes to a rounded point, or the point is quite acute. -The edges of the blade are usually thick and blunt. In some specimens, -however, the edges are thin, sharp, and almost suitable for use for -cutting with. These are well adapted for use as blunt dissectors. - -The shaft, as a rule, is plain, occasionally it is ornamented with -longitudinal or spiral fluting. More rare is a silver band, inlaid in a -spiral round the shaft. I have seen a few specimens which have been -entirely plated with gold. - -Hitherto I have taken no notice of spathomeles in which the spatulae are -not flat. In many specimens, however, the blades are hollowed. For these -it seems advisable to constitute a special class, which may be called the -cyathiscomele class. - - -_Cyathiscomele._ - -German, _Loeffelsonde_. - -Although this variety of the spathomele is not one which is specially -mentioned by any classical writer, it is convenient to have a name by -which we can denote that variety of the spathomele in which the blade is -not flat. - -It has the same large oval nucleus as the flat spathomele, and the same -shaft, plain, or fluted, or overlaid with silver, but the spatula is -replaced by a spoon, the outline of which shows the same variety of form -as we met with in the spatula. The depth of the spoon varies greatly. Pl. -XIV, fig. 3 shows an instrument in which the two lateral halves of the -blade, instead of lying exactly in the same plane, meet in the midline at -a slight angle so as to form a cavity obtusely angular on cross section, -and gently rounded on longitudinal section: - - Cross sec. [Illustration] - - Long. sec. [Illustration] - -Pl. XV, fig. 1 shows a similar arrangement, except that the cavity is more -marked, and the tip instead of being sharp is rounded. In Pl. XIV, fig. 1 -the cavity is so marked that a typical spoon is formed. This specimen is -interesting as showing the ornamentation of the shaft by overlaying a -spiral silver wire. It is from the Naples Museum, and it is figured by -Vulpes. Other varieties are seen in Plates XIV, XV. Pl. XV, fig. 4 shows -a very coarse, thick specimen. The scope of the cyathiscomele in medical -art is evidently like the flat spathomele to act occasionally as a sound, -but mainly to mix, measure, and apply medicaments. Some are adapted for -use as curettes. But the large number in which this instrument occurs -would of itself indicate that it was used for lay as well as medical -purposes. Many are toilet articles. An interesting discovery of two -typical specimens in the grave of a lady artist was made in Vendee in -1847. Among a number of colour pots and alabaster mortars for rubbing down -and mixing colours was an etui similar to the typical cylindrical -instrument case of the ancient surgeon, and in this were two spoon probes -like the one shown in Pl. XIV, fig. 1. Evidently they were favourite -instruments of the painter, and had been used by her for mixing and -preparing her colours.[2] - - [2] Bluemner, _Technologie und Terminologie der Gewerbe und Kuenste bei - Griechen und Roemern_, vol. iii. p. 458. - -The form of cyathiscomele, in which the two lateral halves of the scoop -meet at an angle (Pl. XIV, fig. 1), has a tendency to split along the -ridge in the middle of the scoop if roughly handled. One of these, to -which this accident has happened, is in the Naples Museum (Pl. XV, fig. 3) -and has an interesting history. In 1847 Vulpes described it as a guard for -dividing the fraenum linguae, and successive writers have copied this ever -since, and it is so described in the catalogue. As the photograph shows, -it is only a spoon probe which had been trod on or otherwise damaged, and -which had split down the centre, or rather near the centre, for the crack -has deviated at its termination from the midline. The termination of the -notch thus formed has quite a different appearance from the figure by -Vulpes. The accident is not an uncommon one. There is in the Capitoline -Museum an instrument to which precisely the same has happened, and I have -a probe in my own possession which has split, and which with a little -manipulation would make a beautiful duplicate of the one in the Naples -Museum (Pl. XV, fig. 1). It is almost certain that the guard is quite a -modern invention. - -Many ancient writers point out the danger of wounding the vein, but none -mention the guard. Thus Celsus says: - - Horum extrema lingua vulsella prehendenda est, sub eaque membrana - incidenda: magna cura habita ne venae quae iuxta sunt violentur et - profusione sanguinis noceant (VII. xii). - -Paul says: - - 'The patient is to be placed in a proper seat, the tongue is to be - raised to the roof of the mouth and the membranous fraenum cut - transversely. But if the curvature is occasioned by a cicatrix we - transfix the callus by a hook and draw it upwards, and making a cross - incision free the bent parts, taking care not to make deep incisions - of the parts, for haemorrhages, which have been found difficult to - stop, have thereby been occasioned' (VI. xxix). - -Aetius gives a similar account. - -These writers, then, all take note of the possibility of wounding the -vein, but give no clue that they knew of the utility of a cloven plate in -preventing the accident. Further, the Arabs, timid operators all and fond -of describing safeguards such as this, give no mention of it, although -Albucasis, Rhases, Avicenna, and Haly Abbas all describe the operation. I -can find no reference to the use of a guard for this purpose until quite -recent times. - - -_Ear specillum._ - -Greek, [Greek: melotis, -idos, melotris, apyromele, te pyrena me echouse -toutesti te melotridi] (Galen, Lexicon); [Greek: otoglyphis, melen -exotida] (Galen, Lexicon); Latin, _oricularium specillum_ (Celsus); -_auriscalpium_ (Scrib. Largus); German, _Ohrloeffel_. - -Of all the specilla this is one of the most frequently mentioned by name. -It consists of a small narrow scoop at one end and a simple probe without -olivary enlargement at the other. We shall discuss the scoop first. The -following passage from Archigenes describes it (Galen, xii. 652): - - 'If a bean, stone, &c., fall into the ear remove it with the small - narrow scoop of the ear specillum' ([Greek: kyathisko steno mikro - melotridos]). - -Again Galen (loc. cit.) and Paul (VI. xxiv) say that in cases where -foreign bodies cannot be got out of the ear by more simple methods, we -must incise behind the ear and remove them by means of the ear scoop. The -removal of foreign bodies from the ear by means of this instrument is very -frequently referred to and shows that the scoop was small. Celsus says -(VI. vii): - - 'When a person begins to experience a dullness of hearing, which very - often happens after long continued headaches, first of all we must - examine the ear itself, for there will appear either a scab such as - occurs upon ulcers, or a collection of sordes. If there is a scab it - ought to be fomented with warm oil or with verdigris in honey, or leek - juice or a little nitre in hydromel, and when the scabs have been - detached from the part, the ear is to be washed out with tepid water, - in order that being spontaneously separated it may be the more easily - extracted with the ear specillum (_oriculario specillo_). If there is - cerumen and it is soft, it is to be extracted with the same specillum, - or if it is hard vinegar with a little water is to be put in, and when - it is softened the ear is to be washed out and evacuated in the same - way.' - -In VI. vii he says: - - Ubi vero vermes orti sunt, protrahendi oriculario specillo sunt. - - 'Where worms have arisen they are to be extracted with an ear - specillum.' - -Celsus also recommends it for extracting a calculus from the meatus -urinarius (VII. xxvi): - - Eum, si fieri potest, oportet evellere vel oriculario specillo, vel eo - ferramento quo in sectione calculus protrahitur. - - 'It, if possible, is to be extracted with the specillum or the - instrument for extracting the calculus in lithotomy.' - -Aetius (III. v) also describes removal of urethral calculus in this way. - -The following passage from Paul (VI. xl) on venesection shows that in -cases where the band of Antyllus could not be applied, the back of the ear -scoop was pressed on the proximal end of the vein, in order to obstruct -the flow of blood and cause it to discharge by the opening made with the -phlebotome: - - 'Tie a ligature round the neck, and when the frontal vein is properly - filled divide it with the point of a phlebotome or a scalpel. In the - same way we open the external jugulars for chronic ophthalmia, - producing a discharge of blood with the scoop of a probe' ([Greek: - kyathiskou meles]). - -Adams evidently misunderstood this passage. He translates it 'with the -concave part of a scalpel', which is meaningless. This use of the scoop -will also explain an otherwise obscure passage in Hippocrates (iii. 678). -He says: - - 'In letting blood avoid pressing hard with the specillum ([Greek: kai - hotan aphaires to haima te mele me karta piezein hos me phlasis - prosginetai]) lest injury be caused.' - -Of the use of the ear scoop as a curette we have several instances. Thus -Aetius (II. iii. 81) recommends it for curetting the interior of a -chalazion, and again (II. iii. 84), cf. Galen, _Comp. Med._ vii. 2. The -scoop was also used for applying medicaments, especially to the eye. -Liquid applications were poured from it, semi-solid were applied with the -back of it (_averso specillo_). This use of the back of the scoop has -often been misunderstood. The natural translation of the phrase _averso -specillo_ is 'with the probe turned away', i. e. the back of the probe. -Scultetus, however (_Tab._ VIII. vii), considers that it refers to a -spatula probe, and says it means the probe turned end for end. Other -translators adopt this meaning. Deneffe (_Les Oculistes Gallo Romains_, p. -108), e. g., says: - - Il faut entendre par _averso specillo_ la partie de la spatule - opposee a celle qui sert comme sonde, c'est-a-dire son extremite - large, l'autre bout etant le plus souvent olivaire. - -Scribonius Largus puts the true meaning of the phrase beyond doubt. He -directs us, after the application of caustic to haemorrhoids, to endeavour -to get them to fall off by the back of an ear scoop, which part the Greeks -called the spoon ('auriscalpio averso quam partem [Greek: kyathiskon] -Graeci vocant'). - -Marcellus copies this passage from Scribonius, but alters it. He says: 'de -specilli latitudine illinendae sunt' (xxxi. 6, p. 329). - -I shall now proceed to give a few instances of this use of the back of the -scoop in minor surgical manipulations. - -In ancyloblepharon Celsus says the eyelids are to be separated with the -back of the scoop. - -Igitur aversum specillum inserendum, diducendaeque eo palpebrae sunt (VII. -vii. 6). - -The back of the scoop was used as a retractor for delicate structures. In -radical cure of hernia Celsus directs us to keep the bowel from prolapsing -by means of it: - - 'For if the piece be small it is to be pushed back over the groin into - the abdomen, either with the finger or the back of the specillum.' - - Nam quod parvulum est super inguen in uterum vel digito vel averso - specillo repellendum est (VII. xxi). - -In the cure of varicocele it is used to replace the veins in position: - - Tum venae, quaecunque protractae sunt, in ipsum inguen averso specillo - compelli debent (VII. xxii). - - 'Then the veins which have been drawn upon ought to be replaced with - the back of a specillum.' - -In sloughing ulcer of the bladder it is used to separate the lips of the -perineal wound: - - Quod si antequam vesica purgata est orae se glutinarunt, dolorque et - inflammatio redierunt, vulnus digitis vel averso specillo diducendum - est (VII. xxvii). - - 'But, if before the bladder has become cleansed the lips unite and - pain and inflammation have returned, the wound is to be separated with - the fingers or the back of a specillum.' - -We shall next proceed to discuss the other end of the ear specillum. This -was a simple probe. It had no nucleus. In his Lexicon Galen defines it -thus: - - [Greek: Apyromele: te pyrena me echouse toutesti te melotridi.] - - 'Probe without olivary enlargement--that is to say "the ear - specillum".' - -Not only was its tip not expanded into a nucleus, it was actually sharp. -Galen (xiv. 787) treating of fistula in ano, says in non-perforating -fistulae we perforate all the sound flesh with the sharp end of an ear -probe ([Greek: to oxei tes melotidos]). The chief use of an ear probe in -aural work was to instil liquids into the ear. A large ball of wool -saturated with the liquid was wrapped round the middle of the probe, and -on squeezing this the liquid ran down and dropped into the meatus. There -are many mediaeval illustrations showing the ear probe used in this -fashion. Sometimes, however, we read of the tip of the probe being wrapped -in a small ball of wool, which was dipped in some sticky substance to -extract foreign bodies from the ear. Galen (xii. 689) says foreign bodies -may be removed thus by a probe dipped in resin. - -The ear probe seems to have been much used for probing wounds and fistulae -when a very slender instrument was required. Galen (ii. 581), in -describing the torcular Herophili, says: - - 'And in the double passage you may be able to insert some of the - slender instruments you have at hand, a double ended probe--a - 'double-olivary' if you prefer to call it so--or if something smaller - be necessary even an ear specillum' ([Greek: kai melotrida]). - -In his chapter on the extraction of weapons (VI. lxxxviii) Paul says: - - 'If the weapon has a tang, which is ascertained by examination with an - ear probe' ([Greek: ek tes melotes]). - -As a cautery it was used to destroy the roots of hairs, which had been -removed for trichiasis. Paul says: - - 'We may apply a double olive or an ear probe ([Greek: melotida]) or - some such fine instrument heated' (VI. xiii). - -In fistula in ano Paul says it may be used as a director to cut upon. - - 'Having introduced a sound or an ear probe ([Greek: hypoballontes - koparion e melotida]) through its orifice, we cut the skin over it at - one incision' (VII. lxxviii). - -Illustrations of two ear probes are given. What I regard as the type is -seen in Pl. XV, fig. 5, which shows an instrument from the Roman Hospital -at Baden. Typical specimens are not by any means common. Pl. XV, fig. 2 -shows another variety from my own collection. - - -_Screw Probes._ - -On probes for wrapping round with wool we frequently raise a screw thread -to enable the wool to adhere better. This useful contrivance was also -known to the ancients. I give a figure of one in my possession. It was -found in the Roman Camp at Sandy (Pl. XXI, fig. 5). It measures 9.7 cm. in -length and is 1.5 mm. thick. The screwed portion occupies 7 mm. of one -end. The other end is plain. The little instrument is well adapted for -treating small cavities, such as an ear or a carious tooth by wrapping -round the screw portion with wool and dipping in medicaments. - - -_Ear specillum for wounds._ - -Greek, [Greek: traumatike mele]; Latin, _specillum vulnerarium_. - -There was a special variety of ear specillum which was adapted for wounds. -Paul (VI. lxxxviii) says: - - 'Stones and other missiles from slings may be removed by levers or the - scoop of an ear probe adapted for wounds' ([Greek: kyathiskou - traumatikes melotidos]). - -This was probably an instrument on the same principle as the ear probe, i. -e. a combined probe and scoop, but on a larger scale. Possibly it may have -had a slight olivary enlargement. That it was large we learn from Galen's -Lexicon, where [Greek: melen ischyran] is stated to mean [Greek: ten -traumatiken melen]. It will easily be seen that the _specillum -vulnerarium_ has considerable affinity with the other class of spoon -probes which I constituted, viz. the class of cyathiscomeles--for these -had a scoop at one end--and this being specially intended for wounds most -likely had a certain amount of olivary enlargement at its tip, but smaller -than the olive of a cyathiscomele, which was too large for ordinary -wounds. The typical ear specilla and the typical cyathiscomeles both form -well defined groups, but between these innumerable gradations occur among -the specimens extant. For practical purposes it is convenient to class all -these intermediate forms as _specilla vulneraria_. - - -_Handled Needles._ - -In the find of the oculist Severus were no less than nine handles for -needles. Of these, six were merely cylinders of bronze, expanded slightly -at one end and perforated at the other with a small hole for a needle. -They were from 72 to 40 mm. long and 7 to 5 mm. in diameter. Two were -hexagonal, four were round (Pl. XXI, figs. 2, 4, Pl. XVI, figs. 3, 4, 5, -6). Two others had the same holes for needles at one end, but at the other -they were pierced with a slot, 10 mm. deep, for the insertion of a knife -blade. One was 60 x 7 mm., the other 53 x 5 mm. (Pl. II, figs. 1, 2). -Another, perforated at one end as before, carried at the other an -olive-pointed probe. It was 8 cm. in length, and of this 3.5 cm. consisted -of a hexagonal handle 3.5 cm. in diameter. The remainder was cylindrical, -and it terminated in a probe point with a slight olivary enlargement (Pl. -XVI, fig. 2). In all cases the needles had evidently been made of steel -and had entirely disappeared. - -We have many allusions to the use of handled needles in ophthalmic work. -In describing the couching of cataract Celsus says: - - Tum acus admovenda est, acuta ut foret sed non nimium tenuis (VII. - vii). - - 'Then a needle is to be applied, sharp so as to penetrate, but not too - fine.' - -Sextus Platonicus (_Med. ex Animalibus_) says that cataract is depressed -with a specillum. - -A full description of the operation is given by Paul: - - 'We measure off a nucleus' breadth ([Greek: hoson pyrenomeles]) from - the part called the iris and in the direction of the outer canthus, - then mark with the olivary end of the couching needle ([Greek: pyreni - parakenteriou]) the place to be perforated. If it is in the left eye, - we work with the right hand, and vice versa. Bringing round the - pointed end of the perforator, which is round at the tip ([Greek: kai - anastrepsantes ten akmen strongylen kata to peras hyparchousan tou - kenteriou]), we push it firmly through at the part which was marked - out until we come to an empty space. The depth of the perforation - should be as great as the distance of the cornea from the iris. Then - raising the needle to the apex of the cataract (the bronze of it is - plainly visible through the transparent part of the cornea) we depress - the cataract to the underlying parts. After the couching of the - cataract we gently extract the needle with a rotatory movement' (VI. - xxi). - -It will be seen from Paul's vivid description that the couching instrument -consisted of a handle with a nucleus at one end, to measure off the spot -at which to perforate, and a needle at the other. We saw that the outfit -of the oculist Severus contained one such instrument (Pl. XVI, fig. 2). -The same combination is not infrequently met with. In the Museum at Aarau -there are four from the station at Vindonissa. I have one in my collection -which is interesting as showing a screw thread for fitting on a cover to -protect the needle (Pl. XVI, fig. 7). It was found in Bedfordshire. It -reminds one very strongly of the couching needle figured by Pare. Other -handled needles were used in eye work as cauteries. Of trichiasis Celsus -says (VII. vii): - - Si pili nati sunt qui non debuerunt, tenuis acus ferrea ad - similitudinem spathae lata in ignem coniicienda est: deinde candens, - sublata palpebra sic ut eius perniciosi pili in conspectum curantis - veniant, sub ipsis pilorum radicibus ab angulo immittenda est ut ea - tertiam partem palpebrae transsuat; deinde iterum, tertioque usque ad - alterum angulum; quo fit ut omnes pilorum radices adustae emoriantur. - - -_Ophthalmic Probe._ - -Greek, [Greek: ophthalmike mele]. - -In Hippocrates (ii. 100) we find an ophthalmic probe mentioned. - - [Greek: Lepidos melai treis to platei kai aletou setaniou kolles, - panta tauta leia tripsas, katapotia poiesas didou.] - - 'Of squama aeris three times the full of a specillum and [as much] of - the gluten of wheat. Levigate all up fine, form into pills and - administer.' - -Galen in his Lexicon explains that [Greek: melai treis to platei] means -[Greek: to kyathisko ophthalmikes meles]. This is the only mention which -we have of a special ophthalmic probe with scoop. In applying medicaments -to the eye with a probe whenever any variety of probe is mentioned it is -always the ear specillum which is named. It seems most likely that either -the ear specillum or some variety of it is referred to here. It may have -had a nucleus for applying medicaments at one end and a scoop at the -other. - - -_Rasping Specillum._ - -Greek, [Greek: blepharoxyston]; Latin, _specillum asperatum_ (Celsus). - -A special burred specillum, for curetting the granular lids so common as a -result of the ophthalmia which is endemic in most Eastern countries, and -which was rampant in ancient Greece and Rome, is described by Celsus and -also by Paul. Celsus says: - - In hoc genere valetudinis quidam crassas durasque palpebras et - ficulneo folio, et asperato specillo, et interdum scalpello eradunt, - versasque quotidie medicamentis suffricant (VI. vi). - -Paul says: - - 'But if the granulation be hard and yield to none of these things we - must evert the eyelid, and rub it down with pumice stone, or the - shell of the cuttlefish, or fig-leaves, or the surgical instrument - called blepharoxyston' ([Greek: dia tou blepharoxystou kaloumenou], - III. xxii). - -Heister (vol. i. tab. xvi. p. 591) figures the blepharoxyston as a -spoon-shaped instrument burred on the convex side. There is in the Orfila -Museum, Paris, an instrument of similar form. It consists of a handle with -an olivary point at one end, and at the other a plate with transverse -ridges. This agrees well enough with what we know of the classical -instrument. It was found in Herculaneum. (Pl. XVI, fig. 1). - - -_Styli and Styloid Specilla._ - -Greek, [Greek: graphion, grapheion, graphis]; Latin, _stylus_ or _stilus_. - -The difficulty of deciding as to whether any particular instrument is a -surgical or a domestic article is often well illustrated by styloid -instruments. In the British Museum several types of instrument will be -found classed among surgical instruments, and a series of exactly similar -articles will be found repeated among the styli used for inscribing and -erasing characters on wax tablets. As even the writing stylus was -occasionally used for surgical manipulations we are justified in looking -on all styloid instruments as potentially implements of minor surgery. The -claims of any doubtful instrument to be considered as once having been one -of a surgeon's tools must be decided on such grounds as the circumstances -of its discovery. - -Galen (xii. 865) says teeth may be extracted with the stylus ([Greek: -grapheio analabe]) or with the finger. - -Hippocrates (i. 46) thus describes the method of extraction of the -secundines: - - 'Place the patient on the obstetric chair and, leaving the cord uncut, - place the child on two bladders filled with water and puncture each of - the bladders with a stylus ([Greek: graphio]) so that the water may - slowly flow away.' - -The writing stylus, then, from the fact of its being at hand and of -suitable shape was occasionally, perhaps often, used as a surgical -instrument. - -I give a figure of a stylus in silver, beautifully oxidized, which was -found at York while making excavations there in constructing the railway -(Pl. XVII, fig. 3). - -Pl. XVII, fig. 6 shows an instrument which is figured by Vulpes (op. cit.) -as a specillum. Personally, I think its highly ornamented form shows that -it is rather a domestic article, but, as no information is available as to -the surroundings among which it was found, we can only say that its shape -fits it equally well either for writing or minor surgical manipulations. - - -_Grooved Director._ - -Although we have no actual description of a grooved director, we have many -manipulations described in which such an instrument would be used -nowadays. For example, in describing the treatment of fistulae Celsus -says: - - In has demisso specillo ad ultimum eius caput incidi cutis debet (VII. - iv). - - 'A director being inserted into them down to their termination the - skin ought to be incised.' - -It is interesting to find that we have at least one grooved director -extant to prove that this instrument was known to the Romans. It is in the -Section of Surgical Antiquities of the Musee de Cinquantenaire, Brussels, -and it was discovered, along with several other surgical instruments, in a -surgeon's case of the usual cylindrical form. - -It is 15 cm. long, 2 mm. in diameter. A deep groove runs for 6 cm. from -one end. The other end terminates in a small button. It is of silver, as -also were the other contents of the case. It is possible that grooved -specilla may have been in quite common use, but may have been made of wood -or tin, and have therefore not survived; because we learn from Galen's -Manual of Dissection that probes which were used as directors in -dissecting work were generally of wood, such as boxwood, so that they -might not chip the scalpel (ii. 711). - - -_Surgical Needle (three cornered)._ - -Before discussing the eyed probes it will be well to clear the way by -disposing of the needles, and of these, as the most easily defined class, -it will be best to take the surgical needles first. We have innumerable -references to the surgical needle though we have no actual description of -it. There must have been many different sizes of it, for the manipulations -vary greatly in magnitude. I shall content myself with giving two -quotations describing respectively one of the largest and one of the -smallest of these. Both passages are from Celsus. He thus describes the -operation of suturing the abdominal parietes: - - Sutura autem neque summae cutis neque interioris membranae per se - satis proficit; sed utriusque: et quidem duobus linis iniicienda est, - spissior quam alibi; quia et rumpi facilius motu ventris potest, et - non aeque magnis inflammationibus pars ea exposita est. Igitur in duas - acus fila coniicienda, eaeque duabus manibus tenendae; et prius - interiori membranae sutura, iniicienda est sic ut sinistra manus in - dexteriore ora, dextra in sinisteriore a principio vulneris orsa, ab - interiore parte in exteriorem acum immittat: quo fit ut ab intestinis - ea pars semper acuum sit quae retusa est. Semel utraque parte - traiecta, permutandae acus inter manus sunt, ut ea sit in dextra quae - fuit in sinistra, ea veniat in sinistram quam dextra continuit: - iterumque eodem modo per oras immittendae sunt: atque ita tertio et - quarto, deincepsque permutatis inter manus acubus plaga includenda. - Post haec, eadem fila eaedemque acus ad cutem transferendae similique - ratione ei quoque parti sutura iniicienda; semper ab interiore parte - acubus venientibus, semper inter manus traiectis: dein glutinantia - iniicienda (VII. xvi). - -In the next case, where Celsus describes the treatment of staphyloma of -the cornea, a very small needle must have been used: - - Haec fere circa oculum in angulis palpebrisque incidere consuerunt. In - ipso autem oculo nonnunquam summa attolitur tunica, sive ruptis intus - membranis aliquibus sive laxatis; et similis figura acino fit: unde id - [Greek: staphyloma] Graeci vocant. Curatio duplex est: altera, ad - ipsas radices per mediam transsuere acu duo lina ducente; deinde - alterius lini duo capita ex superiore parte, alterius ex inferiore - adstringere inter se; quae paulatim secando id excidunt: altera in - summa parte eius ad lenticulae magnitudinem excidere (VII. vii). - -Now for suturing tissues, and more especially tissues of such toughness -and thickness as the abdominal parietes, a round needle is absolutely of -no use. A surgical needle not only requires to have cutting edges, as our -three-cornered needles have, but these edges need to be in good condition -to work well. Three-cornered surgical needles were in use from very early -times. They are fully described in the Vedas of the Hindoos (Wise, _Hindoo -System of Medicine_, p. 171). A few three-cornered needles of Roman origin -have been found, although they are rare. Those which exist are of bronze. -Probably the majority were of steel, and of these none have survived. I -give a photograph of a three-cornered needle from my collection (Pl. XVII, -fig. 4). It is imperfect at the point. It measures 7.2 cm. in length, and -the sides are each 2 mm. in breadth. It is important to emphasize the fact -that only needles with cutting edges are to be looked on as surgical, -because it is not unusual to find needles, which are round and of large -calibre, described as surgical, although they are quite unfitted for -surgical work. Such is the one figured by Vulpes (op. cit.). - -Needles of this kind are sometimes found, as this one was, among surgical -instruments. But they are not surgical needles in the sense that they are -intended for suturing tissues. They are for fixing bandages. I shall -describe them in the next section. - - -_Round Needles and Bodkins._ - -Hippocrates tells us that bandages for fixing dressings and splints on a -fractured limb ought to be finished off by stitching with a thread (iii. -55), and Celsus repeats the advice: - - Hieme saepius fascia circumire debet: aestate quoties necesse est. - Tum extrema pars eius inferioribus acu assuenda est; nam nodus vulnus - laedit, nisi tamen longe est (V. xxvi). - -The round sewing needle was therefore part of the recognized outfit of the -surgeon, and numbers have been found associated with surgical instruments. -Apart from this association with other instruments it is quite impossible -to distinguish them from domestic needles. The same may be said of -bodkins, as these too occur in surgical finds, and are also quite -indistinguishable from the domestic articles for embroidering. Pl. XVII, -fig. 2 shows a bronze needle from Roman London. A similar one from -Pompeii, now in the Naples Museum, is given by Vulpes as a surgical -needle, owing to the fact that it was found along with surgical -instruments; but it is evident that it is only a needle for sewing -bandages, &c. - -Other types of needles and bodkins are found in bronze, but many also are -of bone and ivory. Even the latter are quite serviceable, and in spite of -their being comparatively thick will stitch compact cloth easily. An ivory -needle from Roman London is shown in Pl. XVII, fig. 5. - - -_Eyed Probes._ - -We have frequent references to eyed probes, and we also possess a -considerable number of different types. In dealing with the dipyrene I -quoted a passage to show that it sometimes carried an eye in one of its -olives. Hippocrates refers to an eyed probe of tin. In treating of fistula -he directs us to take a rod of tin having one end pierced with an eye -([Greek: melen kassiterinen ep' akrou tetremenen]), and having put one end -of a twisted piece of lint through the eye put the probe into the fistula, -get the end of the specillum, bend it and hold the thread with the finger -and withdraw the ends. Paul quotes this passage (VI. lxxvii), but alters -the wording slightly: - - 'Hippocrates directs us to pass a thread consisting of five pieces - through the fistula by means of an eyed probe or a dipyrene' ([Greek: - dia tetremenou kopariou e dipyrenou]). - -Again in polypus naris (ii. 243) Hippocrates directs us to cut a sponge to -the shape of a ball and tie the ball round with thread, and make it hard -and of such a size as to fill the nose. To the sponge tie a thread of four -pieces, each a cubit long, and make one thread of them. Put the end -through a fine tin rod having an eye at the end. Push the rod bent at an -acute angle into the mouth, and catch the end of the thread under the -palate and pull it through, propping it with another hoof-like probe, and -extract the polypus. Pl. XVII, fig. 1 shows an eyed probe from the Baden -Hospital. Its shape is exactly the same as a lead probe figured by Pare -for the insertion of the apolinose. - -An example of a scoop at one end and an eyed probe at the other was found -at Augst, and is now in the Museum at Basle (Brunner, loc. cit., Taf. I, -fig. 14). It is 16 cm. long, of which the spoon, slightly defective at its -tip, occupies 3 cm. About 2 cm. from its tip, which is fine, there is an -elongated eye, 5 mm. in length. - -Various other combinations are met with. - - -_Ligula type of Specillum._ - -Greek, [Greek: kyathiskos]; Latin, _ligula_. - -Ligulae are found in enormous numbers and in very great variety. They are -toilet articles for extracting from tubes and boxes ointment, the various -salves, balsams, and powders which entered into the mysteries of the Roman -lady's toilet. The ligula is therefore not strictly speaking a surgical -instrument, but as it was used by the laity, and no doubt also by -physicians, for making applications to affected as well as to unaffected -parts, and as it is often found associated with surgical instruments, it -is advisable to bring it within the scope of this investigation. It is -also convenient to do so, because some varieties approach so closely in -form to the true surgical specilla that it is often difficult to decide -which class to place a particular specimen in. In doubtful cases it is -well to remember that the specillum is most usually a combination of two -instruments on one shaft. Brunner (loc. cit.) figures a number of ligulae -from the Swiss museums. These he names specilla oricularia, although -admitting that they are only domestic articles. I have shown, however, -that the specillum oricularium is a well-defined combination of scoop and -probe. - -Plate XVIII shows a variety of ligulae from various sources, some simple, -some combined instruments. Figs. 4, 5, 8 are most typical forms. Some of -this simple type are two feet in length. They are often overlaid with -gold. Fig. 7 shows a ligula which has so been treated. It carries a small -fork on which to poise a pellet of semi-solid medicament. - - -_Spoons for measuring, preparing, and pouring medicaments._ - -A type of spoon not uncommonly met with has a round bowl about 2 cm. in -diameter, and a handle of about 10 cm. long. Usually they are of bronze; -but occasionally they are of silver, and a considerable number in bone -were found in the Roman Hospital at Baden. They are for measuring -medicaments, heating them, and removing them from unguentaria, &c. They -are often found alongside the glass unguentaria which contained the -salves. They were also used for religious purposes. - -Similar spoons with pointed handles are common in finds of domestic -articles. The sharp end is for extracting shellfish, &c. A larger variety -of the unguent spoon has a spout to assist in pouring the contents. This -variety is rather rare. - -Pl. XIX, fig. 4 is from the British Museum. The bowl is 2.5 cm. in -diameter and the handle is 15 cm. long. The handle is round, and it has a -small ringed ornamentation at its end and one close to the bowl. The -bottom has been thinned out with heat, and there is a small perforation -visible in it. A similar spoon was found in the grave of the Paris -surgeon. Traces of medicament remain on it. This type is probably intended -for warming salves and pouring them into the eye and other affected parts. -Another variety is seen in Pl. XIX, fig. 1. This specimen is in the -Naples Museum, and was found along with the spatula shown in Pl. XIX, fig. -2. The handles of each are of bronze, the scoop and spatula parts are of -silver. Vulpes describes these as a lancet for drawing blood and a spoon -for collecting and examining the same. It is impossible to regard an -instrument of silver as a cutting instrument. These are for mixing and -spreading medicaments. A large spoon of a peculiar shape from the Naples -Museum is seen in Pl. XIX, fig. 3. It is of silver. The handle, which is -of ivory, is ornamented with spiral carving, and the end bears a ram's -head. Another interesting little shovel from the same museum is of bronze, -and carries the head of Minerva Medica on the end of the handle (Pl. XX, -fig. 5). We may here include the large double spatulae of the type shown -in Pl. XX, fig. 1, which represents a specimen from Naples. A similar one -was found in the outfit of the Paris surgeon, and Scultetus shows -precisely similar instruments in use in his time for applying the -stiffening to the bandages, &c. for setting fractures. The Romans probably -used theirs for a similar purpose. - - -_Tongue Depressor._ - -Greek, [Greek: glossokatochos]. - -To open a quinsy Aetius says (II. iv. 45): - - 'If the patient is adult, seat him and make him open his mouth, and - depress the tongue with a spathomele, or a tongue depressor, and open - the abscess with a probe or a needle knife.' - -In excision of the tonsil Paul (VI. xxx) bids us seat the patient in the -sun and depress the tongue with a tongue depressor ([Greek: -glossokatocho]). - -Pl. XX, fig. 6 shows one of six bronze tongue depressors, burnished like -small mirrors, from the Lepine collection (Vedrenes, _Celse_). - - -_Uterine Sound._ - -The uterine sound is frequently mentioned by Hippocrates for correcting -malpositions of the uterus, and dilating and applying medicaments to the -interior of the cervix. After falling into disuse in the middle ages it -was reintroduced by Sir J. Y. Simpson, only to disappear once more almost -entirely from sight. - -I have already referred to Galen's statement that the non-pregnant os is -of such a size that it will just admit an olive-pointed probe (p. 54). - -Hippocrates (ii. 836) directs us to treat hysteria by dilating the cervix, -first with an ointment probe and then with the finger. - - [Greek: Kai hypaleiptron kathienai kai anastomoun kai to ge daktylo - hosautos leioun.] - -Soranus (II. x) describes plugging for uterine haemorrhage by means of the -sound: - - [Greek: Kai trypheron erion heni tini ton eiremenon chylon diabrochon - dia daktylou e meles parentithestho to stomati tes hysteras. kai poly - mallon enteuthen tes haimorrhagias hyparchouses.] - -Hippocrates (iii. 34) alludes to applying medicament to the internal os -with the sound: - - 'Grind the pulp of colocynth, &c., and rub it up with honey and smear - it on the sound ([Greek: peri melen]) making the consistence such that - it can enter the os and always be pushed beyond until it has - penetrated to the interior of the uterus. When the medicament has - liquefied extract the sound, and again in the same way apply - elaterium.' - -If pus collect in the uterus post partum, or after abortion or from any -other cause, it is good practice to pass a sound ([Greek: melen -hypaleiptrida]) into the cervix (i. 471). In another place we are directed -to draw off gas in the uterus by fomenting the whole body and the uterus -with vinegar and water, warmed specilla being afterwards inserted ([Greek: -melas diapyrous emballonta]). - -Again we find the sound applied to correct malposition of the uterus (iii. -140): - - 'When the semen is extruded on the third day and the woman - consequently fails to conceive, take small soft feathers and tie them - together, and foment the uterus as we do the eyes. Make the feathers - even at the tips and tie the ends with a very fine thread, and anoint - with much rosaceum. Also place the patient on her back on a couch, and - place a pillow under the loins, and, the woman's thighs being extended - and separated, insert a sound and turn it to this side and that till - it project.' - -In all these cases there is no special instrument designated as being used -for a uterine sound, only the spathomele ([Greek: hypaleiptron]) and the -olivary probe named. With both of these we have met before. However, I -have thought it of historical interest to cast these passages together. It -will also clear the way for the discussion of other instruments, whose use -is entirely reserved for the purpose of dilation of the cervix. - -A more questionable use of the sound is referred to by many authors. -During the Empire the death of the foetus was frequently procured both by -abortifacients and instruments. Frequent references to the use of drugs -for this purpose may be found in the lay writers such as Juvenal and -Suetonius (_Domitian_), and the later medical authors do not hesitate to -describe the composition of abortifacient pessaries. It will be remembered -that the Hippocratic oath specially forbids this practice. - - -_Uterine Dilators--Solid, graduated wooden._ - -Greek, [Greek: diastomotris, melen ten diastellousan--ton diastolea] -(Galen, _Lexicon_). - -Besides the ordinary probes, which we have just seen that Hippocrates used -occasionally for dilating the os, we have frequent mention made of a -special variety of dilators which, although they are called [Greek: mele] -by Hippocrates, are not, strictly speaking, probes or sounds, but a -graduated set of dilators of wood, tin, or lead. They correspond, in fact, -to our Hegar's dilators. - -Hippocrates describes these dilators (ii. 799). The patient is to have -fumigations for five or six days till the cervix is softened. After these -fumigations, dilators ([Greek: prostheton]) made of pieces of very smooth -slipping pinewood are to be introduced into the cervix. There were six of -these. Each was six finger breadths (4.2 in.) in length. They ended in a -point, and each succeeding rod was larger than the preceding one; the -largest being of the diameter and shape of the index finger, being smaller -at one extremity than the other. They should be as round as possible and -with no splinters. Before being introduced they were smeared with oil. -First the point was gradually introduced by rotating the dilator and -pushing it simultaneously till it entered for a distance of four finger -breadths (2.8 in.). After the first rod was introduced it was withdrawn -and replaced by a larger one. During the after treatment a leaden tube -filled with mutton fat was left in the uterus at night, while through the -day one of the pine dilators was used. Pl. XX, fig. 2 shows a specimen -from Pompeii, which Vedrenes regards as a uterine dilator. It is hollow, -and is ornamented to resemble the head and body of a snake. - - -_Metal Dilators mounted on handles of wood._ - -Hippocrates (i. 473) mentions a variety of dilator made of tin or lead, -and hollow behind for mounting on a wooden handle: - - 'After douching and fumigation, dilate, and, if necessary, straighten - the cervix with a dilator of tin or lead ([Greek: te mele te - kassiterine e molybdaine]), beginning with a fine one, and then a - thicker if it be admitted, until it seems to be in proper position. - Dip the dilators in some emollient. The dilators are to be made hollow - behind, and fitted round rather long pieces of wood and thus used.' - -This evidently refers to a portable set of dilators, each capable of -fitting on a common handle, like Fritsch's, Peaslee's, or Lawson Tait's of -modern times. - - -_Bifurcated Probe._ - -Greek, [Greek: mele dikrous, chele]. - -In treating of polypus naris Hippocrates directs us to take a sponge and -tie it into a hard ball, and attach a four ply thread to it. Next to pass -the end of this thread by means of an eyed probe of tin till it is caught -at the back of the mouth, and drawing it out of the mouth to place a -bifurcated probe under the palate, and using this as a fulcrum pull until -the polypus is extracted (_De Morbis_, ii. 243: [Greek: epeita chelen -hypotheis hypo ton gargareona antereidon helkein est' an exeiryses ton -polypon]). In Galen's _Lexicon_ we find [Greek: chele] explained as -meaning a notched probe, split like a hoof at the point ([Greek: melen -dikroun, kata to akron ektetmemenen empheros chele]). And again under the -heading [Greek: dikroun] he gives [Greek: to hoion dikranon, hoper kai -dischides onomazousi to de auto kai deloi], 'what they call cloven and -also cleft.' The same word also means the notch of an arrow. In _De -Morbis_ (ii. 245), Hippocrates describes another method of extracting -polypus with the same instrument. Taking a piece of stringy gut ([Greek: -chorden]) and making a loop on it pass the end through the loop, thus -making a second larger one, i. e. a noose. Pass the end of the gut through -the nose into the mouth with a tin probe. Pull the loop into the nose and -adjust it round the polypus with a notched probe ([Greek: mele te -entetmemene]), and when this is done pull on the gut, using the notched -probe as a fulcrum. - -There must have been one form of bifurcated probe with a rounded end -bearing a notch like an arrow. This is the only form of cleft probe which -it would be safe to use in the back of the throat in the manner described -by Hippocrates. We know, however, of other forms of bifurcated probes. -Celsus describes a bifurcated retractor used for the extraction of weapons -buried in the flesh: - - Saepius itaque ab altera parte quam ex qua venit recipienda est; - praecipueque quia fere spiculis cingitur; quae magis laniant si - retrorsus quam si contra eximatur. Sed inde aperta via caro diduci - debet ferramento facto ad similitudinem Graecae litterae Y; deinde, - ubi apparuit mucro, si arundo inhaeret propellenda est donec ab altera - parte apprehendi et extrahi possit (VII. v). - -Variant readings are V and [Greek: L]. The Aldine edition has [Greek: ps]. -The reading I have adopted is Daremberg's; but whichever is correct -matters little, as all indicate a bifurcated instrument, except the -Aldine, which would indicate a three-pronged one. There are several -bifurcated specilla in the British Museum (Pl. XXII). One in the Orfila -Museum, Paris, of slender construction, carries a hook at the other end. -It is from Herculaneum (Pl. XXI, fig. 1). A plain variety is shown in Pl. -XXI, fig. 6. The specimen shown in Pl. XXI, fig. 3 is interesting as -showing a possible fallacy. It has considerable affinity to the Roman -netting-needle, and may not be a probe at all. The typical netting-needle -has, however, blunt points, and the planes in which the forks lie are at -right angles to each other. - - -_Blunt Dissectors._ - -In his chapter on Angiology (or Division of the Temporal Blood Vessels) -for headache and ophthalmia (VI. v), Paul mentions the use of dissectors: - - 'Having therefore first shaven the hairs of the temples we make an - examination by palpation, applying warm fomentations or even a fillet - round the neck, and mapping out the vessels with ink as they become - apparent, we stretch the skin to either side with the fingers of our - own left hand and those of an assistant, and make a superficial - incision along the vessel. Then cutting down and retracting with hooks - and exposing the vessel with dissectors ([Greek: di' exymenisteron]) - we must raise it up completely isolated. If it be small, having - stretched it and applied torsion we may divide it through in such a - way as to remove a piece of it at one stroke.' - -The typical scalpel handle ends in a leaf-shaped dissector, and Celsus -always describes blunt dissection as being performed with the manubriolus -of the scalpel. We have, however, a few dissecting manubrioli as separate -instruments not designed to carry scalpel blades. Three were found -together in the grave of the surgeon of Paris. There are also two in the -museum of St-Germain-en-Laye, and one in the Museum at Mainz. We may take -as types two from the find of the oculist Severus in the -St-Germain-en-Laye Museum (Pl. XX, figs. 3, 4). They consist of elongated -leaf-shaped blades carried on hexagonal handles, and are exactly similar -in appearance to a scalpel handle, except that they do not carry a slot -for the insertion of a blade. - - -_Curved Dissectors._ - -Greek, [Greek: hydrokelikon koparion]. - -On the cure of hydrocele Paul (VI. lxii) says: - - 'When the fluid is in the tunica vaginalis we make the incision where - the apex of the tunica makes its appearance, and, separating the lips - of the incision with a hook, and having dissected off the fascia with - the hydrocele specillum and the scalpel ([Greek: exymenisantes to te - hydrokeliko kopario kai to smilio]), we divide it through the middle - with a lancet.' - -Treating of the excision of varices (VI. lxxxii) he says: - - 'Having separated the lips of the wound with hooks, and dissected away - the fascia with curved hydrocele specilla, and laid bare the vein and - freed it all round' ([Greek: hydrokelikois epikampesi kopariois]). - -A curved dissector from the find of the oculist Severus, now in the Museum -of St-Germain-en-Laye, has a neatly ornamented handle with a small hook at -one end, and at the other it curves first backward and then forward to -join a small leaf-shaped dissector 3 cm. long and 1 cm. in its greatest -breadth (Pl. XXIII, fig. 2). - - -_Sharp Hooks._ - -Greek, [Greek: ankistron, ankyromele]; Latin, _hamus_, _hamulus acutus_. - -Hooks blunt and sharp are frequently mentioned in both Greek and Latin -literature, and served the same purposes as we use them for; the blunt for -dissecting and raising blood-vessels like the modern aneurism needle, the -sharp for seizing and raising small pieces of tissue for excision, and for -fixing and retracting the edges of wounds. We are fortunate also in -possessing many fine specimens of both sharp and blunt hooks in museums, -&c. In the Naples Museum alone there are upwards of forty examples of -hooks. Of pterygium Celsus says: - - Tum idem medicus hamulum acutum, paulum mucrone intus recurvato, - subiicere extremo ungui debet eumque infigere; atque eam quoque - palpebram tradere alteri; ipse, hamulo apprehenso, levare unguem - eumque acu traiicere linum trahente (VII. vii). - -Aetius also mentions this use of the sharp hook: - - 'And, transfixing the pterygium with a hook ([Greek: kai ankistro - katapeirontes peri ta mesa to pterygion]), we gently make traction on - it' (_Tet._ II. iii. 60). - -Paul also says: - - 'Seizing the pterygium with a hook with a small curve, ([Greek: - ankistro mikrokampei anadeixamenoi]) we stretch it' (VI. xviii). - -The method of excision of the tonsil described by Celsus, Aetius, and Paul -is to bring the tonsil into view by dragging on it with a sharp hook and -then amputating it. Thus Paul says: - - 'Wherefore seating the person in the light of the sun, and, directing - him to open his mouth, while one assistant holds his head and another - presses down the tongue to the lower jaw with a tongue depressor we - take a hook ([Greek: ankistron]) and transfix the tonsil with it and - draw it outwards as much as we can without drawing the capsule along - with it, and then we cut it out by the root with the tonsil knife - suited to that hand' (VI. xxx). - -In contraction of the vulva, Paul says: - - 'Having transfixed the connecting body, whether flesh or membrane, - with hooks, we stretch it and divide it with the fistula knife' (VI. - lxxii). - -Similarly Celsus (VII. xxviii) says: - - At si caro increvit, necessaria est recta linea patefacere; tum ab - ora, vel vulsella vel hamo apprehensa, tamquam habenulam excidere. - -In dissection, many of the manipulations which we perform with the -dissecting forceps were performed by the ancients with sharp hooks. Pl. -XXIV, figs. 1-5 represent specimens from various sources; some simple, -others combined with another implement. - - -_Blunt Hooks._ - -Greek, [Greek: typhlankistron]; Latin, _hamus retusus_. - -Aetius (_Tet._ III. i. 13) says: - - 'Whatever adhesions there are of the lower border of the lids to the - tunics of the eye, we must put them on the stretch with a blunt hook - ([Greek: typhlankistro]) and with a pterygotome free the adhesion.' - -In Aetius (_Tet._ II. iii) we see the blunt hook used in the same way as -we use an aneurism needle, except that the ligature is not introduced with -it, but with another needle. He says we transfix the lips of the incisions -with two hooks and gradually dissecting with the scalpel we free the -vessel from the underlying fascia. Then with a blunt hook ([Greek: -typhlankistron]) placed under the vessel we raise it up from the depth, -and beneath it when raised we place a two ply thread by means of a needle, -and doubly tie and cut between. - -Paul says: - - 'Exposing the vessel with dissectors we must raise it up when it is - separated all round. If it be small, having stretched and twisted it - with a blunt hook, we may divide it through in such a way as to remove - part of it. But if it be large we must apply a double ligature under - it with a needle, either a piece of raw flax or some other strong - thing' (VI. v). - -The 'eyed hook' is mentioned by Galen in describing the dissection of the -spinal cord: - - [Greek: Endechetai de kai choris belones ankistro diatreto genesthai - ten encheiresin, hos epi ton peri tas karotidas arterias neuron eiothe - poieisthai] (ii. 669). - - 'It is advisable that the manipulation be performed not with a needle - but with an eyed hook, as is usually done in the case of the tendons - in the neighbourhood of the carotid arteries.' - -A small variety of the blunt hook is mentioned by Celsus, Galen, and Paul. - -Of the extraction of foreign bodies from the ear Celsus says: - - Sin aliquid exanime est, specillo oriculario protrahendum est, aut - hamulo retuso paulum recurvato (VI. vii). - -Paul says that if stones of fruits, &c. fall into the ear they must be -extracted with an ear scoop, a hook, or a forceps. - -Both types of blunt hook are represented by extant specimens; see Pl. -XXIII, figs. 3, 4. These remind us of our aneurism needles, and it is -interesting to note that Galen (_ut supra_) speaks of an 'eyed hook'. The -instruments shown in Pl. XXIII, figs. 2, 4 we might look on either as -curved retractors or dissectors as they are half sharp. Pl. XXV, fig. 2 -shows a hook of crotchet-hook type combined with a scoop. It is from -Herculaneum. - - -_The Strigil._ - -Greek, [Greek: xystra]. Latin, _strigil_. - -It seems to have been a common method of applying remedies to the auditory -canal to warm them in a strigil and pour them in with it. Galen frequently -mentions this. In _Med. Sec. Loc._ (xii. 622) he says: - - Having warmed the fat of a squirrel in a strigil, instil it. - -Celsus (VI. vii. l) says: - - In aurem vero infundere aliquod alimentum oportet quod semper ante - tepefieri convenit; commodissimeque per strigilem instillatur. - -Marcellus (IX. l) says: - - Conteres et in strigili calefacies, et infundes, et lana occludes - aurem. - -Scribonius Largus (xxxix) says: - - Ad auriculae dolorem et tumorem sine ulcere prodest herbae urceolaris - aut cucurbitae ramentorum sucus tepens per strigilem in foramen auris - dolentis infusus. - -The strigil varied much in size and shape. A common form was a -sickle-shaped instrument, the circular part being hollow and semicircular -on section, and admirably adapted for warming and pouring oil and other -medicaments into the ear as above described. Pl. XXV, fig. 1 shows a small -strigil from my collection. - - -_Spoon for applying astringent liquids to the uvula._ - -Greek, [Greek: staphylepartes]. - -In his description of the medical treatment of diseases of the mouth Paul -(III. xxvi) says: - - 'When the uvula is inflamed we must use the gargles recommended for - inflammation of the tonsils, and those of a moderately astringent - nature, such as the juice of pomegranate, applied by means of a spoon - or the instrument called the "uvula medicator"' ([Greek: - staphylepartou]). - -It is evident that it is quite a different instrument from the -staphylocaustus (_q. v._), which we are specially told had more than one -hollow and was a grasping instrument like a forceps. The present -instrument is for applying liquids, and was apparently of the form of a -spoon. Fabricius describes and figures such an instrument. It is a small -round spoon with a long handle. - - - - -CHAPTER V - -FORCEPS - - -_Epilation Forceps._ - -Greek, [Greek: tricholabis, tricholabion] (== [Greek: tricholabidion]); -Latin, _vulsella_. - -The removal of the hair from the face for cosmetic purposes is a custom -which has come down to us from prehistoric times, and seems to have been -very prevalent among all primitive races. In the bronze age the method by -which this was accomplished seems to have been to fix the hairs with a -broad jawed forceps and cut them off close to the skin by means of a knife -or 'razor'. Thus did primitive men 'shave', and very often in early bronze -age graves in Scandinavia and in the Swiss lake-dwelling excavations these -forceps and razors are found together. No doubt also epilation proper was -practised occasionally, but the majority of the prehistoric forceps are -not for epilation but for fixing the hairs to allow the knife to divide -them close to the skin. At a later time, with the more common use of -steel, the Greeks and Romans shaved as we do, and epilation proper was -practised for removing superfluous hairs from the face and also to remove -trichiasis. Aristophanes, a contemporary of Hippocrates (Ran. 516, Lys. -89, 151), Persius (iv. 37) and Juvenal (vii. 114) refer to the depilation -of the pubes as being common among certain classes, and the early -Christian Fathers deplore the practice. See also the remarks of Suetonius -on the conduct of Domitian (xxii). Prosper Alpinus, who visited Egypt in -the sixteenth century and wrote an interesting book on the state of -medicine in that country, found the custom still prevalent among the -Egyptian women, and thus explains the object with which it was practised -(_Medicina Aegyptiorum_, cap. III. xv): - - A pulveribus, qui Aegyptiis fere toto anno ventorum terraeque - siccitatis occasione perpetuo familiares existunt, atque ab assiduis - sudoribus quibus coeli calore omnia corpora continue abundant, - illuvieque quadam immunda redduntur, atque foetentia, ex quo pleraque - ipsorum et foetere et pediculis abundare solent. Balneis omnes hi - populi utuntur familiarissime pro corporum abstersione, maximeque - mulieres, quibus curae magis est corpora ipsarum pulchriora facere - ipsorum, illuviem et foetorem corrigentes, ut cariores sint suis - viris. Eae etenim saepissime corpora in iis lavant, at mundant ab - illuvie, perlotaque variis ornant odoribus ut recte unguentis oleant. - Ac veluti Italae mulieres atque aliarum multarum etiam nationum ad - capillorum facieique omne cultum adhibent studium, ita Aegyptiae - capillorum cultum negligunt ex consuetudine omnes capillos in bursam - serico panno paratam concludentes, ac ad pudendorum abditarumque - corporis partium ornatum omnem diligentiam adhibent. Pudendis igitur - tota cura in balneis ab iis adhibetur. Ea siquidem in primis lavant, - pilisque nudant, locaque pudendorum perpetuo glabra gestant, turpeque - ibi est mulierum pilis obsitam vulvam habere. Demum lotas eas partes - glabrasque effectas variis unguentis etiam exornant. - -The custom survived in France and Italy in the sixteenth century. - -Epilation as a purely surgical operation was frequently necessary for the -trichiasis consequent on the granular ophthalmia which was so common among -the Romans. Paul (VI. xiii) says: - - 'Turn the eyelid outwards and, with an epilation forceps ([Greek: - tricholabio]) dragging out the offending hairs, either one, or two, or - three or whatever number there are. Then apply a heated olivary probe - or an aural probe or some such slender instrument to the place from - whence the hair or hairs have been removed.' - -The numbers of toilet epilation forceps which have been found are -enormous. Moreover, forceps of exactly similar form were in use in every -household as accessories of the lamp for raising and snuffing the wick, -and artisans used them also for the finer manipulations of their crafts; -so that by far the largest number of forceps of this type are not surgical -instruments, but household implements. However, we have plenty of -specimens from purely surgical finds. - -Of the surgical instruments all forms agree in having no teeth. The -simplest form consists of a strip of metal bent on itself straight as in -Pl. XXVI, fig. 3, or with the jaws turned inwards, as in Pl. XXVI, fig. 5. -These are often pocket forceps. A 'pocket-companion', consisting of a -toilet forceps, an ear-pick and a nail-cleaner, such as is seen in Pl. -XXVI, fig. 4, is a common object in museums, such as the Guildhall Museum, -where this object is. A variety of epilation forceps with rounded legs is -seen in Pl. XXVI, fig. 2. Several of these have been obtained from purely -surgical finds. Others are formed by sawing a bar of bronze up its centre, -as in the specimen shown in Pl. XXVI, fig. 1, which is 13 cm. 4 mm. long, -and with jaws 10 mm. broad. It is from the Naples Museum. - -This is the form most typical of the surgical epilation forceps. Several -of this type were found in the grave of the oculist Gaius F. Severus at -Rheims (Pl. XXVI, fig. 6). They are very large powerful instruments, from -15 to 16 cm. long, and with jaws 7 to 8 mm. in breadth (Deneffe, _Oc. du -3{e} siecle_, ii. 1-8). This form was no doubt used as a dissecting -forceps or tumour vulsellum as well as for epilation, but the typical -tumour forceps was toothed, and it is convenient to classify all those of -the untoothed type as epilation forceps. - -Other epilation forceps, which are however more likely to be toilet -articles, have the jaws of extreme breadth, as in Pl. XXVII, fig. 3 from -the Mainz Museum. It has a sliding catch. They are evidently intended to -remove a considerable number of hairs at once, or to fix them while they -were cut with razor or shears. - -It is certain, however, that in addition to these broader forceps a -variety with quite narrow blades was used, as Paul (VI. xxiv) tells us -that stones, &c. may be removed from the ear with epilation forceps -([Greek: tricholabio]), and again in fracture of the nose Paul (VI. xxiv) -says that splinters of detached bone are to be removed with these forceps. -We have several forceps of this type. There are in the Naples Museum -three, one from Pompeii, two from Herculaneum (Deneffe). One from my own -collection is shown in Pl. XXVI, fig. 2. The points are narrow and -rounded. - -A very interesting form is seen in Pl. XXVII, fig. 4, which shows a -forceps in the Thorwaldsen Museum, Copenhagen. It is 12 cm. long, of which -6 cm. of the upper end are solid and round. The remainder of the length is -occupied by the blades of the forceps, each 5 mm. broad, except for 12 mm. -at the extremity, where it expands into a leaf-shaped portion, 10 mm. -broad in its broader part. These leaf-shaped expansions oppose each other -accurately, and on the narrow part of the blade above them there slides a -rectangular catch which serves to clamp the blades and fix them like the -jaws of a vice. - -The surgical epilation forceps is, as we have seen, usually a simple -instrument. Occasionally we meet with a forceps combined with some other -instrument. These are, as a rule, toilet articles. A pocket ear-scoop and -epilation forceps combined was found in Paris. Precisely similar articles -of steel may be bought in chemists' shops to-day. Another has a small -unguent spatula combined with a forceps, while others carry olivary -probes. There are several of these in the St-Germain-en-Laye Museum (Pl. -XXVII, figs. 5, 2). One from Melos, in the Athens Museum, has a -porte-caustique. - - -_Polypus Forceps._ - -Greek, [Greek: polypoxystes]. - -Galen (_Med. Sec. Loc._ xii. 685) alludes to the method of extraction of -polypus from the nose by means of a forceps ([Greek: epeita labidio -exairei]), and from what Paul says it would seem that there was a special -polypus instrument, consisting of a forceps at one end and a rugine at the -other. After describing extraction by means of a knife and scoop he says: - - 'If, however, any part of the tumour be left behind, we take another - polypus eradicator ([Greek: heteron polypoxysten]), and with the end - of it ([Greek: epakmou autou xysteriou]) bring away what remains, by - stretching, twisting, and scraping it strongly.' - -[Greek: Xysterion] means a small rugine, but stretching and twisting can -only be done with a forceps. Rare as the combination of an antique forceps -with another instrument is, we have one example of the combination of a -rugine and a forceps, and, as it is admirably adapted for the extraction -of nasal polypus, I think we are quite justified in considering it to be -the instrument indicated by Paul. This instrument was found in the grave -of the Paris surgeon. It is elegantly formed and is of one piece of bronze -sawn down the middle. The upper part is surmounted by a rugine strongly -curved, pointed at the tip and cutting on one edge. The rugine measures 3 -cm. in length, and 5 mm. in breadth (Deneffe, _Tr. d'un Chir._, pl. v, -fig. 1) (Pl. XXVII, fig. 1). - - -_Tumour Vulsellum (Myzon)._ - -Greek, [Greek: mydion, mygdion, sarkolabis, sarkolabos]; Latin, _myzon_, -_sarcolabon_, _vulsella_. - -The form vulsellum has got so well established by usage in modern medical -writings that it would seem pedantic to write 'vulsella forceps', but so -far as I am aware it is not a form which has any classical authority. The -classical usage is _vulsella_, _-ae_, feminine. I shall follow custom and -use the modern term when using it as an English word. - -The myzon, or tumour forceps, was a toothed instrument of the dissecting -forceps type. Ducange says it takes its name from the shells which are -called [Greek: mytiloi], vulgo [Greek: mydia] (mussels). It was used -whenever it was desired to make traction on any object--such as a -tumour--to excise it, or to raise and fix a piece of skin. Aetius (xvi. -106) says: - - [Greek: Mydio platystomo syllabon ten nymphen dia tes euonymou cheiros - apoteineto te de dexia apotemneto para tous odontas tou mydiou.] - - 'Seizing the clitoris with a broad jawed vulsellum in the left hand, - put it on the stretch, and with the right cut it off close to the - teeth of the instrument.' - -Paul gives pretty much the same instructions (VI. lxx): - - [Greek: Mydio kataschontes to peritton tes nymphes ektemnomen smile.] - - 'Seizing the hypertrophied portion of the clitoris with a vulsellum, - excise it with a scalpel.' - -Aetius (xvi. 107) also says: - - [Greek: Hosper oun epi tes nymphes proeiretai schematizein chre ten - gynaika kai mydio apoteinein ten hyperochen kai to polypiko spathio - ekbaseos holon to peritton aphairein.] - -Cf. also Paul, VI. lxxi and again Aetius (iv. ii. 3). - -Again Aetius says: - - 'If there is a large and malignant excrescence in the angle of the - orbit, the enlarged part must be seized with vulsella ([Greek: mydio]) - and cut off' (vi. 74). - -In the corresponding passage in Paul (VI. xvii) another name for the -vulsellum is used, viz. [Greek: sarkolabos]:--'granuloma of the inner -canthus we seize with vulsella and excise' ([Greek: sarkolabo]). In -treating of epulis he again uses the same term: 'Epulis we seize with -vulsella and excise' ([Greek: sarkolabo]). - -In Moschion (II. xxx), in the chapter 'De Haemorrhoidibus quae in matrice -nascuntur', we find a Latin transliteration of the two terms [Greek: -mydion] and [Greek: sarkolabos] side by side: - - Myzo vel sarcolabo haemorrhoides teneantur ita ut in aliquantum - extensas scalpello prius radices earum scarifes, et in aliquantum - artifex sarcolabo convertat. - -Here, in all probability, Soranus, from whom Moschion is copying, has -simply used [Greek: mydion], and the added 'vel sarcolabo' is simply a -gloss, for the terms [Greek: mydion] and [Greek: sarkolabos] are -synonymous. However this part of Soranus is lost. Extant specimens of the -vulsellum are common. A simple variety is formed by folding a plate of -bronze on itself, as in Pl. XXVIII, fig. 1, which shows a specimen in the -British Museum. The jaws are finely toothed. - -More usually the myzon is formed by sawing a plate of bronze partly along -its midline as in Pl. XXIX, fig. 2, which is taken from the find of the -oculist Severus. - -An interesting variation is seen in the specimen shown in Pl. XXVIII, fig. -3 which is from my own collection. The line of junction of the jaws -instead of being in the median plane is sloping. The object of this -arrangement is not quite clear. A small variety of the vulsellum is -referred to by Aetius: - - 'Epulis we seize with a small vulsellum and excise with a small - scalpel' ([Greek: he epoulis mydioskello apotatheisa ektemnestho - smilario steno], vii. 24, 25). - -We have one or two of these instruments. They remind one of fixation -forceps. I illustrate one in Pl. XXIX, fig. 3. It is from the Mainz -Museum. There are four similar ones in the Frankfort Historical Museum. -The specimen shown in Pl. XXVIII, fig. 2, from the Naples Museum, is -interesting as being stamped with the name of the maker, Acachcolus. - -We have now to consider an interesting variation produced by extending the -extremity of the blade to one side so as to increase the width of the -blade (coudee type). This is a rare type. - -Pl. XXIX, fig. 1 represents one of two from the find of the surgeon of -Paris. It is 17 cm. long, and the legs of the forceps are 8 mm. wide. The -jaws debouch to one side at an obtuse angle for a distance of 2 cm. and -end in a fairly sharp point. The jaw is thus increased to 2 cm. in -breadth. They are finely toothed. They are concave internally and convex -externally. The other forceps was 14.5 cm. long and 8 mm. wide. The Museum -at Naples has a forceps of this type, but having a sliding ring to fix the -jaws after they have been applied (Pl. XXIX, fig. 4). - -This angled type of forceps may be the one referred to by Paul in his -description of the plastic operation on the eyelid for trichiasis (VI. -viii), when he directs us to raise the redundant skin of the lid with a -fixation forceps and cut it off with a scalpel ([Greek: blepharokatocho -mydio, tout' esti pros ten periphereian tou blepharou eschatismeno -anateinantes to peritton derma, smilio apokoptousi]). It may be noted that -this coudee type of forceps has considerable affinity with the type of -forceps presently to be described for strangling haemorrhoids and the -relaxed uvula, the only essential difference being that the blades are not -crossed here. - - -_Uvula Forceps._ - -Greek, [Greek: staphylagra]. - -In Aetius (II. iv. 12) we have an interesting description of the -amputation of the uvula by first crushing it in a forceps so as to prevent -haemorrhage and then cutting it off: - - 'Then inserting a vulsellum and making traction on it, the uvula - crusher ([Greek: ten staphylagran]) is fitted on about the middle of - the uvula or a little below it, and then it is pulled and twisted (by - the vulsellum). By the torsion it becomes lifeless and, as it were, - snared off; it curls up, becomes livid and comes off without much - effusion of blood. Wherefore it is well to wait some time and hold it - till the patient can stand it no longer, and then cut it off--the cut - being made close to the vulsellum but nearer the tip than to it.' - -The [Greek: staphylagra] therefore corresponds in its action to a -pile-crusher. This instrument I believe to be represented by the type of -forceps shown in Pl. XXX, fig. 1. It is in the British Museum. The two -branches of the forceps cross like scissor blades, and at their ends the -jaws are formed in such a way as to project forwards and enclose a cavity -1 cm. deep and 18 mm. long. Over all the forceps is 18 cm. long. The jaws -are finely toothed. There is in the same museum another instrument similar -in all respects except that it is 1 cm. shorter, and that in each blade, -which is 16 mm. long (Pl. XXX, fig. 2), there is a small hole near the -proximal end. A posterior view of a similar instrument is seen in Pl. -XXXI, fig. 1. It is from the find of the surgeon of Paris. A similar -specimen is in the Mainz Museum. - -Pl. XXXII, fig. 3 shows a smaller specimen from the Naples Museum. It is -11 cm. in length. A large powerful variety with a different arrangement of -the handles is seen in Pl. XXXI, fig. 2 from a specimen in the Antiquarian -Museum at Basle. It is 20 cm. long. - -A forceps which I take to be a staphylagra occurs on the coins of Atrax in -Thessaly (_circa_ 400 B. C.). The forceps stands alongside a bleeding cup. - -The object of the holes in several of the specimens is to permit the -insertion of a cord to bind the jaws firmly together, and thus keep up the -strangulation of the part for some time, as Aetius directs. The -application of a ligature in this way would, of course, not be possible -while the instrument was applied to the uvula, but the following passage -from Leonidas (Paul, vi. 79) shows that the uvula crusher was also used to -clamp piles in the same way: - - 'Having seized the haemorrhoids and held them there for some time with - the uvula crusher ([Greek: staphylagra]) he cuts them off with a - scalpel.' - -In such a case the application of a cord to clamp the jaws together would -be a distinct convenience. The short variety is more suitable for external -operations, as for haemorrhoids; the long variety for manipulations in the -throat. - -Hippocrates mentions the uvula crusher as one of the instruments necessary -for the outfit of the physician (i. 63). - - -_Forceps for applying Caustic to Uvula._ - -Greek, [Greek: staphylokaustes]. - -A remarkable variety of forceps, of which there is only one extant -specimen (which is in the Vienna Museum) is shown in Pl. XXXII, fig. 2. It -is formed of two branches which cross and are fixed by a rivet near the -middle of the instrument. The jaws are 3.5 cm. long, concave internally, -and fit accurately together, enclosing an oval cavity 1 cm. in diameter. -This forceps is, I believe, the one which Paul describes as used for -destroying the uvula with caustic. He says (VI. xxi) that if from timidity -the patient decline excision of the uvula, we are to take the caustic used -for operations on the eyelids, or some such caustic, and fill with it the -hollows of the caustic holder for the uvula ([Greek: tou staphylokaustou -tas koilotetas]), and directing the patient to gape wide, and getting the -tongue pressed down with a tongue depressor, we open the instrument -sufficiently and grasp with it as much of the uvula as we cut off in the -other operation. The medicament must neither be of too liquid consistence, -lest it run down from the uvula and burn the adjoining parts, nor very -hard, that it may quickly act on the uvula. And if from one application -the uvula becomes black this will be sufficient, but if not, we must use -it again. In VI. lxxix he says that some, filling the hollows of the -staphylocaustes ([Greek: tas koilias staphylokaustou]) with caustic, burn -off haemorrhoids in the same way as they do the uvula. An interesting use -of this instrument is mentioned by the same author in the chapter above -referred to, while describing the method of treating haemorrhoids by the -ligature: - - 'By means of the forceps for applying caustic to haemorrhoids, or the - forceps for applying caustic to the uvula ([Greek: to - haimorrhoidokauste e to staphylokauste]), we surround them close to the - jaws of the instrument ([Greek: pros ta cheile]) with a five-ply - thread of lint, and strangle the haemorrhoids separately with this - ligature.' - -It would seem then that, just as there was a long instrument for crushing -the uvula and a short one for crushing haemorrhoids, there were -corresponding instruments for cauterizing these parts, probably differing -from each other only in the length of the handle. - -The passage above quoted has given much trouble to the scribes and -commentators apparently from a lack of knowledge of the instrument -referred to. About a third of the codices omit [Greek: to -haimorrhoidokauste], and Cornarius and Dalechamps reject the words [Greek: -to haimorrhoidokauste e to staphylokauste] as superfluous and -interpolated. Apparently they were unaware that both instruments were -forceps of similar principle but different lengths, and quite suitable for -putting a haemorrhoid on the stretch. The reason why these instruments are -preferred, for this purpose, to the staphylagra is apparently that not -being toothed like the latter instrument they would be both less painful -and less likely to cause bleeding. - - -_Pharyngeal Forceps._ - -Greek, [Greek: ho akanthobolos]. - -Paul (VI. xxxii) describes a forceps for removing foreign bodies from the -pharynx: - - 'Prickles, fish-bones and other substances are swallowed in eating and - stick in different places. Wherefore such as can be seen we are to - extract with the special fish-bone forceps' ([Greek: tois idios - akanthobolois prosagoreuomenois exelkomen]). - -This is the only reference to the acanthobolus I have met with, and it -gives us no information as to the appearance of the instrument. It is -noteworthy, however, that Paul in his chapter on the removal of spiny -bodies from the pharynx is copying Aetius, and the instrument Aetius names -is an epilation forceps. He says 'bones stick near the tonsil or back of -the pharynx and can be seen, and if a considerable part projects out of -the tonsil it can be removed with an epilation forceps ([Greek: -tricholabio])'. A forceps of the epilation type, but angled in its length, -is figured by Vedrenes. It was found in Pompeii. This forceps is eminently -suitable for pharyngeal work (Pl. XXXII, fig. 1). Albucasis figures an -acanthobolus with an up-and-down, not lateral, movement. - - - - -CHAPTER VI - -BLEEDING CUPS, CLYSTERS, ETC. - - -_Bleeding Cups._ - -Greek, [Greek: sikya, kyathos]; Latin, _cucurbitula_. - -The extraction of blood by means of cups has been practised from remote -antiquity. The Hindoo Vedas mention it, and it is interesting to note that -one of the methods was to apply a gourd with fire in it, for both the -Latin _cucurbitula_ and Greek [Greek: sikya] signify a gourd. The usual -theory as to its action was that in a diseased part there was a vicious -[Greek: pneuma] which required removal. - -Celsus (II. xi) thus describes the different kinds of cups: - - Cucurbitularum vero duo genera sunt; aeneum, et corneum. Aenea, altera - parte patet, altera clausa, est; cornea, altera parte aeque patens, - altera foramen habet exiguum. In aeneam linamentum ardens coniicitur, - ac sic os eius corpori aptatur, imprimiturque donec inhaereat. Cornea - per se corpori imponitur; deinde ubi ea parte qua exiguum foramen est - ore spiritus adductus est, superque cera cavum id clausum est, aeque - inhaerescit. Utraque non ex his tantum materiae generibus, sed etiam - ex quolibet alio recte fit. Ac si cetera defecerunt, caliculus quoque, - aut pultarius oris compressioris, ei rei commode aptatur. Ubi - inhaesit, si concisa ante scalpello cutis est, sanguinem extrahit; si - integra est, spiritum. - - 'There are two kinds of cups, bronze and horn. The bronze is open at - one end and closed at the other, the horn, open at one end, as in the - previous case, has at the other end a small foramen. Into the bronze - kind burning lint is placed, and then the mouth is fitted on and - pressed until it sticks. The horn one is placed empty on the body, and - then by that part where the small foramen is, the air is exhausted by - the mouth, and the cavity is closed off above with wax, and it adheres - in the same way as before. Either may advantageously be constructed - not only of these varieties of material but of any other substance. - If other things are not to be had a small cup or a narrow mouthed jar - will answer the purpose. When it has fastened on, if the skin has - previously been cut with a scalpel it extracts blood; but if it be - entire, air.' - -Paul says: - - 'When we are about to apply the empty instrument, having placed the - limb in an erect position, we fasten it to the side, for if we apply - the light above when lying down, the wick falling upon the skin with - the flame burns in a painful manner, and for this there is no - necessity. It is necessary that the size of the instrument be - proportionate to the part to which it is applied, and on that account - there is great difference of cupping-instruments with regard to the - smallness and greatness of size. Moreover those which are made with - longer necks and broader bellies are possessed of a strong power of - attraction' (VI. xli). - -From Oribasius (_Med. Coll._ VII. xvi) we learn that sometimes the lips -were flat ([Greek: epipeda ta cheilea]) and sometimes concave ([Greek: -sesimomena ta cheilea]). This does not, however, mean that the border was -guttered, but that the whole lip instead of lying in one plane was arched. - -From a passage in Aretaeus we learn that one reason for the cup being -bellied out above was that there was oil floating free in the instrument, -which might otherwise escape and scald the patient. Aretaeus says: - - 'Apply plenty of heat so as to warm the part as well as attract. The - cup should be light earthenware ([Greek: kerameoun kouphon]) and - adapted to the side ([Greek: harmozon te pleura]), or bronze with flat - lips ([Greek: prene ta cheilea]) so as to comprehend the parts - affected with pain, and we are able to place inside it much fire with - oil, so that it may keep alive for a considerable time. We must not - apply the lips closely to the skin, but allow access to the air so - that the fire may not be extinguished' (_De Morb. Acut._ i. 10). - -Antyllus says there are three materials of which cups are made, glass, -horn, and bronze. He rejects the silver ones because they heat too -readily. The bronze are the ones most commonly used. Glass is used where -we wish to mark the quantity of blood extracted. Horn ones are useful -about the head, where bronze ones would be difficult to remove, and also -in the case of nervous persons who dread the flame. Bronze and glass cups -may be used without flame like horn ones if a hole is bored in the summit -and the air sucked out, and the finger or a piece of wax is applied -immediately (Oribasius, _Collect._ VII. xvi). - -Aristotle in his _Poetics_ discusses various tricks and arts of authors -and among these he mentions the riddle of which he gives as an example: -[Greek: andr' eidon pyri chalkon ep' aneri kollesanta] 'I saw a man who -had glued on a man bronze by means of fire' the reference being to a -bronze cupping-vessel (see also Mayor's note to Juvenal xiv. 58). The cups -mentioned by Hippocrates are also of bronze. The earliest written -references are thus to bronze cups worked by fire. Ethnological research -would indicate, however, that horns worked by suction represent the more -primitive form. - -A good number of cups have come down to us. There are fourteen in the -Naples Museum. There are two prevalent or usual types, one conical, and -the other flatter and more rounded. The largest cup known is in the Athens -Museum. Attached to it had been a chain 20 cm. long to hang it up by. It -is 16 cm. in height, and was found in a tomb at Tanagra. This cup with its -chain and attachment is shown in Pl. XXXIII. - -In the British Museum there is one of bronze, 4 inches high and of the -elongated conical shape. It was found in Corfu (Pl. XXXIV). One in Naples -of similar shape has a ring attached to its summit as the Athens specimen -had (Pl. XXXV). - -There are four very small cups in the museum at Mainz. These are 2.5 to 3 -cm. in height and 3 to 3.5 cm. in diameter. Two of these are shown in Pl. -XXXVI, figs. 1, 3. - -There are ten cups of glass in the Athens museum. They are of the general -shape of the Mainz cups, but vary in height from 4 cm. to 6.8 cm. and in -the Scottish National Museum of Antiquities there are two cupping-horns -which correspond to the description of Celsus. They were brought from -Shetland, where they were in use until comparatively recent times. Prosper -Alpinus, who visited Egypt in the sixteenth century and wrote a book on -the state of medicine in that country, found these cupping-horns in use -there, and he gives drawings of the instruments he saw (Pl. XXXVII, fig. -1). The horns used were those of young bulls, highly polished and with a -small hole at the tip, by which the air was extracted by suction. To close -this a small tab of parchment was taken into the mouth, and moistened and -affixed by the tongue. The Egyptians also used cupping-vessels of glass, -specially shaped and worked by suction. Pl. XXXVI, fig. 2 shows the shape -illustrated by Prosper Alpinus. The method of using fire with cups was not -known to the Egyptians at the time when Alpinus wrote (_De Med. -Aegyptiorum_, ed. 1541, lib. ii. ch. xii. p. 139). - -Horn cups worked by suction are spoken of in the Hindoo Vedas. - -It is interesting to find that these horn cupping-vessels are still in use -in some parts of Africa, and one, the property of a Hausa barber-surgeon, -was presented to the Aberdeen Anatomical Museum by Sir William Macgregor -(_Proc. Aberdeen Anat. Soc._ 1900-2). - -An interesting form of cup is described by Hero of Alexandria (B. C. -285-222). Hero's description is quite intelligible, although it would be -difficult to give an accurate translation that would be readily -understood. I shall content myself with summarising his account. The -figure (Pl. XXXVII, fig. 2) shows a cup of ordinary flattened form, -divided into two by a diaphragm. Two tubes pass through the fundus, one -passing through the diaphragm, the other not. Each of these tubes is -fitted with another which is open at its inner end, but closed at its -outer end and provided with a small crossbar to rotate it. Each of these -sets of tubes is perforated by small openings. In the case of the short -tube these are outside the cup, in the case of the long tube they are -inside the cup, in the chamber shut off by the diaphragm. By rotating the -pistons these openings can be placed in apposition or not at will, thus -forming valves. Open valve A by placing the holes in apposition. Close -valve B by turning the holes away from each other. The inner chamber of -the cup is now shut off except for the small hole A. Apply the mouth to -the valve A and suck the air out of the chamber. Close valve A. Apply the -cup to the affected part. Open valve B and the negative pressure draws on -the affected part. The advantage of this arrangement is that the affected -part is not directly sucked upon by the mouth, and the instrument is -therefore more pleasant for the operator to use. Bleeding cups occur on -the coins of Epidaurus (300 B. C.), Atrax (400 B. C.) and Aegale (200 B. -C.). - - -_Clysters._ - -The ancients made frequent use of injections into the various orifices of -the body. The apparatus used was a bladder or skin of an animal fixed to a -tube. This form of instrument remained in use till the beginning of the -nineteenth century, although the elaborate enema syringe, on the principle -of the force pump, had been in use since the fifteenth century at least. -The following passage from Heister (anno 1739) is interesting as showing -exactly the method of its manipulation: - - Pl. XXXVII, fig. 3 machinam clysteri iniiciendo adaptam designat, qua - Germani ut et Batavi vulgo utuntur. Litt. AA vesicam denotant cum - liquore contento; quae vero in adultis duplo vel triplo amplior quam - hic indicatur esse solet, pro libra circiter, et quo D excedit, - liquoris continenda; BB tubulum sive fistulam osseam ano immittendam, - per quam liquor in intestina iniicitur; CC vinculum superius, quod, - postquam fistula in ano est, solvitur ac removetur; DD vinculum - inferius, quo vesica clauditur, ne liquor immissus elabi queat (vol. - ii. p. 1117). - -The rectal apparatus is called by Galen [Greek: klyster], the uterine -[Greek: metrenchytes], and the bladder injector is called [Greek: -katheter]. In x. 328 we find all these three terms used in one paragraph: - - [Greek: Es tauta men gar dia =klysteros= eis metran de dia - =metrenchyton= ton epitedeion ti pharmakon eniemen hosper ge kai eis - kystin dia ton euthytreton katheteron.] - -The different varieties of injection apparatus which are specially named -are as follows: - - (1) Rectal: Greek, [Greek: klyster, -eros]; Latin, _clyster_. - - (2) Vaginal: Greek, [Greek: metrenchytes]; Latin, _clyster_. - - (3) Uterine: Greek, [Greek: metrenchytes]; Latin, _clyster_. - - (4) Bladder: Greek, [Greek: euthytretos katheter]; Latin, _clyster_. - - (5) Nasal: Greek, [Greek: rhinenchytes]; Latin, _rhinenchytes_. - - (6) Ear: Greek, [Greek: otenchytes]; Latin, _oricularius clyster_. - - (7) Sinus: Greek, [Greek: pyoulkos]; Latin, _oricularius clyster_. - - -_Rectal Clyster._ - -Early Egyptian writings refer to rectal enemas: numerous prescriptions, -including several for nutrient enemas, are given. - -Oribasius gives us many interesting particulars about enemas (_Collect._ -VIII. xxiv). The amount necessary is less for men than for women. In any -case the largest amount is three heminae ([Greek: treis kotyloi]), the -smallest one hemina (a small half pint). In dysentery and other cases -where the parts would be easily hurt, and where a prompt evacuation was -required, cannulae with the opening placed in the side were used. Cannulae -with the opening in the end of the instrument were used where a large -evacuation was desired to be brought down from the higher parts. To -destroy ascarides, cannulae with a circle of small holes placed laterally -were used. - -From ch. xxxii we learn that the injection pipe varied in length also, for -Oribasius says that in making injections into the rectum for affections of -the bladder (e. g. to excite expulsion of urine in cases of retention), -the tube ([Greek: to keras tou klysteros]) ought to be short. - -In the case of nutrient enemas Mnesitheus says the tube ought to be -extremely long, and in admitting an injection one ought to keep up -compression of the empty part of the clyster because it often happens that -the injection returns from the rectum unless this is done (Oribas. viii). - -Hippocrates (ii. 276) mentions inflation of the rectum with air by an -enema in cases of ileus. A bladder is to be attached to a tube and the air -injected with this. It is then to be removed and a clyster injected. - -In the excavations of the Roman Hospital at Baden there was found the tube -of a clyster in bronze. It is cast in one piece of stout bronze (Pl. -XXXVIII, fig. 2). - - -_Vaginal and Intrauterine Clysters._ - -Greek, [Greek: metrenchytes]. - -It is difficult to separate ancient descriptions of injections into the -vagina from those into the uterus, for the terms for the two parts are -frequently interchangeable. It is undoubted, however, that actual -intrauterine injections were made. Hippocrates (iii. 17) says: - - 'The end of the enema (i. e. the tube) is smooth like a sound. The - tube is of silver. A perforation will be made in the side not far from - the small tip of the tube ([Greek: katheter]). There will also be - other perforations, which will be placed at equal distances on each - side of the tube throughout its length. The extremity of the injection - tube will be solid, all the rest hollow. To the tube will be attached - the bladder of a sow, which has first been well scraped. Place the - milk of a mare in the bladder, having taken the precaution to close - the perforations in the tube with a linen rag. The bladder is then - closed with a cord and given to the woman herself, and she, when the - cord shutting off the bladder has been removed, puts it inside the - uterus. For she herself will know where it ought to be placed. Then - you press the bladder with your hand as long as pus escapes.' - -The description quoted already from Heister will help to make clear the -description of the manipulation. There is in the Naples Museum (No. -78,235) an injection tube of bronze answering to the description given. It -is 13 cm. long, and it has at the end a small opening, while on the side, -not far from the tip, eight small holes are arranged in two superposed -rings (Pl. XXXVIII, fig. 1). - -There is a similar but slightly smaller instrument in the same museum. - - -_Bladder Clyster._ - -Greek, [Greek: euthytretos katheter]. - -There are frequent references to injection of the bladder. Although from -some passages it is clear that the injection really reached the bladder, -it is probable that at other times, under the heading of 'Injection of the -Bladder', only irrigation of the urethra is meant, just as sometimes by -irrigation of the uterus only vaginal douching is meant. Irrigation was -practised by means of a bladder fixed to the end of a catheter. Galen (x. -328), however, calls the bladder syringe [Greek: euthytretos katheter], -which may indicate that the eye was in the tip and not in the side, as in -the ordinary catheter, for a catheter with a straight bore would not reach -the male bladder. - -Paul (VI. lix) says: - - 'But since we often have occasion to wash out an ulcerated bladder, if - an ear syringe be sufficient to throw in the injection it may be used, - and it is to be introduced in the manner described above. But if we - cannot succeed with it we must tie a skin, or the bladder of an ox, to - a catheter and throw in the injection through its lumen.' - -It is highly improbable that with an ear syringe the injection would have -passed the triangular ligament and have actually reached the bladder in -the male; but the use of the ear syringe may refer to irrigation of the -female bladder, and then an ear syringe would suffice. - - -_Blacksmith's Bellows._ - -Greek, [Greek: physa]. - -In cases of volvulus, Hippocrates bids us insert a purgative suppository -and administer an enema. If these means are not successful: - - 'Insert a blacksmith's bellows ([Greek: physan chalkeutiken]) and - inflate the intestine in order that you may dilate the contraction - both of the colon and the intestine. Then remove it and give an enema' - (ii. 305). - - -_Nasal Syringe._ - -Greek, [Greek: rhinenchytes]; Latin, _rhinenchytes_. - -A special nasal syringe with a double tube is mentioned by Aretaeus (ed. -Adams, vol. ii. 459). The medicament is made into liquid form and is -injected by means of a nasal pipe. The instrument consists of two pipes -united together by one outlet so that we can inject by both at one time, -for to inject each nostril separately is a thing which could not be borne. - -Galen also mentions a nasal syringe ([Greek: rhinenchytes]), though he -does not describe it (xi. 125). - -Scribonius Largus also mentions it: - - Per nares ergo purgatur caput his rebus infusis per cornu quod - rhinenchytes vocatur (_Compositiones_, vii). - - -_Aspiration Syringe and Sinus Irrigator._ - -Greek, [Greek: pyoulkos]. - -Galen (xi. 125) says: - - 'In cases of sinus he uses a tube of bronze or horn with a straight - bore, or otherwise the instrument called the pus extractor ([Greek: - pyoulkon]), which has a wide bore. But if you inject rosaceum into the - former (i. e. tube of bronze, &c.) it will not pass through the - syringe ([Greek: pyoulko]), so that in that case a pipe of wide bore - is to be fixed to a sow's bladder.' - -This passage shows that the pyulcus differed in principle from the syringe -formed by fixing a bladder on a tube. Hero (_De Spiritalibus_, c. 57) -shows that it was a syringe formed of a cylinder of metal with a -well-fitting plunger. - -Hero says: - - 'And the instrument called pyulcus works on the same principle. - - 'For a long tube AB is made, to which let there be fitted another CD, - and let C, the end of it, be closed by a plate. At D let it have a - handle EF, and let the mouth of the tube AB at A be blocked by a plate - furnished with a slender syringe GH, perforated. - - 'When therefore we wish to draw out pus, applying the extreme mouth H - of the little syringe to the place in which the pus is, by the handle - we draw the tube CD outward, and the space which is in the tube being - emptied something else is of necessity drawn in, and since there is no - other space than the mouth of the tube the liquid at and near it must - of necessity be drawn into it. - - 'Again when we wish to inject some liquid we put it into the tube AB - and taking hold of EF and pressing in the tube CD we press out as much - as we think necessary.' - -Note that Hero's description does not tally with the drawings which -accompany the edition of his works which we possess (Pl. XXXVIII, figs. 3, -4, 5). These show an instrument with a piston formed by a plug at the end -of a rod, whereas Hero says the piston is to be formed of a second tube -fitting inside the first. This is interesting, because it is much easier -to get a well-fitting piston in this way than in the other; and this -principle has been reverted to in many of our best hypodermic syringes and -in some of the best air pumps, such as Edwards's. - - -_Ear Syringe._ - -Greek, [Greek: otenchytes, otikos klyster]; Latin, _oricularius clyster_. - -The ear syringe is very frequently referred to by both Greek and Latin -writers; in fact, Celsus uses the term so often to denote a syringe for a -large variety of uses that it is evident that it is almost a general term -for any small syringe. - -In addition to its use in washing out the ear in cases of foreign bodies, -impacted cerumen, &c. he uses it to wash out the foreskin in balanitis, to -syringe fistulae, to wash out the bladder through a lithotomy wound, &c. - -In cases of foreign bodies in the ear he says: - - Sternutamenta quoque admota id commode elidunt, aut oriculario - clystere aqua vehementer intus compulsa (VI. vii). - -Aetius and Paul tell us it was used to wash out the vagina, and Paul says -it might be used to make injections into the bladder. Oribasius says: - - 'We use flushing with an ear syringe in abscess of the intercostal - space, and in fistulas to expel first the pus with warm water, then to - cleanse the cavity with melicrate' (_Collect._ viii. 24). - -From a consideration of the various uses to which this instrument was put, -and from the fact that it is contrasted at times (e. g. in Paul, VI. lix) -with syringes formed by adding a bladder to a tube, I am of the opinion -that this instrument, like the pyulcus, was a syringe of the form of a -metal cylinder with a plunger like the ear syringe of to-day, and used, as -the ear syringe was a few years ago, for flushing sinuses and irrigating -wounds, and as a handy instrument for all general purposes of the kind. -This is borne out by the fact that the ear syringe, described in detail by -Albucasis (p. 157), is a cylinder of bronze or silver, wide above and -narrowed to a point with a small opening in it and with a well-fitting -plunger wrapped with a little cotton at one end. His figure, though quite -intelligible, is too conventionalised to give any additional information. - - -_Insufflator for Powder._ - -Insufflation in powder form was a common method of applying medicaments to -the throat and nose. All writers mention this, but the fullest description -of the tube used is given by Oribasius, who says (_Collect._ xii): - - 'Those things which evacuate the head we use in the following manner. - A reed slender and with a straight bore, six inches in length, and of - such a size that it can be placed in the nares, is taken and its - cavity entirely filled with medicament. The reed may be either natural - or of bronze. This being placed in the nares, we propel the medicament - by blowing into the other end.' - -Alexander Trallianus (IV. viii) describes the insufflation of the woolly -hairs of the platanus to stop epistaxis, and Aretaeus mentions the -insufflation of sternutatories (459, vol. ii), and again (408, vol. ii) he -says medicines may be blown into the pharynx by a reed, or quill, or wide -long tube ([Greek: kalamo e ptilo e kaulo pachei kai epimekei]). - -A fine example of a bronze insufflator was discovered among the -instruments of the surgeon of Paris. It is 15-1/2 cm. in length, and 5 mm. -in diameter. It is formed by a plate of bronze bent round and soldered. It -terminates in a little elliptical shovel slightly cup-shaped, of which the -transverse diameter is 3 cm. and the longitudinal 3 mm.; it had originally -been overlaid with gold (Pl. XL, fig. 4). - - -_Cannulae for draining Ascites and Empyema._ - -Celsus describes the cannula for draining ascites (VII. xv): - - Ferramentum autem demittitur magna cura habita ne qua vena incidatur. - Id tale esse debet ut fere tertiam digiti partem latitudo mucronis - impleat; demittendumque ita est ut membranam quoque transeat qua caro - ab interiore parte finitur; eo tum plumbea aut aenea fistula - coniicienda est vel recurvatis in exteriorem partem labris vel in - media circumsurgente quadam mora, ne tota intus delabi possit. Huius - ea pars quae intra paulo longior esse debet quam quae extra, ut ultra - interiorem membranam procedat. Per hanc effundendus humor est; atque - ubi maior pars eius evocata est claudenda demisso linteolo fistula - est; et in vulnere si id ustum non est relinquenda. Deinde per - insequentes dies circa singulas heminas emittendum, donec nullum aquae - vestigium appareat. - -The following passage from Paul shows that the tip was bevelled off like a -writing pen: - - [Greek: Chalkoun kalamiskon ... kathisomen echonta ten ektomen - paraplesian tois graphikois kalamois.] - - 'We introduce through the incision in the abdomen and peritoneum, a - bronze cannula having a tip like that of a writing pen' (VL. l). - -Two instruments answering to the above description are to be seen in the -museum on the Capitol at Rome. - -Another, answering more closely to the description of Celsus, is to be -seen at Naples (Pl. XXXIX, fig. 2). It consists of a bronze tube, 9 cm. in -length, 7 mm. wide at one end, narrowing to 4 mm. at the other end, which -is bevelled off as described by Paul. Surrounding the tube and 2.5 cm. -from the bevelled tip is a ring 2.5 cm. in diameter. - -A more elaborate form of the cannula for ascites is seen in another -specimen, also in the Naples Museum (Pl. XXXIX, fig. 3). A tube 6.5 mm. in -diameter and 39.2 cm. long, has one end rounded and closed, except for a -small hole in its tip and another in the side near the first. The other -end carries a circular plate 2.5 cm. in diameter. Near the middle of the -tube there is a slightly raised projection as if to carry a circular disc. -Inside the cannula is fixed by oxidation an obturator, which carries on -its end a small handle fixed on in T-fashion. Scoutetten described this to -the Royal Academy of Medicine of Paris as a trocar and cannula, but the -formation of the end is not such that the instrument could have pierced -its own way through. It is rather an instrument which could be inserted in -an incision made by a scalpel, and which could be closed after the -abstraction of a certain amount of fluid--the obturator acting as an -improvement on the pledget of wool described by Celsus--but otherwise -inserted like the previous example. A tube on similar principles to the -ascites cannula was employed in empyema (Hippocrates, ii. 259): - - 'After opening let out pus once a day. After the tenth day, when - everything has been evacuated, flush with wine and tepid oil. At night - let out what you have put in, and when the pus becomes thin and watery - insert a hollow tin tube' ([Greek: entithenai moton kassiterinon - koilon]). - - -_Tubes to prevent Contractions and Adhesions._ - -Greek, [Greek: motos molybous]; Latin, _plumbea fistula_. - -After operations on the nose, rectum, vagina, &c. it was usual to insert a -tube of lead, bronze, or tin, to prevent contraction or adhesion and also -to convey medicaments. - -Celsus says that after the operation for occlusion of the vagina a tube of -lead is to be inserted during cicatrization: - - Quumque iam ad sanitatem tendet, plumbeam fistulam medicamento - cicatricem inducente illinere, eamque intus dare; supraque idem - medicamentum iniicere, donec ad cicatricem plaga perveniat (VII. - xxviii). - -A similar tube is recommended by Celsus and Paul for insertion after -operations on the rectum and vagina. Hippocrates (ii. 244) and Paul (VI. -xxv) direct a leaden tube to be inserted in the nostril after the -abstraction of nasal polypus. - -After dilation of the cervix uteri a hollow tube was put in to keep it -open. The tube was also filled with medicaments which were intended to -have a beneficial effect on the interior of the uterus. The fullest -description of this is given by Hippocrates (ii. 799). After describing -the dilation of the womb with graduated dilators, he says: - - 'It is necessary to insert a leaden tube, similar in shape to the - largest dilator but hollow so as to contain substances, and the width - of the bore will be the same as that used for ulcers, in order that - the mouth of the tent may be smooth and do no damage, and it will be - prepared like the wooden dilators. When the tent has been prepared - fill it with rubbed down mutton fat, and when ready extract the wooden - dilator and insert the leaden one.' - -This leaden dilator is referred to over and over again by Hippocrates. -There are in the Naples Museum three of these metal tubes. They are of -bronze. One is 18 cm. long, 14 mm. wide at one end, narrowing gradually to -6 mm. at the point (Pl. XXXIX, fig. 1). - - -_Calamus Scriptorius._ - -Greek, [Greek: graphikos kalamos]; Latin, _calamus scriptorius_. - -The writing pen reed is frequently referred to as an implement of minor -surgery. - -Alexander Trallianus (IV. viii) says that a calamus scriptorius whose -joints have been removed may be used as an insufflator. Celsus (VII. v) -says that when a weapon buried in the flesh has barbs too strong to be -broken with forceps they may be shielded with split writing reeds, and the -weapon thus withdrawn: - - Fissis scriptoriis calamis contegenda, ac, ne quid lacerent, sic - evellenda sunt. - -Paul says 'Some apply a tube ([Greek: kalamiskon]) round about the barbs' -(VI. lxxxviii). - -Celsus (III) mentions a narrow tube of this sort for drinking water -through in cases of nocturnal thirst. - -Paul (VI. xxiv and III. xxiii) says that foreign bodies may be sucked from -the ear with a reed. - - -_Quill._ - -Greek, [Greek: ptilon]. - -Galen (x. 1011) says that warts may be extracted by means of quills of -feathers. - -Paul quotes this (VI. lxxxvii): - - 'Some, among whom are Galen, advise us to scarify round the wart with - the quill of a hard feather, such as those of old geese or of eagles, - and to push it down so as to remove the wart from its roots. Others do - the same with a copper or iron tube.' - -Aretaeus says a quill may be used for blowing powder into the pharynx -(408, vol. ii). - - - - -CHAPTER VII - -CAUTERIES - - -_Cautery._ - -Greek, [Greek: kauterion, kauter, kauteridion sidereon]; Latin, _Ferrum -candens_. - -The cautery was employed to an almost incredible extent in ancient times, -and surgeons expended much ingenuity in devising different forms of this -instrument. A considerable number of these shapes are definitely -mentioned. The cautery is nearly always spoken of as made of iron. Bronze -becomes too soft to act well as a cautery, so that even the earliest -references to the cautery in the authentic Hippocratic writings refer to -cauteries as 'the irons' ([Greek: sideria]). It is true, of course, that -in special cases bronze was used--and Priscianus recommends a cautery of -gold or silver for stopping haemorrhage from the throat (_Logicus_, -xxii)--but iron was the usual thing, and in spite of the enormous numbers -of cauteries which must have existed only a very few have come down to us, -as the iron has perished. The cautery was employed for almost every -possible purpose, as a 'counter-irritant', as a haemostatic, as a -bloodless knife, as a means of destroying tumours, &c. - -The following passage is interesting as showing its application in two of -these capacities (Aet. IV. iv. 45): - - 'I put the patient lying on her back, then I incise the sound part of - the breast outside the cancer and burn the incision with cauteries - until the eschar produced stops the flow of blood. By and by I incise - again and dissect the depth of the breast and again burn the incision; - and often repeat the same, both cutting and cauterizing to stop the - haemorrhage, for then the danger of a rush of bleeding is avoided, and - after the amputation is completed I again burn all the parts to - desiccation. The first cauterization is for the sake of stopping the - haemorrhage, the second for eradicating all traces of the disease.' - - -_Cautery Knife._ - -Greek, [Greek: xyraphion]. - -Paul on several occasions mentions the use of the cautery knife. In -radical cure of hydrocele, as an alternative to the excision of the sac by -the knife, he explains how it may be done with the cautery, and says, -'Afterwards, when the whole is laid bare, we stretch it with hooks and -remove it with a sword-shaped cautery ([Greek: machairoto kauteri])' (VI. -lxii). - -Galen, speaking of cancer, says, 'Some use heated razor blades ([Greek: -xyraphiois]), at once cutting and burning' (xiv. 786). - - -_Trident Cautery._ - -For forming issues over the spleen Paul (VI. xlviii) says: - - 'Some pick up the skin with hooks and push through it a long cautery, - and repeat this three times so that there are six eschars. Marcellus, - however, by using the instrument called a trident or trident-shaped - cautery ([Greek: triaine e triainoeidei kauterio]), formed six eschars - at one application.' - -Vulpes describes an instrument of bronze which he considers to be a -trident-shaped cautery. It was found along side an instrument which I take -to be a phlebotome. If it is for the purpose described above by Paul it is -unusual in being of bronze, and it must have lost a good part of its -teeth. - - -_Olivary Cautery._ - -Greek, [Greek: pyrenoeides kauterion]. - -Malignant polypus of the nose is removed, says Paul (VI. xxv), with -olivary pointed cauteries ([Greek: pyrenoeides kauterion]); and again, -quoting Leonidas, he says empyema may be opened in the same way (VI. -xliv). - -The special cautery which was used for 'aegilops' (fistula lachrymalis) -was probably an olivary pointed cautery, as the cautery recommended by -both Scultetus and Pare for this is an olivary pointed one. Paul (VI. -xxii) says, 'Some after excision of the flesh use a perforator, and make a -passage for the fluid or matter to the nose, but we are content with -burning alone, using the cauteries for fistula lachrymalis ([Greek: -aigilopikois kauteriois]) and burning down till a lamina of bone -exfoliates.' - - -_Gamma-shaped Cautery._ - -Paul (VI. lxii), describing the radical cure of hernia, says: - - 'Wherefore having heated ten or twelve cauteries shaped like the Greek - letter [Greek: G] ([Greek: gammoeidon kauteron]) and two cautery - knives, we must first burn the scrotum through with the [Greek: - G]-shaped ones, &c.' - - -_Obol Cautery._ - -In the treatise on haemorrhoids (iii. 340) Hippocrates says: - - 'I order, therefore, seven or eight instruments to be prepared, a palm - long, and the thickness of a thick specillum, bent towards the end and - flattened on the point like a small obol' ([Greek: hos epi obolou - mikrou]). - - -_Lunated Cautery._ - -Greek, [Greek: menoeides kauterion]. - -Paul says in cases of sloughing of the prepuce we must cut it off, and if -there be haemorrhage we must use lunated cauteries ([Greek: menoeidesi -kauteriois]). They both stop the haemorrhage and prevent the spreading of -the sore (VI. lvii). - - -_Nail, Tile and Button Cautery._ - -Treating of bubonocele, Paul says (VI. lxvi): - - 'Make a triangular mark over the centre of it and apply to the mark - nail-shaped ([Greek: helotous]) cauteries heated in the fire, and - afterwards burn the triangle with gamma-shaped cauteries, and - afterwards level the triangle with cauteries shaped like bricks - ([Greek: plinthotois]) or lentils ([Greek: phakotois]).' - -Cauteries of nail shape are also referred to by Hippocrates in the -treatment of recurrent dislocation of the shoulder: - - 'Raise up the skin. Burn with cauteries which are not thick nor much - rounded but of an elongated shape ([Greek: promeke]). For thus they - pass more readily through' (iii. 151). - -Galen has a long note in explanation of this term: - - [Greek: Phalakra kekleke ta periphereian echonta kata to peras hoion - hoi kata tas maschalas echousi pyrinas etoi ta diapyrina kaloumena kai - hai spathomelai, promeke de ta toutois enantios diakeimena - prosegoreusen, hon ouk esti peripheres to peras all' oxyteran per' - empleroma paraplesion pos tois eis tas parakenteseis epitedeiois - organois.] - - 'He (Hippocrates) calls [Greek: phalakra] (globose) those having a - ball at the tip, such as those for the axilla, which have olivary - points and also those which are called double olivary probes and - spathomeles. But those which are the reverse he calls [Greek: - promeke], i. e. those which have the end not globose but rather sharp, - exactly like the instruments for paracentesis' (xviii. 376). - -In the Naples Museum there are three tile-shaped cauteries, one of iron -and two of bronze. One of the latter is shown in Pl. XL, fig. 1. - - -_Wedge-shaped Cautery._ - -Hippocrates (iii. 223) says that the oblique veins of the head are to be -burned with wedge-shaped cauteries ([Greek: spheniskoisi siderioisi]). - - -_Needle Cautery._ - -Celsus (VII. viii) says: - - At ubi aures in viro puta, perforatae sunt et offendunt, traiicere id - cavum celeriter candente acu satis est, ut leviter eius orae - exulcerentur. - -Treating of trichiasis he says (VII. vii. 8): - - Si pili nati sunt qui non debuerunt tenuis acus ferrea, ad - similitudinem spathae lata, in ignem coniicienda est; deinde candens, - sublata, palpebra sic ut eius perniciosi pili in conspectum curantis - veniant, sub ipsis pilorum radicibus ab angulo immittenda est, ut ea - tertiam partem palpebrae transsuat; deinde iterum, tertioque usque ad - alterum angulum; quo fit ut omnes pilorum radices adustae emoriantur. - -This indicates a needle beaten out into the shape of one of our spuds for -removing foreign bodies from the eye. The needle handles from the find of -the oculist Severus are well adapted for this work, but are dealt with -elsewhere (p. 69). - - -_Cautery guarded by a Tube._ - -In the treatise on haemorrhoids (iii. 345) Hippocrates says: - - 'We must make a [tubular] cautery like a writing reed and fit it to a - well-fitting iron' ([Greek: kautera chre poiesasthai hoion kalamiskon - phragmiten, siderion de enarmosai kalos harmozon]). - -Again, in the treatment of polypus of the nose, he says: - - 'When that occurs we must insert a tube and cauterize with three or - four irons'([Greek: hotan houtos eche, enthenta chre syringa kausai - siderioisin e triosin e tessarsin]) (ii. 244). - -Celsus says this tube may be a calamus or a tube of pottery: - - Apud quosdam tamen positum est, vel fictilem fistulam vel enodem - scriptorium calamum in narem esse coniiciendum, donec sursum ad os - perveniat: tum per id tenue ferramentum candens dandum esse ad ipsum - os (VII. xi). - - -_Wood dipped in boiling Oil._ - -Hippocrates, in diseases of the liver, says that cauterization may be -performed with boxwood spindles dipped in boiling oil ([Greek: pyxinoisin -atraktoisi bapton es elaion zeon]) (ii. 482). Aetius (XII. iii) says that -the root of the birthwort (aristolochia) may be used in the same way. - - -_Ignited Fungi, &c._ - -In the passage in Hippocrates on cauterizing for disease of the liver, -Hippocrates, as an alternative to the hot iron, says that eschars may be -produced by fungi. This must mean that they were set on fire like the old -moxa. - -This is probably what is meant by Paul when, in treating of cauterizing -over the stomach, he says (VI. xlix): - - 'But some do not burn with iron but with the substances called iscae. - The iscae ([Greek: iskai]) are spongy bodies forming on oaks and - walnut trees, and are mostly used among the barbarians.' - -Aetius (II. iii. 91) says iscae are the medullary wood of the walnut tree. - -In Hippocrates (ii. 482) the word [Greek: mykes], a fungus, is -used--[Greek: e mykesin okto escharas kausai] (or with fungi burn eight -scars). - - - - -CHAPTER VIII - -BONE AND TOOTH INSTRUMENTS - - -_Raspatory._ - -Greek, [Greek: xyster]; Latin, _scalper excisorius_, _scalper -medicinalis_. - -The raspatory or rugine consists of a blade of varying shape fixed at -right angles to the shaft, and it is operated by pulling instead of by -being driven forwards by striking or pushing. Although no ancient -raspatory has been preserved to us we are quite familiar with the -instrument, as it has been in continuous use throughout ancient and -mediaeval times, and it is in use at the present day. The raspatory is the -instrument upon which Hippocrates relies for eradicating fissured and -contused bone in injury to the skull: - - 'If you cannot discover whether the bone is broken or contused, or - both the one and the other, nor can see the truth of the matter, you - must dissolve black ointment and fill the wound with the solution, and - apply a linen rag smeared with oil, and then a poultice of maza with a - bandage; and on the next day, having cleaned out the wound, scrape the - bone with the raspatory ([Greek: epixysai]). And if the bone is not - sound but fractured and contused, the rest of the bone will be white - when scraped, but the fracture and contusion, having imbibed the - preparation, will appear black, while the rest of the bone is white. - And you must again scrape more deeply the bone where it appears black, - and if you thus remove the contusion and cause it to disappear you may - conclude that there has been a contusion of the bone to a greater or - less extent, which has occasioned the fracture that has disappeared - under the raspatory' ([Greek: hypo tou xysteros]) (iii. 366). - -From Galen we learn that there were different sizes and shapes of the -raspatory (x. 445): - - 'In simple fissure reaching to the second plate narrow raspatories - are used, and they should be of different sizes to suit all cases. The - affected bone being exposed _secundum artem_, first the broader ones - are to be used, then the smaller down to the narrowest. The narrowest - are to be used in the diploe.' - -Paul refers to a small raspatory ([Greek: xysterion]) for use as a tooth -scaler (q. v.). All the mediaeval writers figure numerous shapes of -raspatories--many more than we use to-day, but all on the same principle -as ours. - - -_Chisel._ - -Greek, [Greek: ekkopeus]; Latin, _scalper_, _scalprum planum_. - -The flat chisel is referred to by Celsus in his description of the -levelling of an elevation on one side of a depressed fracture of the -cranium: - - Ergo, si ora alteri insedit, satis est id quod eminet plano scalpro - excidere; quo sublato, iam rima hiat quantum curationi satis est - (VIII. iv). - -Numerous references occur in other authors. There is a fine example of a -flat chisel in the Cologne Museum (Pl. XLI, fig. 2). It is all of steel, -and delicately ornamented with spiral indentations. This interesting -little instrument was found in the surgeon's outfit already described, and -is one of the best authenticated instruments--as regards its having been -the property of a surgeon--we possess. The chisel figured by Vulpes, -consisting of a cylindrical bronze handle and a flat blade, is, I believe, -a variety of scalpel. - -We have many interesting references to the use of the chisel in bone work. -It was used as an osteotome to divide the bone in distorted union: - - 'If the callus be of stony hardness incise the skin with a scalpel, - and divide the union with chisels' ([Greek: ekkopeusi]) (Paul, VI. - cix). - -In the removal of supernumerary digits we are to cut away the flesh all -round, and either chop the bone through with a chisel ([Greek: to -ekkopei]), or remove it by sawing (Paul, VI. xliii). In using the chisel -as an osteotome one chisel was often placed behind the bone to steady it -while it was being struck by another in front. This method of applying two -chisels, which is only described by the Greek authors, is always referred -to by the phrase [Greek: ekkopeon antitheton]. - -The following passage from Galen fully describes the manipulation (ii. -687): - - 'Separate off the membranes adhering to the bone, which being properly - done, divide the bone of the rib by means of two chisels placed in - opposition to each other _secundum artem_' ([Greek: antiballomenon - dyoin allelois ekkopeon hos ethos]). - -The following passage from Paul shows the chisel used for a similar -purpose: - - 'If part of the clavicle is broken off and unconnected, and if we find - it irritating the parts, we must make a straight incision with a - scalpel and remove the broken portion and smooth it with chisels - ([Greek: di' ekkopeon]), taking care that the instrument called - 'meningophylax' (q. v.), or another chisel, be put under the clavicle - ([Greek: meningophylakos e heterou ekkopeos]) to steady it' (VI. - xciii). - -The phrase [Greek: di' ekkopeon antitheton], which Paul uses in describing -the treatment of a fistula leading to carious bone, is translated by -Briau--'a l'aide de tenailles tranchantes'. It does seem here, and -occasionally in other passages, as if the phrase might suggest 'cutting -forceps', but we have no knowledge of such an instrument being used by -surgeons in classical times, and the passages from Paul and Galen show -that only two chisels are meant. We may compare the passage on extraction -of the foetus in Paul (VI. lxxiv), where he directs a second hook to be -fixed on opposite the first ([Greek: kai antitheton touto deuteron]). - - -_Gouge._ - -Greek, [Greek: kykliskos, koiliskotos ekkopeus, kykliskotos ekkopeus, -skyliskotos ekkopeus]; Latin, _scalper excisorius_. - -The Greek writers frequently refer to the gouge. Celsus never does so by -any special name, although it is evident that many of the manipulations -he describes as being performed by the 'scalper', his general term for -chisels of all kinds, could only be performed with gouges and not with -flat chisels. The gouge was a favourite instrument of Galen's, especially -in injury to the skull. With it he removed pieces of fractured bone from -the skull. He also used it to groove a path for the vertical cutting -instrument called the lenticular (q. v.). He calls it a 'hollow chisel' -([Greek: ton koilon ekkopeon hous kai kykliskous onomazousin], x. 445). - -Paul (VI. xc) says: - - 'And if the bone be weak, naturally, or from the fracture, we cut it - out with gouges ([Greek: skyliskotois]), beginning first with the - broader ones, and changing to the narrower, and then using those which - are probe-like, striking gently with the mallet to prevent concussion - of the head.' - -The gouge is still familiar to us. - - -_Lenticular._ - -Greek, [Greek: phakotos]. - -The lenticular of the ancients was a vertical chisel cutting on one edge -and struck on the other by a hammer, while the end carried a rounded -button, which being smooth did not injure the brain (Pl. XL, fig. 4). It -takes its name from the lentil-like ([Greek: phakotos]) shape of the -button. Galen had a high appreciation of it, and gives a full description -of its principle (x. 445), which is transcribed by Paul (VI. xc): - - 'The method of operating with a sort of incisor called lenticular is - greatly praised by Galen, being performed without drilling after the - part has been grooved all round with gouges.' - -Wherefore he says: - - 'If you have once exposed the place, then applying the chisel, which - has at its point a blunt (rounded), smooth, lentil-shaped knob, but - which longitudinally is sharp, when you apply the flat part of the - lenticular to the meninges divide the cranium by striking with the - small hammer. For we have all that we require in such an operation, - for the membrane, even if the operator were half asleep, could not be - wounded, being in contact only with the flat part of the lenticular, - and if it be adherent anywhere to the calvarium the flat part of the - lenticular removes its adhesion without trouble. And behind it follows - the incisor or lenticular itself, dividing the skull, so that it is - impossible to discover another method of operating more free from - danger or more expeditious.' - -The earliest illustration of the lenticular I have been able to obtain is -that given by Vidus Vidius (Pl. XL, fig. 2). It evidently is the same -instrument as that described by Galen. - - -_Hammer._ - -Greek, [Greek: sphyra]; Latin, _malleolus_. - -I have already quoted passages where the hammer is referred to as being -used in cranial surgery. Paul says: 'When you apply the flat part of the -lenticular to the meninges divide the skull by striking with a small -hammer,' and again in using gouges, 'strike gently with hammer ([Greek: -sphyra]) to avoid concussion of the head' (VII. xc). - -Paul and Celsus describe a method of extracting foreign bodies from the -ear by laying the patient on a board and striking the under side with a -mallet. Pare mentions a hammer made of lead, and Fabricius describes one -padded with leather, but neither of these is described by the ancients. -There is, however, a Roman hammer of lead from the excavation at Uriconium -in the Shrewsbury Museum. - - -_Block._ - -Greek, [Greek: epikopon], a butcher's block. - -The ancients frequently amputated parts by placing them on a block and -striking them with a chisel. The mediaeval surgeons amputated parts as -large as the forearm in this way, but the Greeks all describe amputation -by knife and saw. We have reference to the 'block' in Greek literature, -however. In describing the plastic removal of a portion of the scrotum -Paul (VI. lxvii) says: - - 'Leonidas, laying the patient on his back, cuts off the redundant - portion upon a chopping block of any kind of wood or stiff leather' - ([Greek: kat' epikopou sanidiou tinos e sklerou dermatos]). - -Galen uses the same word in the eighth book of his work on Practical -Anatomy--apologizing somewhat for calling the article used by anatomists -and surgeons by the undignified term of butcher's block: - - [Greek: Chromenos epikopo, kalesai gar houtos ouden cheiron estin - homoios tois anatomikois te kai cheirourgois to sterigma ton - hypobeblemenon te tome ton somaton] (ii. 685). - - -_Meningophylax._ - -Greek, [Greek: meningophylax]; Latin, _membranae custos_. - -The meningophylax was a small plate, which was inserted under a bone which -was being cut in order to protect underlying structures. 'In cutting or -sawing the bone,' says Paul (VI. lxxvii), 'when any vital parts are -situated below, such as the pleura, spinal marrow, or the like, we must -use the instrument called the meningophylax for protecting them ([Greek: -meningophylaka]).' - -Celsus thus describes it (VIII. iii): - - Factis foraminibus eodem modo media septa, sed multo circumspectius, - excidenda sunt, ne forte angulus scalpri eandem membranam violet; - donec fiat aditus, per quem membranae custos immittatur; [Greek: - meningophylaka] Graeci vocant. Lamina aenea est, firma paulum resima, - ab exteriore parte laevis; quae demissa sic ut exterior pars eius - cerebro proprior sit, subinde ei subiicitur quod scalpro discutiendum - est; ac si excipit eius angulum, ultra transire non patitur; eoque et - audacius, et tutius, scalprum malleolo medicus subinde ferit, donec - undique excisum os eadem lamina levetur, tollique sine ulla noxa - cerebri possit. - -Pl. XL, fig. 3 shows a figure of the meningophylax from Vidius. - - -_Drill._ - -Greek, [Greek: trypanon]; Latin, _terebra_, _terebella_. - -There are, says Celsus, two kinds of drills. The first like those used by -artisans and driven by a thong, the second with a guard to prevent the -instrument from sinking too deeply into the bone. The drill was used in -excising a piece of the skull where the diseased portion was larger than -could be comprehended by the modiolus of a trephine. The part to be -removed was surrounded by perforations with the drill and the intervening -spaces were divided with chisels or raspatories. Celsus says: - - At si latius vitium est quam ut illo comprehendatur, terebra res - agenda est. Ea foramen fit in ipso fine vitiosi ossis atque integri; - deinde alterum non ita longe, tertiumque, donec totus is locus qui - excidendus est his cavis cinctus sit. Atque ibi quoque, quatenus - terebra agenda sit, scobis significat. Tum excisorius scalper ab - altero foramine ad alterum malleolo adactus id quod inter utrumque - medium est excidit; ac sic ambitus similis ei fit qui in angustiorem - orbem modiolo imprimitur (VIII. iii). - -Paul says: - - 'If a weapon be lodged deep in bone of considerable thickness it may - be bored out with drills' ([Greek: trypanois]) (VI. lxxxviii). - -Aretaeus (ed. Adams, p. 467) says that exposed bones are to be surrounded -with perforations by means of the drill and thus reduced ([Greek: teretro -chre perikoptein ta gymna]). - -The boring parts of drills are not unfrequently found. The most ancient -illustrations known to me of drills driven by thongs are in the work by -Vidus Vidius (_Chirurgia e Graeco in Lat. Conversa_, V. Vidio. Florent. -interprete c. nonn. eiusd. commentariis. Lutec. Paris., 1544). - -Vidius shows three arrangements for driving these drills with thongs: the -first method consists simply of a thong attached to the shaft of the drill -(Pl. XLII, fig. 4); the second consists of a bow with the string of the -bow wound once round the shaft (Pl. XLII, fig. 5); and the third consists -of a crosspiece with a hole in the centre of it through which the shaft -passes, and having strings from the end of the crosspiece to the top of -the shaft (Pl. XLII, fig. 3). Primitive arrangements truly, yet all three -methods of producing rotary motion are to be seen in use at the present -day, and be it known that some of the most delicate boring performed by -the hand of man at the present day is done with drills turned by the thong -stretched across a bow. The latest developments in mechanical devices for -drilling have failed to displace thong-driven drills for boring the holes -in which the wheel spindles of the best hand-made chronometers move, and -the spindles themselves are turned in chucks rotated not by belts in -continuous rotary motion, but in alternating motion by means of a thong -stretched across a bow. A bow of cane with a strong but fine thread, one -turn of which is taken round the drill, is drawn backwards and forwards -and rotates the drill with marvellous rapidity and accuracy. The bows used -by watchmakers average about a foot along the string. Similar drills are -used by engineers in turning out small work. The form with the crosspiece -may be seen in use by travelling crockery menders, who drill holes in -broken pottery and clamp the pieces with rivets. A turn or two of the -string is made round the shaft, and the point of the drill being adjusted -on the spot to be bored the crosspiece is gently pressed down by the first -and third fingers, causing the shaft to rotate. When the thong has nearly -uncoiled itself the pressure is slightly removed, the momentum causes the -shaft to overrun and coil the thong in the opposite direction to which it -originally was. The crosspiece is again depressed and the alternating -rotation goes on without intermission, and the drill bores through the -pottery. The travelling crockery mender is, in the northern towns of -England, not an unusual sight squatting at work on the kerb. On the -continent the 'Rastelbinder' is a regular domestic institution. Not only -crockery but glass is readily drilled by these means, and one who has seen -the rapidity with which these drills rotate can readily understand the -necessity for the advice given both by Hippocrates and Celsus to -frequently remove the drill and dip it in cold water, in case sufficient -heat be generated by the friction to cause subsequent exfoliation of the -neighbouring bone. - -The remaining method of producing rotation by means of a string fixed to -the shaft can be seen in use by boatmen when clearing water out of a boat -with a mop, The mop is laid over the side of the boat. A few turns of a -rope fixed to the shaft are made round it and the rope being pulled the -shaft rotates. The momentum generated causes the shaft to overrun and the -rope to coil itself in the reverse way to the original. This is repeated -till the speed generated causes the water to fly off the mop by -centrifugal motion. - -The fire drill of the ancient Egyptians was turned by a bow, and it is -interesting in connexion with the advice of Hippocrates to avoid -generating too much heat in drilling the skull, and also because it helps -to explain the construction of the instruments of Vidius. A sketch of an -ancient fire drill found by Flinders Petrie (_Ten Years Digging in Egypt_) -shows that the head of the drill was separate and the points were also -removable. - - -_Drill with Guard._ - -Greek, [Greek: trypanon abaptiston]; Latin, _terebra abaptista_. - -This is the second variety of drills described by Celsus. It had a collar -which prevented it from sinking beyond a certain depth, so that in -excising a piece of bone from the skull, which was the object for which it -was used, there was little danger of its doing injury to the brain or its -membranes: - - Terebrarum autem duo genera sunt; alterum simile ei quo fabri utuntur; - alterum capituli longioris, quod ab acuto mucrone incipit, deinde - subito latius fit; atque iterum ab alio principio paulo minus quam - aequaliter sursum procedit (VIII. iii). - -Further on in the same passage Celsus states that they were to be -frequently removed and dipped in water lest too great heat should be -generated, so that they were evidently driven at a rapid rate with a thong -like the other drills. They are not mentioned by Hippocrates, but Galen -(x. 445) describes them: - - 'In order to make less chance of error they have invented drills - called abaptista ([Greek: abaptista trypana]), which have a circular - border a little above the sharp point of the drill. It is best to - have several for every thickness of the calvarium; for thicker bone - longer are required, for thinner bone shorter.' - -Paul (VI. xc) says: - - 'But if the bone is strong it is first to be perforated with that kind - of perforators called abaptista ([Greek: peritrypesantes abaptistois - tois legomenois]), which have certain eminences to prevent them - sinking down to the membrane, and then with chisels we remove the bone - not whole, but in pieces.' - -The illustrations of drills given from Vidius (Pl. XLII) are really -abaptista. - - -_Saw._ - -Greek, [Greek: prion, machairotos prion] (as if from [Greek: machairoo]); -Latin, _serrula_. - -The saw is very frequently mentioned in the description of operation on -bone. Celsus (VII. xxxiii), in describing the amputation of a gangrenous -limb, says: - - Dein id serrula praecidendum est, quam proxime sanae carni etiam - inhaerenti: ac tum frons ossis, quam serrula exasperavit, laevanda - est. - -And Paul says that in amputating a gangrenous limb the flesh ought to be -retracted with a band lest it be torn by the saw. Saws were also used in -cranial surgery. Hippocrates frequently mentions a saw ([Greek: prion]) in -this connexion, but it is evident that he means the trephine, as he -describes its circular motion. Paul, however, makes it quite clear that he -means flat cranial saws, for he mentions both saws and trephines in one -paragraph: - - [Greek: Ede kai ton prionon te kai choinikidon cheirourgiai, ktl.] - - 'The method of operating with saws and trephines is condemned by the - moderns as a bad one' (VI. xc). - -Pl. XLI, fig. 3 shows a surgical saw from the British Museum (No. 2,328). -It is of bronze, and measures 112 mm. long, 3 cm. broad at one end, -narrowing to 23 mm. at the other. There are surgical saws of steel in the -Naples Museum. Many of the saws extant are for use as 'frame' saws. Others -have the saw portion continuous with the handle, like a knife. Galen -(xviii. 331) mentions these 'knife-shaped' saws: 'For in this way each -does not become so exactly smooth as with sword-shaped saws ([Greek: -machairoton prionon]).' There is an example of this form of saw in the -Guildhall Museum, London. - - -_Trephine._ - -Greek, [Greek: trypanon, prion, prion charaktos, choinikis, orthoprion]; -Latin, _modiolus_. - -The ancient trephine is referred to by Hippocrates, who mentions a saw -([Greek: prion] and [Greek: prion charaktos]) having a circular motion -(iii. 374): - - 'In trephining you must frequently remove the trephine, on account of - the heat in the bone, and plunge it in cold water. For the trephine - ([Greek: prion]), being heated by the circular motion ([Greek: - periodou]) and heating and drying the bone, burns it and makes a - larger piece of bone exfoliate than would otherwise be necessary.' - -And again: - - 'You must saw the bone down to the meninges with a serrated trephine - ([Greek: prioni chre charakto empriein]), and in doing so must take - out the trephine ([Greek: priona]), and examine with a probe and by - other means along the track of the trephine' ([Greek: perix kata ten - hodon tou prionos]). - -In injuries to the head in young people (iii. 371) he mentions a small -trephine ([Greek: smikron trypanon]), so that apparently several sizes -were available. Hippocrates, we have seen, uses the words [Greek: prion] -and [Greek: prion charaktos] to denote the trephine. Galen always uses -[Greek: choinikis], but in his Lexicon he gives two other words, viz. -[Greek: orthoprioni] and [Greek: pereterio], ostensibly from the works of -Hippocrates: - - [Greek: Orthoprioni--te choinikidi. - - pereterio--trypano to euthei kai oxei, esti gar kai heteron he - choinikis.] - -These terms do not, however, occur in any extant Hippocratic writings, -unless, as seems possible to me, the latter term [Greek: pereterio] be a -_var. lect._ for the obscure word [Greek: trygleterio] applied to [Greek: -trypanon] in ii. 470 in the description of trephining a hole through a rib -to drain an empyema. Galen held the trephine in little esteem. It must -have been difficult to manufacture a satisfactory instrument of bronze. In -x. 448 he says: 'Some people, shall I call them rather cautious or rather -timid, have used trephines' ([Greek: choinikisin]); and Paul, in a passage -I have already quoted, says: 'The mode of operating with saws and -trephines is condemned by moderns as a bad one.' - -The term [Greek: choinikis] is derived from [Greek: choinike] and [Greek: -chnoe], the nave of a wheel. The Latin term for the trephine, _modiolus_, -has the same meaning. Celsus graphically describes the trephine and the -method of its application. From him we learn how the ancients solved the -problem of the centre-pin, which is necessary until the toothed portion -has begun to bite. In modern trephines this difficulty is got over by -withdrawing the pin up the centre of the shaft. In mediaeval trephines it -was solved by providing two instruments, a male and a female, the male -with centre-pin being used till a circular track had been cut by the -toothed ring, the female without pin being then used. In the time of -Celsus the centre-pin was removable, being taken out after the instrument -had begun to bite. From Celsus too we learn that the trephine was driven -by a thong. - -Celsus and Hippocrates both remark that, as in the case of the drill, it -is necessary to dip the trephine in cold water at intervals in order to -cool it, lest heat sufficient to injure the surrounding bone be generated. -The thong manipulated by a bow would seem to be the method most applicable -to an instrument like the trephine, which has a large boring radius, as -slower motion is more easily produced by this arrangement than by one -consisting of a cross-piece with thongs. Celsus says: - - Exciditur vero os duobus modis: si parvulum est quod laesum est, - modiolo, quem [Greek: choinikida] Graeci vocant: si spatiosius, - terebris. Utriusque rationem proponam. Modiolus ferramentum concavum - teres est, imis oris serratum; per quod medium clavus, ipse quoque - interiore orbe cinctus, demittitur. Terebrarum autem duo genera sunt: - alterum simile ei quo fabri utuntur: alterum capituli longioris, quod - ab acuto mucrone incipit, deinde subito latius fit; atque iterum ab - alio principio paulo minus quam aequaliter sursum procedit. Si vitium - in angusto est quod comprehendere modiolus possit, ille potius - aptatur: et si caries subest, medius clavus in foramen demittitur; si - nigrities, angulo scalpri sinus exiguus fit qui clavum recipiat ut, eo - insistente, circumactus modiolus delabi non possit: deinde is habena, - quasi terebra convertitur. Estque quidam premendi modus, ut et foret - et circumagatur; quia si leviter imprimitur parum proficit, si - graviter non movetur. Neque alienum est instillare paulum rosae vel - lactis, quo magis lubrico circumagatur; quod ipsum tamen, si copiosius - est, aciem ferramenti hebetat. Ubi iam iter modiolo impressum est, - medius clavus educitur, et ille per se agitur: deinde, quum sanitas - inferioris partis scobe cognita est, modiolus removetur. - - -_Perforator for Fistula Lachrymalis._ - -Greek, [Greek: lepton trypanon]. - -Galen (xii. 821) says that Archigenes in cases of fistula lachrymalis -perforated the nasal bone with a small drill ([Greek: lepton trypanon]), -and Paul (VI. xxii) says: - -Some, after excision of the flesh, use a perforator ([Greek: trypanon]) -and make a passage for the fluid or matter to the nose. - -Albucasis figures a drill for this purpose which he says had a triangular -iron point and a conical wooden handle. - -In the find of instruments of the third-century oculist Severus is a drill -which Deneffe regards as intended for this purpose. It is 6 cm. in length -and 7 mm. on each of its four sides. One end is pointed, the other has a -slit for a knife-blade. It is beautifully damascened with silver (Pl. II, -fig. 7). - - -_Bone Lever._ - -Greek, [Greek: mochliskos, anaboleus]. - -Instruments for levering fractured bones into position are described in -several places. Hippocrates (iii. 117) says: - - 'In those cases of fracture in which the bones protrude and cannot be - restored to their place, the following mode of reduction may be - practised: pieces of steel ([Greek: sideria]) are to be prepared like - the levers ([Greek: hoi mochloi]) which the cutters of stone make use - of, one being rather broader and the other narrower, and there should - be at least three, or even more, so that you may use those that suit - best, and then along with extension we must use these as levers, - applying the under surface of the piece of iron to the under fragment - of bone, and the upper surface to the upper bone, and in a word we - must operate powerfully with the lever as we would do upon a stone or - a log. The pieces of steel should be as strong as possible so that - they may not bend.' - -In a note to this passage Galen (xviii. 593) says: - - 'It is evident that the instruments described resemble those of stone - cutters, not in size but in principle. For the instruments prepared by - us for levering bone are similar in size to those used for levering - out teeth. But for levering bones several ought to be prepared, - differing from each other in length as well as breadth and thickness - at the point, by which means they may afford their greatest effect.' - -Paul (VI. cvi) gives us some additional information: - - 'Of whatever bones therefore we endeavour to replace the protruded - ends, we must not meddle with them when in a state of inflammation. - But on the first day before inflammation has come on, or about the - ninth day after inflammation has gone off, we may set them with an - instrument called the lever ([Greek: to legomeno mochlisko]). It is an - instrument of steel about seven or eight fingers' breadth in length, - of moderate thickness that it may not bend during the operation, with - its extremity sharp, broad, and somewhat curved.' - -There are two bone levers in the Naples Museum, both of bronze. Pl. XLI, -fig. 1 shows one of them (No. 78,012). It is 15.5 cm. in length, and with -its ends flattened, and curved, and pointed, as described by Paul. The -other instrument is of similar shape, but is somewhat less in size. The -concave surface at one end is smooth, at the other ridged like a file. - -It may be remarked, that though the similarity in form to the instruments -figured by Pare as in use in his time for levering up depressed bones -shows that these are undoubtedly bone levers, it is quite possible, from -what Galen says, that they may also have been used for levering out teeth. -The smooth end also corresponds to the description of the meningophylax, -so that it is possible it may have been used in that capacity also. - - -_Bone Forceps._ - -Greek, [Greek: ostagra]. - -Galen (x. 450) says, in comminuted fracture of the skull we must make a -way for the lenticular with the bone forceps ([Greek: dia tes ostagras]); -and in depressed fracture Paul (VI. xc) says: - - 'If the bone is strong it is first to be perforated with the drills - called abaptista and the fractured bone is to be removed in fragments, - with the fingers if possible, if not, with a tooth forceps or a bone - forceps' ([Greek: odontagra e ostagra]). - -Soranus (lxiv. p. 366) says that in impaction of the foetal cranium the -head may be opened with a sharp instrument and the pieces of the skull -removed with tooth or bone forceps ([Greek: odontagras e ostagras]). -Aetius copies this (IV. iv. 24) and so does Paul (VI. lxxiv). - -An excellent specimen of the sequestrum forceps was found in the house of -the physician at Pompeii, and is now in the Museum at Naples (No. 78,029). -It is formed of two crossed branches moving on a pivot. The handles are -square, the jaws are curved, and have across the inside of them parallel -grooves which oppose each other accurately (Pl. XLIII). It is classed in -the catalogue as an instrument for crushing calculus of the bladder. This -is, however, not a manipulation which is described by the ancients. The -only case in which splitting of calculi is referred to is in Celsus, and -then a chisel is used. - - -_Varix Extractor._ - -An instrument, apparently a forceps, for extracting varicose veins in -segments is mentioned by Galen: - - 'And with regard to varices in the legs, first having mapped them out - on the surface with scarifications, then setting about the operation, - taking hold of the skin we divide it first. Then pulling up the varix - with a hook we tie it, and, doing this at all the cuts in the skin, - and cutting the ends, we either remove it with a varix extractor - ([Greek: kirsoulko]) or, taking hold of it with a doubled thread, we - draw it through the channel of the varix after the manner of flaying' - (xiv. 790). - -Celsus (VII. xxxi) directs us to expose the vein and raise it by a blunt -hook at intervals of four finger breadths, and divide the vein at one hook -and pull the vein out at the next place. Galen, however, indicates that -there was a special instrument for the purpose, and this can scarcely have -been anything else than a forceps of some kind. The operation must have -been excessively painful. Pliny (xi. 104) remarks that C. Marius was the -only man who had undergone it in the upright position. - - -_Blacksmith's Tongs._ - -Latin, _vulsella quali fabri utuntur_. - -For replacing a protruding bone in a case of compound fracture Celsus -(VIII. x) says that a forceps such as smiths use may be employed: - - Tum ipsum recondendum est; ac, si id manus facere non potest, vulsella - quali fabri utuntur iniicienda est, recte se habenti capiti ab ea - parte qua sima est; ut ea parte qua gibba est eminens os in suam sedem - compellat. - - 'Then it is to be replaced, and if that cannot be done by hand the - forceps such as smiths use is to be inserted, the head being kept - straight by the snub-nosed part so that the curved part forces the - bone into position.' - -The blacksmith's tongs is very frequently represented in ancient art. Pl. -XLII, fig. 2 shows a forceps from Roman London in the Guildhall Museum. - - -_Tooth and Stump Forceps._ - -Greek, [Greek: odontagra, rhizagra]. - -The ancients regarded tooth extraction as an operation to be avoided -wherever possible. Caelius Aurelianus says death had followed in some -cases, and that in the temple of Apollo at Delos there hung a tooth -forceps of lead as a reminder for operators to exert little force in tooth -extraction (_Pass. Tard._ II. iv). Scribonius Largus (_Comp._ liii) is -equally pessimistic: - - Ad dentium dolorem quamvis plurimi dicant forcipes remedium esse, - multa tamen citra hanc necessitatem scio profuisse. - -Celsus (VII. xii) says extraction may result in injury to the temples and -eyes, and fracture or dislocation of the jaw may occur. He recommends -therefore to free the tooth all round down to the socket, then to shake it -repeatedly till it has been thoroughly loosened, and remove it with -fingers or forceps. If the tooth be hollow, it should be plugged with lint -or lead to prevent it breaking under the forceps. The tooth should be -pulled out straight, lest the alveolus be broken. Stumps are to be removed -with the forceps which the Greeks call [Greek: rhizagra]. Paulus Aegineta -(VI. xxvii) bids us scarify down to the socket and loosen the tooth -gradually by shaking with a tooth extractor ([Greek: odontagra]) and -extract it. Supernumerary teeth are, if fast, to be rasped down with a -graving tool; if loose, to be extracted with tooth forceps ([Greek: dia -tes odontagras]). There is no ancient forceps which can with certainty be -set down as a tooth forceps, although some have looked upon the Pompeian -forceps (see p. 135) as a tooth extractor. Although its shape is not -otherwise unsuitable for this purpose its jaws are not particularly well -adapted for seizing a tooth, as they are not hollowed inside. It may be -noted that the tooth forceps was evidently a 'universal', as no special -variety is ever mentioned beyond the two I have given--'tooth' and -'stump'. Whatever the shape of the Graeco-Roman forceps was it seems to -have been a handy instrument for many different manipulations. Soranus -(ii. 63) says that in impaction of the foetal cranium we may open the head -and remove the bones with a bone forceps or a tooth forceps ([Greek: -ostagras e odontagras]). Paul (VI. xc) says that in fracture of the skull -the fragment is to be surrounded with perforations by the drill and -finally separated with chisels, the chips being removed with the fingers -or with tooth forceps, bone forceps, &c. ([Greek: odontagra e ostagra]). -Again in ch. lxxxviii he says that if the shaft of a weapon imbedded in -the flesh be broken off, the weapon may be extracted with a tooth forceps -or a stump forceps ([Greek: odontagras e rhizagras]). - - -_Tooth Elevator._ - -In a note on a passage in Hippocrates describing the lever for replacing -the protruding end of a fractured bone, Galen mentions an instrument for -levering teeth. He says the instruments for levering the bone are of the -same size as the instrument for levering teeth (xviii. 593). As we know -from Paul (VI. cvi) that these bone levers were seven or eight finger -breadths in length, we may take this as the length of the tooth elevator. - - -_Tooth Scalers._ - -Greek, [Greek: xysterion, smilion, smilioton] (sc. [Greek: organon]); -Latin, _scalper medicinalis_. - -Paul (VI. xxviii) mentions a small raspatory used for removing tartar from -teeth: - - 'The scaly concretions which adhere to teeth we may remove with the - scoop of a specillum, or with a scaler ([Greek: xysterio]) or a file.' - -Scribonius Largus (_Comp._ liii) mentions an excavator: - - Itaque cum etiam exesus est aliqua ex parte, tum non suadeo protinus - tollendum, sed excidendum scalpro medicinali, qua cavatus est, quod - sine ullo fit dolore, reliqua enim solida pars eius et speciem et usum - dentis praestabit. - -Marcellus conveys this passage entire (_De Med._ xii). - -Paul (VI. xii) says supernumerary teeth may be cut down with excavators -([Greek: ton smilioton]). - - -_File._ - -Greek, [Greek: rhinarion, rhine, rhinion]; Latin, _lima_, _limula_. - -In compound fracture with protrusion of bone Celsus says: - - 'Should any small piece of bone protrude, if it is blunt it should be - reduced to its place. If it is sharp its point should first be cut off - if it is long, and if short it should be filed. "In either case it - should be smoothed with the raspatory."' (Si longius est, - praecidendum; si brevius, limandum, et utrumque scalpro laevandum.) - -The application of the raspatory to smooth the bone after the use of the -file shows that it must have been more of the nature of a rasp than a file -which was used for bones. Scribonius Largus speaks of a wood file or rasp -used in reducing a hart's horn to powder (_Comp._ cxli): - - Ad lumbricos satis commode facit et santonica herba, quae non viget, - et cornum cervinum limatum lima lignaria. - -Files were largely used in dental work. All the surgeons state that where -a tooth projects above its fellows it should be filed down; Galen says -that for this purpose he has invented an olivary pointed file of steel: -[Greek: siderion epoiesa rhinion pyrenoeides] (xiv. 871). - -Aetius copies Galen's chapter word for word (II. iv. 30). Paul (VI. -xxviii) says the file ([Greek: rhinarion]) may be used to remove tartar -from teeth. - -There are several files of steel in the Naples Museum which are classed -among the surgical instruments. Many Roman files of steel which have been -found in London are now in the Guildhall Museum. Some of these have -transverse edges like our own files. Other extant specimens have coarse -frets on them, like our wood rasps. Pl. XLII. fig. 1 shows one in the -Guildhall collection, which is of the rasp variety. - - -_Forceps for extracting Weapons._ - -Greek, [Greek: beloulkon] (sc. [Greek: organon]). - -Paul has a most interesting chapter on the extraction of weapons, and in -it he mentions a special instrument for extracting weapons, evidently a -forceps: - - 'If the head of the weapon has fixed in the flesh, it is to be drawn - out with the hands, or by laying hold of the appendage which is called - the shaft, if it has not fallen off. This part is commonly made of - wood. When it has fallen off we make the extraction by means of a - tooth forceps, or a stump forceps, or a forceps for extracting weapons - ([Greek: beloulkou]), or any other convenient instrument. And - sometimes we make an incision in the flesh around it in the first - place, if the wound do not admit the instrument' (VI. lxxxvii). - -It is true that etymologically we are only entitled to translate [Greek: -beloulkou] by 'weapon-extractor', but its association with the other two -forceps shows pretty conclusively that a forceps is meant, and Celsus says -weapons are to be extracted with the forceps under similar conditions. In -the picture of Aeneas wounded, found in a house at Stabiae and now in the -Naples Museum, the surgeon, Iapix, is engaged in extracting a weapon from -the wound in the thigh of the hero. The instrument he is using is a long -forceps with crossed legs (Pl. XLIV). - - -_Periosteal Elevator for the Pericranium._ - -Greek, [Greek: hypospathister, spathister]. - -The hypospathister was an elevator for separating the pericranium from the -calvarium. It gave the name to a formidable operation in which it was -used, viz. hypospathismus. This operation is described by Galen, Aetius, -and Paul, by the latter (VI. vi) best of all. Paul is the only one who -mentions the instrument by name. The operation consisted in making three -vertical incisions, one down each side of the forehead and one down the -centre. Next the skin was raised along with the pericranium from the whole -of the front of the forehead with the hypospathister ([Greek: -hypospathister]), and the vessels lying in the raised flaps were -subcutaneously divided by a knife passed under them, with its back to the -skull. The elevator by which the pericranium was separated is called by -Paul [Greek: hypospathister]. The operation is mentioned by Epiphanius, a -bishop of Alexandria in the fourth century, by whom the instrument is -referred to as [Greek: spathister]. - - -_Impellent._ - -Greek, [Greek: dioster]. - -In his chapter on the extraction of weapons, one of the most remarkable -chapters in the whole of his works, Paul mentions an impellent for forcing -an arrow head through a part so as to extract it at the side opposite to -that by which it went in. - - 'If the head of the weapon has passed to the other side and it is - found impossible to extract it by the way it entered, having divided - the parts opposite we extract it through the middle of them, either - extracting it in the manner spoken of (i. e. with forceps), or we make - an opening by means of the weapon itself, pushing it by the shaft, or, - if that has come away, by an impellent instrument ([Greek: - diosteros]), taking care not to divide a nerve, artery, vein, or any - important part; for it would be malpractice if, in extracting the - weapon, we should do more mischief than the weapon itself had done. If - the weapon has a tang, which is ascertained by examination with the - probe, having introduced the female part of the impellent instrument - and engaged it, we push the weapon forwards, or, if it has a socket, - the male part' ([Greek: ten theleian tou diosteros kathentes kai - enarmosantes othesomen to belos ei de aulon ton arrhena]). - -Impellents formed an important part of the armamentarium of the surgeon, -at least down to the time of Scultetus, and in his works and in those of -Albucasis and Pare there are numerous figures of these instruments. None -of these quite agree with the idea of the instrument which one gathers -from Paul's description. It would seem to have been a very simple affair, -probably a plain rod of metal pointed at one end and hollowed at the -other, the pointed end being introduced into the socket of an arrow where -it possessed one, the hollow end being fitted over the tip of the tang in -cases where the arrow was tanged. - - -_Arrow Scoop._ - -Greek, [Greek: kyathiskos Diokleios]. - -A scoop for extracting arrow heads is thus described by Celsus (VII. v): - - Latum vero telum, si conditum est, ab altera parte educi non expedit, - ne ingenti vulneri ipsi quoque ingens vulnus adiiciamus. Evellendum - est ergo genere quodam ferramenti quod [Greek: Diokleiou kyathiskon] - Graeci vocant, quoniam auctorem Dioclem habet: quem inter priscos - maximosque medicos fuisse iam posui. Lamina, vel ferrea vel etiam - aenea, ab altero capite duos utrimque deorsum conversos uncos habet; - ab altero duplicata lateribus, leviterque extrema in eam partem - inclinata quae sinuata est, insuper ibi etiam perforata est. Haec - iuxta telum transversa demittitur; deinde ubi ad imum mucronem ventum - est paulum torquetur, ut telum foramine suo excipiat; quum in cavo - mucro est, duo digiti subiecti partis alterius uncis simul et - ferramentum id extrahunt et telum. - - 'But a broad weapon if buried should not be extracted from a counter - opening, lest to one large wound we add another; therefore it is to be - extracted with a special variety of instrument which the Greeks call - the Scoop of Diocles, since Diocles invented it. I have already stated - that he was one of the most eminent of the old practitioners. Its - blade of iron, or even of bronze, has at one end two hooks, one at - each side turned backwards. At the other end it is folded over at the - sides, and the end is slightly curved up towards that part which is - bent. Moreover in it there is a perforation. This is introduced - crosswise near the weapon, then when it comes near the point it is - twisted a little so that it receives the point in the hole. When the - weapon is in the cavity two fingers placed under the hooks at the - other end simultaneously extract both the instrument and the weapon.' - -This description seems very definite until we attempt to reconstruct the -instrument, when it becomes evident that more than one construction may be -put on some parts of it. Pl. XLV, fig. 4, shows the instrument as -conceived by me. - - - - -CHAPTER IX - -BLADDER AND GYNAECOLOGICAL INSTRUMENTS - - -_Catheter._ - -The catheter is very frequently referred to. Galen (xiv. 787) thus -describes it: - - 'When urine is not passed on account of excessive dilatation of the - bladder so that it cannot contract, we draw off the urine with a - catheter. Therefore an instrument like the Roman letter S is let down - into the bladder by the urethra. A thread is passed into it which has - in its tip a little wool dipped in urine. Then it is drawn out and the - urine follows it like a guide.' - -This method of preparing the catheter and the reasons for so doing are -discussed at somewhat greater length in the following selection from Paul -(VI. xix): - - 'Wherefore taking a catheter proportionate to the age and sex we - prepare the instrument for use. The mode of preparation is this: - having bound a little wool round with a thread and introduced the - thread by means of a sharp rush into the pipe of the catheter, and - having cut off the projecting parts of the wool with a pair of - scissors, we put the catheter into oil. Having then placed the patient - on a convenient seat and used fomentation, if there be no - contra-indication we take the catheter and introduce it direct down to - the base of the penis, then we must draw the penis up to the umbilicus - (for at this part there is a bend in the passage), and in this - position push the instrument onwards. When in the perinaeum it - approaches the anus we must bend the penis with the instrument in it - down to its natural position, for from the perinaeum to the bladder - the passage is upwards, and we must push the instrument onwards till - we reach the cavity of the bladder. We afterwards take out the thread - fastened into the opening of the catheter, in order that the urine, - being attracted by the wool, may follow as happens in syphons.' - -It is occasionally, in cases of cancer of the prostate, of service to -adopt this proceeding to prevent the eye of the catheter from getting -blocked before the bladder is entered, but it is strange that Galen should -have fallen into the mistake of thinking that it is necessary to set up a -syphon action, as he was well aware of the expulsive power possessed by -the bladder; in fact, his explanation of the physiology of urination is -almost up to date. - -Celsus gives a good description of the catheter both male and female (VII. -xxvi): - - Res vero interdum cogit emoliri manu urinam, quum illa non redditur, - aut quia senectute iter eius collapsum est, aut quia calculus vel - concretum aliquid ex sanguine intus se opposuit: ac mediocris quoque - inflammatio saepe eam reddi naturaliter prohibet. Idque non in viris - tantummodo, sed in feminis quoque interdum necessarium est. Ergo - aeneae fistulae fiunt; quae ut omni corpori ampliori minorique - sufficiant, ad mares tres, ad feminas duae medico habendae sunt; ex - virilibus maxima decem et quinque digitorum, media duodecim, minima - novem, ex muliebribus maior novem, minor sex. Incurvas vero esse eas - paulum, sed magis viriles, oportet, laevesque admodum; ac neque nimis - plenas neque nimis tenues. - -There are fine specimens of the catheter, both male and female, in the -Naples Museum. The male catheter is from the 'House of the Physician' in -Pompeii. It is 24 cm. in length and is about the size of a No. 11 English. -It has two gentle curves, so that it closely resembles the instrument -reintroduced by Petit in the eighteenth century. See Pl. XLV, fig. 1. A -catheter of similar shape, but broken in three pieces, was found by some -workmen at Baden in the Seventies. They were given by Dr. Wagner, of -Baden, to Mr. Atkinson, M.P., London, and are possibly now in some English -collection (Brunner, _op. cit._ p. 42). - -In the excavation of the Roman Military Hospital at Baden, 1893, a -fragment of a catheter was found, and is now in the possession of M. -Kellersberger. It consists of the curved part of a catheter, and it is 13 -cm. long and about the size of a No. 10 English. The curve is -considerably greater than that of the Naples specimen (Un Hopital -Militaire Romain, planche ix). - -The female catheter in the Naples Museum is 0.98 m. long, and of the same -diameter as the male one. It is straight (Pl. XLV, fig. 2). - - -_Bladder Sounds._ - -Had the ancients solid bladder sounds? They must have been well aware of -the characteristic grating sensation conveyed to the skilled hand on -striking a stone with a metal instrument, for we have several references -in the classics to the manoeuvre of pushing back, by means of a catheter, -a stone impacted in the urethra. Rufus of Ephesus ([Greek: Peri lithioses -kysteos]) says of impacted urethral calculus: 'Those that are stuck fast -push back with the catheter if you prefer not to do lithotomy' ([Greek: -ereidontas oun ei me thelois temnein aposai to aulisko]). Soranus (II. -xviii) says if a stone is the cause of dystocia we must push it out of the -neck of the bladder into the bladder with a catheter ([Greek: katheter]). -The word Rufus uses puts it beyond doubt that a hollow tube is meant, or -we might have argued that [Greek: katheter] did not necessarily mean a -hollow tube, since Hippocrates uses it in the sense of a uterine plug (ii. -830). Yet strange to say, the sensation conveyed to the hand and ear on -striking a stone with a metal instrument is nowhere definitely given as a -cardinal symptom by a classical writer. - -Rufus describes the symptoms of vesical calculus at length and finishes -with instructions for searching the bladder. The word he uses ([Greek: -melosis]) at first sight seems to indicate that this was done with a -sound, but it turns out to be bimanual rectal examination only which he -describes. The use of the sound as a staff in lithotomy, or as a dilator -of a strictured urethra, was not known to the ancients, and thus we have -no evidence from the literature that a solid bougie existed. Some -instruments have come down to us, however, which seem undoubted solid -bladder sounds. There are three sounds of bronze in the Naples Museum, -which have the identical appearance of our modern bladder sounds. It might -be argued that these have not quite the shape of the catheter described by -the ancients, but there is an instrument in the Mainz Museum against which -even this objection cannot be brought. It is a solid sound of the double -curvature described by Celsus, and is identical in shape with the catheter -from the Pompeian surgeon's house (Pl. XLV, fig. 3). - - -_Lithotomy Scoop._ - -Greek, [Greek: lithoulkos]; Latin, _uncus_, _ferramentum quo in sectione -calculus protrahitur_. - -Celsus thus describes the extraction of calculus through a perineal -incision by means of a lithotomy scoop: - - Quum vero ea patefacta est, in conspectum calculus venit; in cuius - colore nullum discrimen est. Ipse si exiguus est, digitis ab altera - parte propelli, ab altera protrahi potest; si maior, iniiciendus a - superiore parte uncus est, eius rei causa factus. Is est ad extremum - tenuis, in semicirculi speciem retusae latitudinis; ab exteriore parte - laevis, qua corpori iungitur; ab interiore asper, qua calculum - attingit. Isque longior potius esse debet; nam brevis extrahendi vim - non habet. Ubi iniectus est in utrumque latus inclinandus est, ut - appareat an calculus teneatur; quia si apprehensus est, ille simul - inclinatur. - - 'When it is opened there comes into view the calculus, the colour of - which is unmistakeable. If it is small it is to be pushed by the - fingers from one side and pulled from the other. If too large the hook - for the purpose is to be put in above it. The hook is slender at the - end and flattened out in the shape of a semicircle, smooth externally - where it comes in contact with the tissues, rough internally where it - meets the calculus. The hook should be pretty long, for a short one - has no power of extraction. When it has been inserted it should be - inclined to either side, so that it may be seen whether the calculus - is caught, because if it is held it also is inclined to the side' - (VII. xxvii). - -The above passage gives a very complete account of the lithotomy scoop. -The only thing it leaves undecided is the breadth. Was it a broad, -spoon-like scoop, or was it a hook-like instrument? That the latter was -the case is proved by the following passage also from Celsus (VII. xxvi): - - Nonnunquam etiam prolapsus in ipsam fistulam calculus: quia subinde ea - extenuatur non longe ab exitu inhaerescit. Eum, si fieri potest, - oportet evellere vel oriculario specillo, vel eo ferramento quo in - sectione calculus protrahitur. - - 'Sometimes also a stone slips into the urethra itself and lodges near - the meatus, because at that part there is a constriction. It should if - possible be extracted either with an ear probe, or with the instrument - for the extraction of calculus in lithotomy.' - -This shows that the scoop must have been quite a narrow instrument, or it -could not have passed into the urethra. It must have had very much the -same appearance as the modern 'Ferguson's Scoop'. We have two extant -specimens of the ancient lithotomy scoop in the Naples Museum, one of -which is shown in Pl. IV; and in the marble _ex voto_ tablet in the Athens -Museum, to which I have already referred, there is a representation of a -manubriolus curved so as to serve as a lithotomy scoop (Pl. XLVI, fig. 2). -Rufus of Ephesus mentions this form of scalpel handle. - - -_Lithotomy Forceps._ - -Was there a forceps for extracting calculus from the bladder? The -sixteenth-century translation of Aetius (IV. iv. 94) by Cornarius has the -following passage, under the treatment of calculus in the female: - - Et tunc paululum supra pudendi alas, quo loco calculus occurrit - sectionem facito et per calcularium forcipem extrahito. - -The original Greek of this part of Aetius has not yet been published, but -from a pretty intimate knowledge of Cornarius's methods I have a strong -suspicion that 'calcularium forcipem' may be a free translation of [Greek: -lithoulkos], as in the following passage in Paul: - - 'Sometimes from the pressure of the finger or fingers at the anus the - stone starts out readily at the same time as the incision is made, - without requiring extraction. But if it does not of itself start out - we must extract it with the instrument called the stone extractor' - ([Greek: tou lithoulkou]) (VI. lx). - -Adams translates [Greek: lithoulkos] by 'forceps for extracting stone', -but this is not quite a justifiable translation. The instruments whose -names end in [Greek: -oulkos], and which are derived from [Greek: helko], -are certainly in many instances forceps, e. g. [Greek: beloulkos], a -forceps for extracting weapons, but in other cases they are as certainly -not. I need only refer to [Greek: embryoulkos], which is conclusively -described as a hook for extracting the dead foetus. Thus while it is -possible that the [Greek: lithoulkos] may have been a forceps, the -etymology of the word does not entitle us to translate by any term more -definite than 'stone extractor'. Galen (xiv. 787) uses the word [Greek: -litholabos], which has a more definite meaning. The majority of words -compounded of [Greek: -labos] means some variety of forceps, e. g. [Greek: -sarkolabos], tumour vulsellum. The etymological evidence thus leaves the -matter open, with a slight balance in favour of there having been a -forceps. I should have had no hesitation in translating [Greek: -litholabos] to mean a forceps, had it not been that Celsus evidently had -no cognizance of a stone forceps. Galen, however, lived after Celsus, and -we may note that the Arabians used such an instrument. Albucasis says that -if the stone does not start out it must be seized with a forceps or a -hook, and failing removal by these means it is to be broken up with -forceps. One forceps in the Naples Museum, from the house of the -physician, seems to be suited for the operation (Pl. XLVI, fig. 3). The -handles are short in proportion to the blades, and it seems better suited -to grasp some substance inside the bow than between the jaws. The -unfinished condition of the tips of the handles indicates that they had -been inserted into handles of wood. - - -_Lithotrite._ - -Latin, _ferramentum_. - -A sort of chisel by which a calculus was split is thus described by -Celsus: - - Si quando autem is maior non videtur nisi rupta cervice extrahi posse, - findendus est; cuius repertor Ammonius ob id [Greek: lithotomos] - cognominatus est. Id hoc modo fit: uncus iniicitur calculo sic ut - facile eum concussum quoque teneat, ne is retro revolvatur; tum - ferramentum adhibetur crassitudinis modicae, prima parte tenui, sed - retusa, quod admotum calculo, et ex altera parte ictum, eum findit. - - 'If at any time it seems too large and impossible to be extracted - without splitting the cervix, it is to be split. The originator of - this is Ammonius, hence called the lithotomist. It is performed in - this manner. A scoop is put over the calculus in such a way that it - easily holds it even when struck from sliding back; then there is - applied an instrument of moderate thickness, slender at the tip, but - blunt, which being placed against the calculus and struck on the other - end splits it' (VII. xxvi). - -The above paragraph really gives us all the information we possess about -the instrument. It is evidently a slender chisel. A passage in Aretaeus -(_Morb. Chron._ ii. 9) is held by some to refer to lithotripsy (digital). -The reading, however, is dubious. - - -_Rectal Speculum._ - -Greek, [Greek: hedrodiastoleus, mikron dioptrion, katopter]. - -The earliest mention of the rectal speculum is to be found in the treatise -on fistula by Hippocrates: - - [Greek: Hyption kataklinas ton anthropon katopteri katidon to - diabebromenon tou archou.] - - 'Laying the patient on his back and examining the ulcerated part of - the bowel by means of the rectal speculum' (iii. 331). - -Again, a little further on, he mentions its use in the treatment of piles; -and Paul (VI. lxxviii) says: - - 'With regard to blind fistulae Leonidas says: "We dilate the anus, as - we do the female vagina, with the anal or small speculum"' ([Greek: to - hedrodiastolei (to mikro dioptrio lego) diasteilai ten hedran hos - gynaikeion kolpon]). - -There is a rectal speculum in the Naples Museum (No. 78,031). It is a -two-bladed instrument, working with a hinge in the middle. It is O.15 m. -in length, and the greatest stretch of the blades is O.07 m. It represents -an instrument used to dilate the vagina as well as the rectum, and got its -name 'small dilator' in contradistinction to the other vaginal speculum, -which we shall see was worked by a screw, and was called the speculum -magnum. The rectal speculum was also called [Greek: katopter], in -contradistinction to the vaginal speculum which was called [Greek: -dioptra]. In Galen's Lexicon they are explained as follows: - - [Greek: Katopteri, to kaloumeno hedrodiastolei, hosper ge kai dioptra - ho gynaikon diastoleus.] - - 'The catopter, which is called the anal dilator, in the same way as - the diopter is called the female dilator.' - -Pl. XLVI, fig. 1 shows one of two similar rectal specula from Pompeii -(Naples Museum). - - -_Vaginal Speculum._ - -Greek, [Greek: dioptra]; Latin, _speculum magnum matricis_ (late). - -Soranus is the first author who makes mention of the speculum specially -made for the vagina. The original Greek of this chapter of Soranus is -lost, but we have a Latin translation of it preserved to us by Moschion. -The heading of this chapter in Soranus, which was No. xxxiv, was [Greek: -Peri dioptrismou]. I shall give part of this chapter from Moschion: - - QUA DISCIPLINA ORGANO APERIENDAE SINT MULIERES. - - Scio me retro ad inspiciendam altitudinem mulieris frequentius organi - mentionem fecisse quod Graecitas dioptran vocat. Et quoniam nisi - insinuata fuerit disciplina quatenus hoc ipsud fieri possit, - occurrente necessitate obstetrices facere non audent, idcirco placuit - nobis ut etiam hoc gynaeciis adderemus, ut ex rebus huic corpori - necessariis nihil dimisisse videamur. Itaque supinam iactans eam quae - inspici habet, accipies fasciam longam et in media parte eius duobus - laqueis factis, ita ut inter se cubitum unum habeant laquei illi, - duabus vero manibus mulieris missis, medietatem quae interest cervici - eius inducis. Deinde reliqua fasciae sub anquilas missa ad manus - alligabis, ita ut patefacti pedes ventri eius cohaereant. Deinde - accepto organo et uncto priapisco, quem Graeci loton dicunt, in - aliquantum ad prunas calefacere (debes), deinde sine quassatione - priapiscum inicere, susum scilicet axe posito, iubere etiam ministro - ut aperiendo organo axem torquere incipiat, ut paulatim partes ipsae - aperiantur. Cum vero post visum organo tollere volueris, ministro - iubere ut iterum axem torqueat quo organum claudi possit, ita tamen ut - cum adhuc in aliquantum patet sic auferatur, ne universa clusura - aliquas teneat et nocere incipiat. - -We have also preserved by Paul a chapter by Archigenes on abscess of the -womb (VI. lxxiii), in which the different parts of the speculum are again -named, and from it also we learn that there were different sizes of the -instrument proportioned to suit different ages. The patient having been -fixed in the lithotomy position in the manner described by Soranus: - - 'The operator is to make the examination with a speculum ([Greek: - dioptra]) proportioned to the age of the patient. The person using the - speculum should measure with a probe the depth of the woman's vagina, - lest the priapiscus of the speculum ([Greek: tou tes dioptras lotou]) - being too long it should happen that the uterus be pressed on. If it - be ascertained that the tube is longer than the woman's vagina, folded - compresses are to be laid on the labia in order that the speculum may - be laid on them. The priapiscus is to be introduced while the screw - ([Greek: ton kochlion]) is uppermost. The speculum is to be held by - the operator. The screw is to be turned by the assistant, so that the - blades of the tube ([Greek: ton emplesmaton tou lotou]) being - separated, the vagina may be expanded.' - -We have little difficulty in recognizing among the instruments found in -Pompeii three of the vaginal specula referred to in these passages. All -are excellent specimens of the instrument maker's skill. They are in the -Naples Museum. The first discovered (No. 78,030) was found in the house of -the physician at Pompeii. The blades are at right angles to the instrument -(Pl. XLVII), and when closed form a tube the size of the thumb. On turning -the screw a cross-bar forces the two upper blades outwards, till -sufficient dilation is got for operative purposes. The diameter of the -tube at its maximum of expansion is 0.09 m. The whole instrument is 0.23 -m. long. Another instrument on a similar principle but with a quadrivalve -priapiscus was discovered in 1882 (Pl. XLIX). It is 0.315 m. long. It is -now fixed by oxidation, so that the blades cannot be moved. On turning the -screw the lower blades could be drawn downwards, at the same time -separating slightly, while the upper blades diverged also (No. 113,264 -Naples Mus.). Lately a third, similar to that shown in Pl. XLVII, has been -found in Pompeii. Note that the screw in the three-bladed instrument is a -left-handed one. That in the four-bladed instrument is right-handed. This -causes right-handed motion to open the instrument in either case. There -is, however, an instrument similar to these trivalve instruments in the -museum at Athens. It differs in having the screw right-handed (Pl. -XLVIII). Mr. Bosanquet, late of the British Institute of Archaeology at -Athens, was kind enough to procure me a photograph of this instrument, but -he tells me that there is no satisfactory account of its provenance and -its authenticity is doubtful. It seems possible that it is a copy of one -of the Naples specimens by some one who has omitted to observe that the -screw in these is left-handed. - - -_Traction Hook for Embryo._ - -Greek, [Greek: embryoulkos]; Latin, _uncus_. - -Celsus has an interesting chapter on the removal of the foetus in -difficult labour. He says (VII. xxix): - - Tum, si caput proximum est, demitti debet uncus undique laevis, - acuminis brevis, qui vel oculo, vel auri, vel ori, interdum etiam - fronti recte iniicitur; deinde attractus infantem educit. Neque tamen - quolibet is tempore extrahi debet. Nam, si compresso vulvae ore id - tentatum est, non emittente eo, infans abrumpitur, et unci acumen in - ipsum os vulvae delabitur; sequiturque nervorum distentio, et ingens - periculum mortis. Igitur, compressa vulva, conquiescere; hiante, - leniter trahere oportet; et per has occasiones paulatim eum educere. - Trahere autem dextra manus uncum; sinistra intus posita infantem - ipsum, simulque dirigere eum debet. - - 'Then if the head presents there ought to be inserted a hook, smooth - all round, with a short point which is properly fixed in the eye or - the ear or the mouth, sometimes even in the forehead, which being - drawn on extracts the child. Nor is it to be drawn on without regard - to circumstance. For if the attempt is made with an undilated cervix, - not getting exit the foetus is broken up, and the point of the hook - catches on the cervix and inflammation follows and much danger of - death. Therefore, it is necessary with a contracted cervix to wait - quietly, with a dilated one to make gentle traction, and during these - times to extract it gradually. The right hand ought to make the - traction on the hook, the left place inside to draw the child and at - the same time to direct it.' - -The following passage in Soranus shows that it was customary also to -insert a second hook opposite the first and to make traction on both at -the same time: - - 'The best places for the insertion of the hooks are in head - presentations, the eyes, the occiput, and the mouth, the clavicles, - and the parts about the ribs. In footling cases the pubes, ribs, and - clavicles, are the best. Warm oil having been applied as a lubricant - the hook is to be held in the right hand; the curvature concealed in - the left hand is to be carefully introduced into the uterus, and - plunged into some of the places mentioned till it pierce right through - to the hollow part beneath. Then a second one is to be put in opposite - to it ([Greek: katapeirein de kai antitheton touto deuteron]), in - order that the pulling may be straight and not one-sided' (II. xix). - -Aetius (IV. iv. 23) and Paul (VI. lxxiv) copy this. - -Hippocrates (ii. 701) bids us break up the head with a cephalotribe in -such a way as not to splinter the bones, and remove the bones with bone -forceps; or, a traction hook ([Greek: to helkysteri]) being inserted near -the clavicle so as to hold, make traction but not much at once, but little -by little, withdrawing and again inserting it. - -There are three traction hooks from Pompeii in the Naples Museum. One of -these is given in Pl. L, fig. 1. They are of steel, with handles of -bronze. Hooks on the same principle, and differing in appearance very -little from the Pompeian hooks, are still used by veterinary surgeons. - - -_Decapitator._ - -Of transverse presentations, Celsus says: - - Remedio est cervix praecisa; ut separatim utraque pars auferatur. Id - unco fit, qui, priori similis, in interiore tantum parte per totam - aciem exacuitur. Tum id agendum est ut ante caput deinde reliqua pars - auferatur. - - 'The treatment is to divide the neck so that each part may be - extracted separately. This is done with a hook which, though similar - to the last, is sharpened on its inside only, along its whole border. - Then we must endeavour to bring away the head first, and then the rest - of the body.' - -Decapitation has now given way before Caesarean section; but the -decapitator, little altered since the days of Celsus, still finds a place -in surgical instrument catalogues. - -Paul and Aetius both mention division at the neck, but do not describe a -special instrument. A ring knife for dismembering the foetus has already -been discussed among the cutting instruments; but this seems to be a -different variety with a handle, which it is convenient to discuss in -proximity to the embryo hook. Pl. L, fig. 2 shows a knife on this -principle in the Bibliotheque Nationale. - - -_Cranioclast._ - -Greek, [Greek: piestron, embryothlastes, thlastes]; - -The cranioclast is mentioned by Hippocrates (ii. 701). - - [Greek: Schisanta ten kephalen machairio xymplasai hina me thrause to - piestro kai ta ostea helkein to osteoulko.] - - 'Opening the head with a scalpel, break it up with the cranioclast in - such a way as not to splinter it into fragments, and remove the bones - with a bone forceps.' - -The nature of the cranioclast is pretty well indicated by this passage, -and in Galen's Lexicon we find [Greek: piestro] defined as [Greek: to -embryothlaste kaloumeno]. I give drawings from Albucasis of a 'forceps to -crush the child's head' (Pl. LI, fig. 3). - - -_Cephalotribe._ - -Whether or not the instrument last described was used also for the -operation of cephalotripsy, or whether there was a special instrument, we -cannot say, but it is certain that the operation of crushing the head and -delivering the child without removing the bones was practised. In Aetius -(IV. iv. 23) cephalotripsy is thus described: - - 'But if the foetus be doubled on itself and cannot be straightened, if - the head is presenting, break up the bones of it without cutting the - skin. Then to some part of it fix on a traction hook and make - traction, and the legs becoming straightened out we get it away.' - -Though there is an essential difference between the operations of -cephalotripsy and cranioclasie there is no essential difference between -the instruments necessary for carrying out the same, and it is possible -that the instrument used may be the same as the last. The cephalotribe -figured by Albucasis is not essentially different from his cranioclast -(see Pl. LI, fig. 4). - - -_Midwifery Forceps._ - -Had the Greeks and Romans a forceps for extracting the child alive? -Probably not. We have no mention of any such instrument by Soranus or -Paul, both accomplished obstetricians, nor can any description of such an -instrument be found in the voluminous pseudo-Hippocratic works on women. -Adams, in a note to Paul, III. lxxvi, says that though the Roman and Greek -writers do not mention the forceps, Avicenna does so, and he says that a -forceps was dug up in the house of an obstetrix at Pompeii bearing a -considerable resemblance to the modern forceps. The only passage I have -met with in the slightest degree supporting the notion that the ancients -ever delivered the child alive with instruments is one in the -pseudo-Hippocratic treatise _De Superfoetatione_, where we are told that: - - 'If the woman has a difficult labour, and the child delay long in the - passage and be born not easily but with difficulty and with the - mechanical aids ([Greek: mechanais]) of the physician, such children - are of weak vitality, and the umbilical cord should not be cut till - they make water or sneeze or cry' (i. 465). - -We are not entitled to translate [Greek: mechanais] by 'instruments', -because it may mean any mechanical aid such as a fillet, or even -assistance with the fingers of the accoucheur; but, even granting that it -refers to instruments, it might mean no more than, e. g., the embryo hooks -already described. With them, terrible as they were, the child must -frequently have been born alive, though mutilated. A child would have had -a far better chance of being born alive with them than with the -murderously toothed forceps of Albucasis (Pl. XLI, figs. 3, 4), with which -probably no child could have been born alive. As regards the statement -that Avicenna knew of the forceps, his directions are that the fillet is -to be applied, and, if that fail, the forceps is to be put on and the -child extracted with it. If that fail, the child is to be extracted by -incision, as in the case of a dead foetus. This passage, says Adams, puts -it beyond doubt that the Arabians were acquainted with the method of -extracting the child alive with the forceps. - -This is, however, not quite correct. A full consideration of Avicenna's -words seems to me to lead to the conclusion that he is describing no more -than extraction with a craniotomy forceps. If the forceps fail the child -is to be extracted by incision, as in the case of a foetus already dead -(and decomposed so that the forceps would not hold). - -As regards Adams' statement that a forceps like ours was dug up in Pompeii -one may ask, 'Where is that forceps now?' It is certainly not in the -Naples Museum, where all the finds from Herculaneum and Pompeii have been -stored since the excavations were commenced. Adams has probably been -misled by some notice of the 'Pompeian forceps' (Pl. XLIII), which many -consider adapted for removing the cranial bones when the child's head is -broken up in cephalotripsy. It is, however, a sequestrum forceps. - - -_Uterine Curette._ - -Hippocrates (ed. Van der Linden, vol. ii, p. 394) says: - - If the menses form thrombi ... we must wind the skin of a vulture or a - piece of vellum round a curette and curette the os uteri ([Greek: kai - peri xystran perieilixas gypos derma e hymena, diaxyein to stoma ton - metreon]). - -[Greek: xystra] may of course mean the strigil, and some forms of strigil, -such as the one shown in Pl. XXV, fig. 1, are not ill adapted for the -purpose. - - -_Instrument for destroying foetus in utero._ - -Greek, [Greek: embryosphaktes]; Latin, _aeneum spiculum_. - -Apart from the destruction of the foetus in criminal abortion, which was -so common at Rome in the time of the Empire, we have mention of an -instrument for legitimately producing the death of the foetus from humane -motives before forced delivery. It is mentioned by Tertullian in his -sermon _De Anima_, and the passage is so interesting that I give it in -full. It is, moreover, an example of the unexpected places in which -information regarding the surgery of the ancients crops up. Tertullian is -arguing that the foetus is alive in utero, and does not, as others hold, -simply take on life in the act of birth, and to support his conclusions he -uses the following argument: - - Denique et mortui eduntur quomodo, nisi et vivi? qui autem et mortui, - nisi qui prius vivi? Atquin et in ipso adhuc utero infans trucidatur - necessaria crudelitate, quum in exitu obliquatus denegat partum; - matricida, ni moriturus. Itaque et inter arma medicorum et organon - est, quo prius patescere secreta coguntur tortili temperamento, cum - anulo cultrato, quo intus membra caeduntur anxio arbitrio, cum hebete - unco, quo totum facinus extrahitur violento puerperio. Est etiam - aeneum spiculum, quo iugulatio ipsa dirigitur caeco latrocinio; - [Greek: embryosphakten] appellant de infanticidii officio, utique - viventis infantis peremptorium. Hoc et Hippocrates habuit et - Asclepiades et Erasistratus et maiorum quoque prosector Herophilus et - mitior ipse Soranus, certi animal esse conceptum, atque ita miserti - infelicissimae huiusmodi infantiae, ut prius occidatur ne viva - lanietur. - - 'Finally there are cases of children that are dead when they are born, - how so unless they have also lived? For who are dead unless they have - previously been alive? And yet, an infant is sometimes by an act of - necessary cruelty destroyed when yet in the womb, when owing to an - oblique presentation at birth delivery is made impossible and the - child would cause the death of the mother unless it were doomed itself - to die. And accordingly there is among the appliances of medical men - an instrument by which the private parts are dilated with a priapiscus - worked by a screw, and also a ring-knife whereby the limbs are cut off - in the womb with judicious care, and a blunt hook by which the whole - mass is extracted and a violent form of delivery in this way effected. - There is also a bronze stylet with which a secret death is inflicted; - they call it the [Greek: embryosphaktes] (_foeticide_) from its use in - infanticide, as being fatal to a living infant. Hippocrates had this - (instrument), Asclepiades and Erasistratus, and of the ancients also - Herophilus the anatomist, and Soranus, a man of gentler character. - Who, being assured that a living thing had been conceived, mercifully - judged that an unfortunate infant of this sort should be destroyed - before birth to save it from being mangled alive.' - -We have here apparently a different instrument from the embryotome, which -we saw was a form of knife. This is a pointed spike-shaped instrument. It -must have had much the shape of one of the huge bodkins in the Naples -Museum (Pl. LI, fig. 1). - - -_Apparatus for fumigating the Uterus and Vagina._ - -Fumigation formed an important part of the treatment of all varieties of -disease of the uterus and vagina. The notion that the uterus was an animal -within the body which could wander about on its own initiative and which -was attracted by pleasant smells and repelled by disagreeable smells, was -responsible for much of the treatment of gynaecological diseases by the -ancients. To make a fumigation, Hippocrates directs us to take a vessel -which holds about four gallons ([Greek: dyo hekteas]), and fit a lid to it -so that no vapour can escape from it. Pierce a hole in the lid, and into -this aperture force a reed about a cubit in length so that the vapour -cannot escape along the outside of the reed. The cover is then fixed on -the vessel with clay. Dig a hole about two feet deep and sufficiently -large to receive the vessel, and burn wood until the sides of the hole -become very hot. After this remove the wood and larger pieces of charcoal -which have most flame, but leave the ashes and cinders. When the vessel is -placed in position, and the vapour begins to issue out, if it is too hot -wait for some time; if, however, it be of the proper temperature the reed -should be introduced into the uterine orifice and the fumigation made. -Oribasius, quoting Antyllus (_Coll._ X. xix) varies the treatment somewhat -by placing a vessel similarly prepared underneath an obstetrical chair, -which had an opening in the seat, allowing a leaden pipe connected with -the tube of the fumigating vessel to be passed into the vagina. - -A fumigating apparatus of a more portable nature is mentioned by Soranus -(xxiii) who tells us that Strato, a pupil of Erasistratus, used to place -in a small vessel of silver or bronze, closed by a cover of tin, herbs of -various kinds, and, having adjusted a small tube to the vessel, the mouth -of the tube was placed in the vagina, and the vessel was then gently -heated. Soranus admits that severe burning might follow this practice if -unskilfully used. - - -_Pessaries._ - -Greek, [Greek: balanos, pesson, pessos]; Latin, _pessum_, _pessus_, -_pessulum_. - -Pessaries are frequently mentioned. They are usually bags filled with -medicaments and not mechanical supports. However, in ii. 824, Hippocrates -says that prolapse of the womb is to be reduced and the half of a -pomegranate is to be introduced into the vagina. Soranus says that in -prolapse Diocles was accustomed to introduce into the vagina a -pomegranate soaked in vinegar. He also says that a large ball of wool may -be introduced after reduction, and Aetius, Oribasius, and Paul copy him. - -Hippocrates (iii. 331) says that in cases of fistula in ano, after the -introduction of a medicated plug of lint, a pessary of horn is to be -inserted ([Greek: balanon entheis keratinen]). This would appear to be -partly to distend the rectum, but partly also most likely to carry -medicament, like the leaden tubes full of medicaments which were inserted -into the uterus. - -A pessary of bronze was found in Pompeii (Pl. LI, fig. 2), and is -described by Ceci. It is hollow and has a plate perforated with holes -(evidently for stitching it on a band, to fix it round the body). Heister -figures a similar instrument. It is impossible to say whether this -specimen was intended for rectal or vaginal use. - - - - -CHAPTER X - -SUTURES, ETC. - - -_Sponge._ - -Greek, [Greek: spongos]; Latin, _spongia_. - -Sponges were used for many purposes. Paul (VII. iii) says they should be -fresh and still preserve the smell of the sea. They were applied with -water, wine, or oxycrate to agglutinate wounds, and also soaked in asphalt -and set fire to and applied to wounds to stop haemorrhage. - -Galen (_De Simp._ xi) says he has seen haemorrhage stopped by applying a -sponge dipped in asphalt to a bleeding wound and setting fire to it, and -leaving the unburnt part to cover the wound. Celsus says a sponge dipped -in oil and vinegar or cold water relieves gouty swellings. He also -recommends a sponge dipped in vinegar or cold water for stopping -haemorrhage. - -Dioscorides says that fistulae may be dilated with sponge tents. - -Scribonius Largus says that in epistaxis the nose may be plugged with -sponge: - - Proderit et spongeae particulam praesectam apte forfice ad - amplitudinem et patorem narium figuratam inicere paulo pressius ex - aceto per se (xlvi). - -Soranus (xli) says haemorrhage from the uterus may be stopped with a -sponge tent: - - [Greek: Hopote trypheron kai katharon spongarion epimekes hosautos - diabrochon hos esotato parentithenai prosekei.] - - -_Sutures._ - -Celsus (V. xxvi) says sutures should be of soft thread not overtwisted -that they may be the more easy on the part: 'Ex acia molli non nimis -torta quo mitius corpori insidat'. They were made of flax. The apolinose -described by Hippocrates (iii. 132) is directed to be made of crude flax -([Greek: omolinou]), the strands of which were stronger than those of -dressed lint. This also is what Paul used for the deligation of arteries. - -Galen alludes to sutures of wool, and Paulus Aegineta in the operation for -ectropion says: - - 'Afterwards we unite the divided parts with a needle carrying a - woollen thread, being satisfied with two sutures.' - -We have no mention of catgut being used for this purpose, though that -substance was early known to the Greeks. The Homeric harp was strung with -catgut. In fact [Greek: chorde], the term for harp-string, simply means -intestines. Paul used a woman's hair in a needle to transplant hairs in -trichiasis (VI. xiii). Horsehair was used to raise a pterygium in Paul VI. -xviii, but it is not mentioned as being used for suturing wounds. - - -_Serres Fines._ - -Greek, [Greek: ankter]; Latin, _fibula_. - -Celsus (V. xxvi) in describing the closing of wounds says: - - Nam si plaga in molli parto est, sui debet, maximeque si discissa - auris ima est, vel imus nasus, vel frons, vel bucca, vel palpebra, vel - labrum, vel circa guttur cutis, vel venter. Si vero in carne vulnus - est hiatque, neque in unum orae facile attrahuntur, sutura quidem - aliena est; imponendae vero fibulae sunt; [Greek: ankteras] Graeci - nominant; quae oras paulum tamen contrahant, quo minus lata postea - cicatrix sit. - - 'Suture is indicated if the lesion is in a soft part, especially in - the lobule of the ear, or the ala nasi, or the forehead, or cheek, the - edge of the eyelid, or the skin over the throat, or the abdominal - wall. But if the wound is in a muscular part and gape, and the edges - cannot easily be opposed, suture is contraindicated, and fibulae - (Graece [Greek: ankteras]) are to be used in order that the cicatrix - afterwards may not be wide.' - -We have here contrasted two methods of closing a wound, and the conclusion -is readily arrived at that sutures in the first case and some metal -contrivance in the second are intended. Celsus goes on to say, however: - - Utraque optima est ex acia molli, non nimis torta, quo mitius corpori - insidat. Utraque neque nimis rara, neque nimis crebra iniicienda. - - 'Both are best made of soft thread, not too hard twisted that it may - sit easier on the tissues, nor are too few nor too many of either of - them to be put in.' - -A consideration of various passages in which the Greek authors use the -term leaves a distinct impression on one's mind that a metal clasp is -intended. Thus Paul (VI. cvii), in treating of compound fractures, says -that if a large portion of the bone is laid bare we use fibulae and -sutures ([Greek: anktersi kai rhaphais]). It must be confessed, however, -that the words of Celsus render it difficult for us to assert with -certainty that fibulae were metal clasps, and we find ancient commentators -in equal difficulty. Fallopius and Fabricius d' Aquapendente think fibulae -mean interrupted sutures. Guido de Cauliac thinks they mean metal clasps. -There is just the possibility that a contrivance like our harelip pin with -a figure of eight thread may be indicated. This would satisfy both sides -of the question. If fibulae were metal clasps, however, we have several -varieties of ancient fibulae that might have been used for closing wounds. -That most suited for the purpose in hand seems to me to be one consisting -of a small bar terminating in two hooks. Several of these from Roman -London are in the Guildhall Museum (Pl. LII, figs. 5, 6, 7). They -represent a useful form of 'clip' still in use by cyclists, and they could -be applied to wounds to act on the principle of Malgaigne's hooks for the -patella. A modicum of support for this view may be derived from the fact -that whereas Galen, from whom the above passage on compound fractures is -quoted by Paul, uses the word [Greek: anktersi], the codices of Paul -almost unanimously have [Greek: ankistrois]. Fourteen out of fifteen give -the latter rendering. - - -_Band of Antyllus._ - -In the interesting dissertation which Oribasius gives on the subject of -phlebotomy (_Med. Collect._ vii) he states that Antyllus directs us to -apply a ligature of two fingers' breadth round the arm when going to let -blood at the elbow. He says that they are mistaken who affirm that the -same effect may be produced by applying the band below, for the veins will -not then swell even if the arm be fomented. When going to bleed at the -ankle the ligature is to be applied at the knee. When the blood does not -flow well he advises us to slacken the bandage if too tight. This is the -famous 'band of Antyllus'. - -It is mentioned also in the pseudo-Hippocratic treatise on Ulcers (iii. -328): - - 'When you have opened the vein and after you have let blood and have - loosened the fillet ([Greek: tainian]) and yet the blood does not - stop.' - -Paul also mentions the band, including one round the neck when the veins -of the forehead are to be opened for ophthalmia. So far as we know the -fillet was nothing more than a plain strip of linen or some such material, -but Deneffe, commenting on two bronze fibulae which were found in the -grave of the surgeon of Paris, conjectures that they may have been used to -fix the fillet in venesection. I give figures of these after Deneffe, but -it seems to me that these buckles are more likely to have belonged to the -straps of a portable instrument-case of canvas or leather which had -disappeared. One is a neat little heptagonal fibula, 2.8 cm. in its widest -part, with a tongue 27 mm. long (Pl. LII, fig. 2). The other fibula is in -the form of a penannular ring, formed by a two-headed serpent curved on -itself so that the two heads look at each other, separated from each other -by a space of a few millimetres (Pl. LII, fig. 8). Opposite the heads -there is a small rectangular opening to receive the end of the strap. -There is no tongue. It may have been fixed by a metal bar attached to the -other end of the strap. - - -_Sieves and Strainers._ - -Greek, [Greek: ethmos, kyrtis]; Latin, _cribrum_. - -Scribonius Largus mentions sieves of different sizes. In ch. xc a small -one is mentioned: - - Contunditur hic cortex per se et cribratur tenui cribro. - -In other places larger sizes are mentioned: - - In his macerantur res quae infra scriptae sunt, contusae et - percribratae grandioribus foraminibus cribri (cclxix). - -Marcellus (_De Medicamentis_, xxxiii. 9) says: - - Pulverem facito, et cribello medicinali omnem pulverem cerne et - permisce, et cum vino vetere calefacto locum inline. - -There are large numbers of sieves and strainers in bronze and earthenware -in the Naples Museum. - -Paul (VII. xx) says oil of sesame is to be prepared from sesame pounded, -softened, and pressed in a strainer with screws ([Greek: dia kyrtidon ton -kochlion]). The word [Greek: kyrtis] literally means a basket or wicker -eel-trap. Here it must mean a strainer. - - -_Mortar and Pestle._ - -Greek, [Greek: igdion], mortar: [Greek: doidyx], pestle; Latin, -_mortarium_, _pilum_. - -In the find of the oculist Severus is a bronze dish which Deneffe regards -as a mortar. It is 8 cm. in diameter and 3.5 deep, and rests on a base of -3 cm. diameter, so that it sits firmly. Marcellus (_De Medic._ i) mentions -a mortar of marble: - - Haec universa conteres in mortario marmoreo, et aceto admixto fronti - inlines. - -He also mentions one of wood: - - Huius radicem colliges et findes in partes duas, quarum unam siccabis - ac minutatim concides et mittes in pilam ligneam atque illic - diligenter tundes (xxiii). - -Scrib. Larg. speaks of pestles of wood: - - Hoc medicamentum cum componitur pilum ligneum sit (clii). - -In Paul we have a mortar of lead and a leaden pestle mentioned several -times: - - [Greek: En molybdino igdio kai molybdino doidyki leiosas.] - - 'Triturate ceruse with wine and rose oil in a leaden mortar with a - leaden pestle and anoint with it' (III. lix). - -Galen (_De Simpl._ x) speaks of bronze mortars: - - 'Wherefore, some call only the natural mineral by this name, but some - also the substance which is prepared in a bronze mortar with a copper - pestle by means of the urine of a boy, which some value according to - the differences of the verdigris. But it is better to prepare it in - summer, or at least in hot weather, rubbing up the urine in the - mortar, and it answers the more excellently if the bronze of which you - make the mortar is red and the pestle too, for more is thus rubbed off - by the turning of the pestle when the bronze is of a softer nature.' - -Paul mentions a mortar of marble. A small mortar of bronze was found -amongst the instruments of the surgeon of Paris. Another small one from my -own collection is shown in Pl. LII, fig. 3. The excavation of the temple -of Aesculapius in the forum has brought to light a large number of mortars -of marble. They are mostly about six or seven inches in diameter, but are -much deeper in proportion than our modern mortars are. The spathomele and -other olivary probes were no doubt often used as small pestles. - - -_Whetstone._ - -Greek, [Greek: akone]; Latin, _cos_. - -We saw that several of the slabs on which ointments were prepared had -evidently been used for sharpening knives, and whetstones are often found -of varying degrees of roughness from sandstone to fine argillaceous smooth -stones. Paul (VII. iii) says: - - [Greek: To ge men tes Naxias akones apotrimma psyktikon einai phasin - hoste kai titthous parthenon kai paidon orcheis prostellein. tes - elaiakones de to apotrimma rhyptikon hyparchon alopekiais harmottei.] - - 'The filings of the Naxian whetstone are said to be refrigerant, - repressing the breasts of maidens and the testicles of boys. The - filings of the oilstone being detergent suit with alopecia.' - -It is uncertain what the Naxian whetstone was, but it was considered the -best variety of whetstone. It is mentioned in Pindar. From the fact that -emery is found in Naxos one might conclude that the Naxian whetstone was -of emery, but a few lines before the passage quoted from Paul he has -already mentioned the emery: - - [Greek: He de smyris rhyptiken echousa dynamin odontas smechei.] - - 'The emery having detergent powers cleanses teeth.' - -Galen makes the Naxian stone a variety of ostracites which was apparently -marble formed of shells. One of the marble ointment tablets had, we saw, -been used as a whetstone, but the whetstones for which Naxos was famous -must, if not emery, have been some variety of shale or slate. It seems -contrasted to some extent with the 'oilstone', i. e. whetstone which -required oil. This was a clay slate (see Pliny, _H. N._ xxxvi. 47). - -There are several whetstones from Stabiae in the Naples Museum which are -classed among surgical implements. Whetstones are common objects in the -finds from any Roman settlement, but they are not ground to regular shapes -as our whetstones are. They usually consist of fine sandy schistaceous -shale. - - - - -CHAPTER XI - -ETUI, ETC. - - -_Portable Outfit._ - -After describing the larger apparatus necessary for the equipment of the -surgery, Hippocrates mentions a portable equipment for use on journeys: - - 'Have also another apparatus ready to hand for journeys, simply - prepared, and handy too by method of arrangement, for one cannot - overhaul everything' (i. 72). - -The component parts of this portable outfit so far known to us are as -follows: - -The scalpels of different shapes seem to have been carried in boxes, -probably wooden, which opened in two halves like a modern mathematical -instrument box. In these the scalpels lay head and tail, separated from -each other by small fixed partitions. A box of scalpels of this kind is -represented in a marble votive tablet which was found on the Acropolis on -the site of the Temple of Aesculapius. A similar box with different -instruments is seen in a donarium in the Capitoline Museum. The probes and -forceps were carried in cylindrical cases like those in which the scribes -carried their pens. A good many of these have come down to us. From the -fact that in the grave of the surgeon of Paris there were found two -buckles, it is probable that there had been buried along with the -instruments a case of leather or some such perishable material, which had -been used to contain instruments, but which had disappeared when the grave -was opened. There have also been found boxes of various shapes for -containing medicaments, cylindrical boxes for drugs in sticks, boxes -divided into little partitions for drugs in semi-solid form, and other -boxes for powders. - - -_Portable Probe Cases._ - -The spatulae, sounds, hooks, and forceps were carried about in a -cylindrical case of bronze. Several of these etui have been found -containing instruments. They average 18 cm. in length and 1.5 cm. in -diameter. The lid lifts off. One in the museum at Lausanne was found in a -Roman conduit at Bosseaz and contained a cyathiscomele of the usual type -(Bonstetten, _Recueil des Antiqq. Suisses_, pl. xii, figs. 11 and 12). A -case exactly similar to the above containing a cyathiscomele and a toothed -vulsellum was found in the Rhine Valley. Another case of the same kind was -found at Bregenz. It contained a long ligula, a spathomele, a -cyathiscomele, and a double olivary probe. - -In the Naples Museum are four of these cases, three of which were found in -Pompeii and one in Herculaneum. One of these is a plain cylindrical case -18 cm. long and 1.5 in diameter. It contained instruments (Pl. LIII, fig. -1). Another case is ornamented with raised rings. It was found in the -House of the Physician, and contained six specilla of different kinds and -a vulsellum. A third is of similar size and shape, but it is considerably -destroyed by oxidation, and it is adherent to a rectangular slab of black -stone which had been used for mixing medicaments. Through the cracks in -the case there may be seen the probes which it contains. The case from -Herculaneum is a plain cylindrical case 19 cm. long and 2 cm. in diameter. - -Lately, several other cases have been found in Italy which are placed in -the Naples Museum. One in a fragmentary condition showing its contents is -seen in Pl. LIII, fig. 2. - -In the Musee de Cinquantenaire, Brussels, there is one of these cases -which was brought by M. Ravenstein from Italy. It contained three -instruments all of silver, a cyathiscomele, a grooved director, and a -plain double-ended stylet. It is 18 cm. long and 1.5 in diameter. - -A fragment of a similar case was found in the Roman Hospital at Baden. - - -_Box for Scalpels._ - -Among the ruins of the Temple of Aesculapius on the top of the Acropolis -at Athens there was found a marble donarium or votive tablet, which -represents a box of scalpels flanked by a pair of bleeding-cups. - -The box reminds one of a modern box for mathematical instruments, being -divided into a top and bottom half, each of which contains instruments -separated from each other by small blocks. There are three instruments in -each half and they are arranged head and tail. Five are scalpels of -different shapes; the sixth has a curved cutting instrument at one end and -at the other a lithotomy scoop. The size of each half of the box is 9 x 18 -cm. outside measurement, and 7 x 16.5 cm. inside. See Pl. IV. - -A similar box is seen in a marble tablet in the Capitoline Museum at Rome. -Here the instruments are different. - - -_Ointment Boxes._ - -Among the instruments of the surgeon of Paris was a box which Deneffe -regards as a portable unguentarium. Unlike the medicament boxes it is not -divided into compartments and the lid lifts off instead of sliding in -grooves. It is 83 mm. long, 45 wide, and 35 deep. A line running round the -middle of the box divides it into two equal parts and shows the division -between cover and box. On the top is a little ring attached by a little -pyramidal eminence 1.5 cm. high by which the cover was lifted off. Several -circular ointment boxes, some containing medicaments, are to be seen in -the Naples Museum. - - -_Collyrium Boxes._ - -A large number of cylindrical boxes containing sticks of medicament have -been found in Pompeii. In the find of the oculist of Rheims there were -five cylindrical boxes, all of the same size and shape. They were 14 cm. -long and 12 mm. in diameter. The covers are 35 mm. high. In them were the -remains of sticks of collyria which they had contained. The term collyrium -includes in classical writings not only liquid but also solid -applications. Collyria were often moulded into sticks for portability, and -liquefied with water, wine, white of egg, &c., as required. These boxes -which have come down to us are exactly similar to the case shown in Pl. -LIII, but they are on a smaller scale. - - -_Slabs for preparation of Ointment._ - -In the Roman provinces small rectangular slabs are occasionally found -which have evidently been used for rubbing medicaments upon. Some have -also their edges worn by the sharpening of scalpels. As they are rarely of -the stone of the country in which they are found they have evidently been -manufactured in Italy and carried by their owners on their travels. They -are rather rare. There are two in the museum at Naples. One was discovered -in Herculaneum which is 13 cm. long and 8 cm. broad. A cylindrical -instrument case is adherent to it. The edges are bevelled on its upper -surface. One of similar size and shape, but made of white marble, was -found in the grave of the surgeon of Paris. It shows by the hollowing out -of one of its edges that it has been used for sharpening scalpels. - -There are two in the Archaeological Museum at Namur. They are of black -marble. They measure 11 cm. by 7.5, but a bevelling of .75 cm. all round -reduced the top surface to 9.5 cm. by 6. One of these was found along with -surgical instruments in a second-century cemetery at Wancennes near Namur. - -There is one of a dark-coloured stone in the museum at Chesters, -Northumberland. A small specimen of my own is shown in Pl. LII, fig. 4. -Similar small slabs, engraved with oculists' names and the names of drugs -to serve as seals, have been found in considerable numbers, but these -oculists' seals have already an extensive literature of their own. - - -_Boxes for Drugs._ - -A considerable number of medicament boxes have been found. They are -usually of bronze, rectangular and of a convenient size and weight for -carrying in the pocket. In size they average 12 cm. in length by 7.5 in -breadth and 2 in height. As a rule they are divided into four or more -small divisions by partitions. Those reported are as follows: - -There are two in the Royal Antiquarian Museum at Berlin. Of these, one was -found in the Rhenish country between Neuss and Xanten. It is of bronze. -Inlaid with silver on its sliding cover is the figure of Aesculapius -standing in a small temple. - -The second, of similar construction and appearance, was brought by -Friedlander from Naples and presented by him to the museum. - -A third, in the museum at Mainz, was found in the Rhine while dredging -near the town. It is of bronze, 10 cm. long, 8 wide, 2 in height. It -weighs 123 grammes. The sliding lid is decorated with the snake of -Aesculapius, twisted round the stem of a laurel tree. The tree and the -body of the snake are formed by inlaying copper in the bronze. The outline -of the head of the snake and the scales of the body are of silver. On -withdrawing the lid the interior is seen to be divided into four -compartments each shut by a little hinged lid, which may be lifted by -means of a little ring. Two of these compartments are 6 cm. by 3, the two -others are 4 cm. by 3. - -In the Naples Museum there are three of these boxes. They are all of -bronze and divided into compartments. One is divided into five -compartments. It is 18 cm. long by 8 wide and 2 deep. Of the compartments -three are 8 cm. by 2 and two are 5 cm. by 3. There is at the upper end of -the box a small handle by which to carry it. Another box is 13 cm. by 7.5. -On removing the lid it is seen to be divided into six compartments, two of -which have hinged lids of their own, like the Mainz box. These -compartments still contain medicaments (Pl. LIV). - -The third of the Naples boxes is of an unusual type. It is 12.5 cm. by -7.5, but it is 3 cm. high and is divided into an upper and a lower -division each 1.5 cm. deep. Each division has a sliding lid of its own. -The upper division is separated into four compartments, two of which are 7 -cm. by 2 and two are 4 cm. by 2. The lower stage occupies the whole area -of the box. - -A medicament box of a unique character was in use in a chapel as a -reliquary till its original use was pointed out. It is of ivory, and -carved on its sliding lid is a representation of Aesculapius and his -daughter Hygeia. Aesculapius carries in his left hand a staff, round which -is coiled a snake, and in his right a pine cone. Hygeia carries a snake in -her right hand, and in her left a bowl from which she feeds the snake. The -execution of the design shows the box to belong to the third century. The -box is divided into eleven compartments. It is now in the Castle Valeria -at Sitten. - - - - -APPENDIX - - -I. INVENTORY OF CHIEF INSTRUMENTS IN VARIOUS MUSEUMS - - -ENGLISH MUSEUMS. - -The _British Museum_ contains the following (Case ii. B): - -Bleeding cup (No. 2313); collyrium spoon with spout (two, Nos. 2314-5); -staphylagra (two, Nos. 2316-7); hook, sharp (No. 2318); ditto blunt, i. e. -retractor (No. 2319); forceps (No. 2320); two-pronged retractors (Nos. -2322-6); scarifier (No. 2327); knife, steel (No. 2321); scalpel handles -(Nos. 2331-9); spathomeles; cyathiscomeles; spatulae; ligulae; ear -specilla; aneurism needle (No. 2372); epilation forceps (narrow), ditto -(broad), ditto ditto with catch. - -The Guildhall Museum contains a good few instruments found in London, -amongst others a considerable number of ear specilla, vulsella, lancets, -and numberless instruments common to both domestic and surgical use, such -as strigils, ligulae, styli, and needles. The Celtic cutting instruments -are of interest for comparison. This collection is in many ways one of the -most interesting we have in England. - -The museum at Shrewsbury contains several surgical instruments from the -ancient Roman city of Uriconium on which Wroxeter now stands. The most -interesting is a bleeding lancet. There are also styli and an ointment -slab and the seal of an oculist. - -The museum at Chesters, Northumberland, containing finds from the Roman -camps at Cilurnum, Procolitia, Borcovicus, and other sites on the Roman -Wall, contains amongst other things hooks, spatulae, bougie, a triangular -medicine weight of tin, forceps, needles of bone and bronze, borers, knife -blades, ear specilla, steelyard, counterpoises, many in the form of snakes -and therefore, perhaps, for pharmaceutical purposes, the serpent being the -symbol of Aesculapius. - - -MUSEUMS IN FRANCE. - -_Saint-Germain-en-Laye._ Outfit of Severus, viz. two iron pitchers, four -bowls, mortar, two balances, seven forceps, one spathomele, scalpel -handle, ditto damascened, spatulae (two), two knife-and-needle handles, -four needle handles, olive-and-needle, scalpel-handle-and-borer, three -sharp hooks, blunt and sharp hook, small blunt hook, seal. Also four -scalpel handles, forty forceps, four pocket companions with forceps, fifty -bodkins and needles, thirty-three ligulae, fourteen spathomeles, thirty -cyathiscomeles, twelve olivary probes. - -_Le Puy-en-Velay._ Outfit of Sollemnis, viz. two knife-handles, ditto -damascened, amulet, fragments of two forceps, seal, spathomele. - -_Paris._ Private museum of M. Tolouse. Instruments from the grave of the -Surgeon of Paris--Large bronze bowl which contained: - -1, Marble slab for preparing ointments; 2, amulet of black obsidian; 3, -bronze ointment box with silver damascening; 4, 5, 6, 7, 8, five -cylindrical boxes for collyrium sticks; 9, 10, two buckles; 11, pharyngeal -insufflator; 12, collyrium spoon; 13, 14, 15, three spathomeles; 16, 17, -probes; 18, polypus forceps and scoop; 19, 20, epilation forceps; 21, 22, -vulsella (toothed); 23, staphylagra; 24, 25, coude vulsella; 26, -spathomele of elegant form; 27, bleeding cup; 28, three-pronged fork. - -_Louvre Museum._ Double curette, cyathiscomele, ear probe, stylet with -large olivary point, forceps with olivary point. - -_Cluniac Museum._ Scoop probe, scalpel. - -_Orfila Museum._ All from Herculaneum. Ligula, ear scoop, two raspatories, -hook and scoop, scalpel, fork and hook, curette and hook, bodkin. - -_Montauban Museum._ (Tarn-et-Garonne.) Large surgical needle, -cyathiscomeles (four), spathomele (one), scoop and spatula (steel), -epilation forceps (one), four ear specilla, round spatula, bistoury -handle, all from Cosa. - -_Rouen._ Four epilation forceps, one small forceps with locking -arrangement, one forceps with narrow rounded legs, one fine-toothed -forceps, twelve cyathiscomeles, three needles and bodkins, twenty styloid -instruments, three ligulae. - -_Amiens._ Round scalpel handle with spiral lines, one large epilation -forceps, one spud and probe, one blunt hook, one styloid probe, two -spathomeles, six cyathiscomeles. - - -MUSEUMS IN BELGIUM. - -_Namur._ Find of Surgeon of Wancennes, including ointment slab (Deneffe). - -_Brussels._ Mus. de Ravenstein _alias_ Cinquantenaire. Etui with silver -specilla brought from Italy by M. Ravenstein; three specilla; scalpels. - -_Charleroi._ Fine bistoury. - - -MUSEUMS IN GERMANY. - -_Mainz_ (Germano-Roman Museum). Spatula-probe, medicine box, staphylagra, -four bleeding-cups. - -_Frankfort_ (Historical Museum). Four epilation forceps with sliding -catch, two ligulae. - -_Kiel._ Forceps of silver. - -_Cologne._ Chisel, two forceps, pestle, phlebotome. - - -MUSEUMS IN AUSTRIA. - -_Vienna._ Staphylocaustus. - - -MUSEUMS IN GREECE. - -_Athens._ Six knives (four from tomb in Milos, two from tomb in Tanagra); -forceps and porte-caustic, large cup and chain (Tanagra); ex-voto tablet -from Acropolis, representing box of scalpels and two cups, twenty-four -spathomeles, one trivalve vaginal speculum. - - -MUSEUMS IN DENMARK. - -_Copenhagen_ (Thorwaldsen). Two epilation forceps, one ditto with leaf -shaped ends and catch, three spoon probes, one spatula probe. - - -MUSEUMS IN SWITZERLAND. - -The instruments from the Roman hospital at _Baden_, now in the Baden -Museum, have already been summarized (page 22). Instruments in other -museums in Switzerland are: - -_Basel Augst._ (Augusta Rauracorum). Uvula forceps, probe, spoon-probe. - -_Avenches._ Broken uvula forceps, two vulsella, spatula of bronze plated -with silver, probes, needle. - -_Yverdon._ Probes. - -_Bern._ Two probes from Hermance, forceps and spatula probe from Tiefenau. - -_Lausanne._ Spoon probe from Bosseaz and Allaz. Etui for probes, seal for -medicament pots, vulsella. - -_Sierre._ Four spoon probes, spatula probe, large needle. - -_Schaffhausen._ Probe from Schleitheim. - -_Zuerich_ (Landesmuseum). A. Fifteen specilla (spathomeles) all with a -sharp-edged long and narrow spoon at one end and at the other an elongated -knob; length 130-160 mm.; seven from Galgenbuck in Albisrieden, seven from -Windisch, one from Upper Italy. B. Small bronze instrument probably for -extracting weapons from wounds; present length 110 mm. (Naples). C. -Probably a spatula for applying plaster (Athens). D. Ear spoons (three) of -bone, 80-130 mm. long (two from Rome, one from Athens). E. Small bronze -spatula, 125 mm. (Athens). F. Similar one of bone, 110 mm. (Windisch). G. -Rod pointed at both ends, 155 mm. long (Zuerich). H. Bronze rod with a -depression 30 mm. long in the middle, 225 mm. long (Windisch). - - -MUSEUMS IN ITALY. - -_Naples._ Bleeding-cups (fourteen), spoons with bone handles (two), lancet -and spoon, shears (bronze), fleams (veterinary), cannulae for ascites -(two), bone elevators (two), catheter (one male, one female), bone -forceps, specula uteri, trivalve and quadrivalve, speculum ani, toothed -forceps, cauteries (three), needles, tongue tie guard, enema tube, probes, -whetstones, etui, scalpels, medicament boxes, balances, ointment slabs. - -_Rome, Capitoline Museum._ Curved double olivary probe, four spathomeles, -four cyathiscomeles, thirty-six forceps toothed and plain, bodkins (four) -eight cm. in length, three ear specilla, four ascites tubes, large -scalpel, votive tablet with box of instruments. - -_Rome, Lateran Museum._ Votive tablet representing forceps and other -instruments. - -_Milan._ Many knife blades, two bodkins, spathomele, two ligulae, scoop -and curette, olive and stylet. - - -II. BIBLIOGRAPHY - -CHOULANT.--De rebus Pompeianis ad medicinam facientibus. Leipzig, 1823. - -KUEHN.--De instrumentis chirurgicis veteribus cognitis et nuper effossis. -Leipzig, 1823. - -In 1846-7 Benedetto Vulpes made a series of communications to the Royal -Academy of Archaeology at Herculaneum as follows:-- - -(1) Illustrazione di un forcipe Ercolanese a branche curve. (March 3, -1846.) - -(2) Memoria concernente la interpretazione dell' uso di un forcipe -Ercolanese di bronzo con le estremita delle branche a semi-cucchiai -dentellati: la illustrazione di due cannelli di bronzo anche trovati in -Ercolano, de' quali servivansi gli antichi per cavar l'acqua dall' -addomine degl' idropici: l'indicamento di tre cannelli Pompejani di -bronzo. (April 28, 1846.) - -(3) Illustrazione degli specilli e di altri strumenti chirurgici affini -trovati negli scavi di Ercolano e di Pompei. (September 15, 1846.) - -(4) Descrizione dello speculum magnum matricis e dello speculum ani. -(November 24, 1846.) - -(5) Delle pinzette, degli ametti, degli aghi chirurgici e del tridente -scavati en Ercolano e in Pompeii. (December 1, 1846.) - -(6) Illustrazione degli strumenti chirurgici di ferro trovati in Ercolano -e in Pompeii. (January 19, 1847.) - -In March, 1846, Quaranta made a communication to the same Society -entitled 'Osservazioni sopra nu forcipe Pompeiano', in which he expressed -a different opinion from that held by Vulpes, and pointed out that the -forceps described by the latter in his first communication was found in -Pompeii. This is the famous forceps which is always referred to as the -'Pompeian Forceps'. - -These valuable papers of Vulpes and Quaranta were published in vol. vii of -the _Memorie della Regale Academia Ercolanese di Archeologia_. These -articles are profusely illustrated. In 1847 Vulpes gathered these papers -together, and with some slight alterations published them under the title -of 'Illustrazione di tutti gli instrumenti chirurgici scavati in Ercolano -e in Pompeii'. - -At the time when Vulpes wrote there were in the Museum among other things -45 probes of various kinds, upwards of 90 forceps, 13 bleeding-cups of -bronze, and 16 scalpels. - -VACHER.--Les instruments de chirurgie a Herculanum et Pompei. (_Gazette -Medicale_, 1867, xxii. pp. 491-94.) - -SCOUTETTEN.--Histoire des instruments de chirurgie trouves a Herculanum et -a Pompei. (_France Medicale_, Paris, 1867, xiv. p. 483.) - -OVERBECK.--Pompeji, 1884, p. 461. - -Museo Borbonico, Vol. xiv. Pl. 35, Vol. xv. Pl. 23. - -CECI.--Piccoli bronzi del Museo Nazionale di Napoli. - -NEUGEBAUER.--Warsaw Medical Transactions, 1882. - -NEUGEBAUER.--Ueber Pincetten alter Voelker. (Korrespondenzblatt der -Deutschen Anthropologischen Gesellschaft, 1884, No. 11.) - -HAESER.--Lehrbuch der Geschichte der Medicin, 1875, p. 499. - -GUHL and KOHNER.--Life of the Greeks and Romans, 1862, p. 296. - -MONACO.--Guide General du Musee National de Naples. (Naples, 1900.) - -MONACO.--Les monuments du Musee National de Naples. - -MONACO.--Specimens of domestic articles from the Naples Museum (Naples, -n.d.). - -LINDENSCHMIDT.--Die Altertuemer unserer heidnischen Vorzeit, Bd. iv. Heft -iii. - -Anzeiger fuer schweizerische Geschichte and Altertumskunde, Jahrgang 1857, -No. 3. - -ULRICH.--Jahrbuecher des Vereins fuer Altertumsfreunde in den Rheinlaenden, -xiv. 1849. - -ULRICH.--Catalogue of the Collection of the Antiquarian Society of Zuerich -(now placed in the Landesmuseum). Pt. I. Roman and Pre-Roman, by R. -Ulrich, Conservator. (Published by Ulrich & Co., 1890, p. 140, pl. 1037.) - -BRUNNER.--Die Spuren der roemischen Aerzte auf dem Boden der Schweiz. -(Zuerich, 1894.) - -ANONYMOUS.--Un hopital militaire romain. Zuerich. (A sketchy pamphlet -published as an advertisement by the town of Baden.) - -Mitteilungen der Antiquarischen Gesellschaft, Zuerich.--References of -interest occur in the following volumes: vol. vii, Meyer, Geschichte der -XI. und XXI. Legion; vol. ix, Mommsen, Die Schweiz in roemischer Zeit (15); -vol. xii, Die roemischen Ansiedelungen in der Ostschweiz (19. M. B.); vol. -xiv, Bochat, Recherches sur les antiquites d'Yverdon; vol. xvi, Roemische -Alterthuemer aus Vindonissa; Roemische Ansiedelungen in der Ostschweiz, ii; -vol. xvi, Bursian, Aventicum Helvetiorum, Mosaikbild von Orbe. - -TOLOUSE.--Recherches historiques et archeologiques sur divers points du -vieux Paris (Memoires de la Societe Dunkerkoise pour l'encouragement des -Sciences, des Lettres et des Arts, 1885). - -HAESER.--Lehrbuch der Geschichte der Medicin, 1875. - -FREIND.--History of Physick from the time of Galen to the beginning of the -Sixteenth Century, 1725. - -DAREMBERG.--Histoire des sciences medicales, 1870. - -MCKAY.--History of ancient Gynaecology, 1901. - -LAMBROS.--[Greek: Peri sikyon kai sikyaseos para tois archaiois.] Athens, -1895. An exhaustive monograph with many illustrations of ancient cups. - - - - -I. INDEX OF SUBJECTS - - - Abaptista, 129. - - Abortion, artificial, 81. - - Acanthobolus, 100. - - Aesculapius, 19, 172. - - Aetius, 4. - - Albucasis, 8. - - Alexander Trallianus, 6. - - Ali Abbas, 8. - - Amputation, 125, 130. - - Antyllus, band of, 36, 164. - - Aretaeus, 3. - - Arrow scoop of Diocles, 142. - - Ascites cannula, 112. - - Aspiration syringe, 109. - - Avicenna, 8. - - - Bellied scalpel, 27. - - Bellows, 108. - - Bistoury, blunt-pointed, 30. - curved, 43, 48. - probe-pointed, 43. - sharp-pointed, 28. - - Blacksmith's bellows, 108. - tongs, 136. - - Bladder calculus, 145, 146. - sound, 145. - - Blepharoxyston, 71. - - Block, 125. - - Blowpipe, 25. - - Bodkin, 76, 158. - - Bone, 17. - forceps, 135. - lever, 133. - - Bougie, 145. - - Bow drill, 127. - - Box, collyrium, 170. - drug, 172. - ointment, 170. - scalpel, 170. - - Boxwood cautery, 120. - - Brass, 14. - - Bronze, 14. - - Buckle, 164. - - - Caelius Aurelianus, 4. - - Calculus, bladder, 40, 135, 145, 146. - urethral, 64, 145, 147. - - Cannula for ascites and empyema, 112. - for rectum and vagina, 113. - - Case, instrument, 164, 168, 169, 170. - - Cataract needle, 69. - - Catgut, 162. - - Catheter, 143. - - Caustic forceps for haemorrhoids and uvula, 99. - spoon, 89. - - Cautery, 116. - - Celsus, 2. - - Cephalotribe, 155. - - Chair, obstetrical, 159. - - Chisel, 122. - - Clyster, 105. - - Copper, 14, 58. - - Couching needle, 69. - - Cranioclast, 154. - - Craniotome, 43. - - Crowbill, 43. - - Crusher, pile and uvula, 97. - - Cupping vessel, 101. - - Curette, 62, 65. - uterine, 157. - - Curved bistoury, 43, 48. - - Cuttlefish bone, 72. - - Cyathiscomele, 61. - - - Damascening, 17, 25, 133, 172. - - Decapitator, 154. - - Deities, 19, 172. - - Depilation, 90. - - Dilator, rectal, 149. - uterine, 81. - vaginal, 150. - - Diocles, scoop of, 142. - - Dioscorides, 7. - - Dipyrene, 56. - - Director, grooved, 73. - - Dissector, 60, 84, 85. - - Donarium, 26, 147, 168, 170. - - Douche, aural, 110. - bladder, 108. - rectal, 106. - uterine, 107. - vaginal, 107. - - Drill, 126. - with guard, 129. - - - Ear probe, 63, 68. - syringe, 110. - - Electrum, 16. - - Elevator, bone, 133. - periosteal, 140. - tooth, 72, 134, 138. - - Embryo hook, 152. - killer, 157. - - Embryotome, 43. - - Empyema, 27, 33, 112, 117, 132. - of lachrymal sac, 44. - - Enema, 106. - - Entropion, 55. - - Epilation forceps, 90. - - Etui, 168. - - Excavator, dental, 138. - - - Fibula, 162, 164. - - File, 139. - - Fillet, 36, 156, 164. - - Finds, 20. - - Fistula knife, 47. - - Forceps, blacksmith's, 136. - bone, 135. - coudee, 96. - epilation, 90. - for applying caustic to piles and uvula, 98. - for crushing foetal cranium, 154. - for crushing piles and uvula, 97. - lithotomy, 147. - midwifery, 155. - pharyngeal, 100. - polypus, 93. - Pompeian, 135. - stump, 136. - tooth, 135, 136, 140. - tumour, 94. - uvula, 97. - varix, 135. - weapon, 139. - with sliding catch, 92, 96. - - Fraenum guard, 62. - - Fumigation, uterine, 158. - - Fungi as cautery, 120. - - - Galen, 3. - - Gold, 15. - - Gouge, 123. - - Granular lids, curette for, 71. - - Grooved director, 73. - - - Haemorrhoids, crusher for, 98. - forceps for applying caustic to, 99. - - Hammer, 125. - - Handled needles, 69. - - Haussa surgeon, 13. - - Heister, 8. - - Hemispathion, 38. - - Hernia, 49, 118. - - Hero of Alexandria, 7, 104, 109. - - Hippocrates, 1. - - Honain, 8. - - Hook, blunt, 87. - eyed, 88. - lithotomy. 146. - sharp, 85. - traction, 152. - - Horn, 16. - - Hospital at Baden, 22. - - Hygeia, 19, 173. - - Hypospathister, 140. - - - Impellent, 141. - - Inlaying, 17, 25, 133, 172. - - Iron, 10. - - Iscae, 120. - - Ivory, 17, 76, 173. - - - Katias, 36. - - Knife, 24. - - - Labour difficult, 31, 43, 135, 137, 152, 154, 155, 157. - - Lancet, 28, 32. - - Lead, 15, 166. - - Lenticular, 124. - - Lever, bone, 133. - - Ligula, 77. - - Lithotomy forceps, 147. - knife, 40. - scoop, 25, 41, 146. - - Lithotripsy, 149. - - Lithotrite, 148. - - Loeffelsonde, 61. - - Long dissecting knife of Galen, 31. - - - Marcellus, 6. - - Meges, lithotomy knife of, 27, 41. - - Meningophylax, 126, 135. - - Minerva Medica, 19, 25, 79. - - Mirror handle, 35. - - Mortar, 165. - - Moschion, 4. - - Mounting scalpel blade, 24. - - Myzon, 94. - - - Nasal insufflator, 111. - - Needle, 69, 74, 75. - knife, 36. - netting, 84. - - - Obstetrical chair, 159. - - Octavianus Horatianus, 6. - - Oculist, 21. - - Oilstone, 167. - - Ointment box, 170. - slab, 171. - - Ophthalmic needle, 69. - probe, 71. - scalpel, 44. - - Oribasius, 3. - - Ornamentation, 17. - - Osteotome, 122. - - - Painter, 59, 62. - - Pare, 8. - - Paris, surgeon of, 20. - - Patina, 19. - - Paulus Aegineta, 6. - - Perforator for foetal cranium, 43. - for lachrymal fistula, 133. - - Periosteal elevator, 140. - - Periscyphismus, 36. - - Pessary, 159. - - Pestle, 166. - - Pharyngeal forceps, 100. - - Phlebotome, 32. - - Pile crusher, 98. - - Plating, 18, 56, 61, 112. - - Pocket companion, 92. - - Polypus forceps, 93. - knife, 39. - - Pompeian forceps, 135. - - Portable outfit, 168. - - Primitive shaving, 13. - - Probe, 51. - - Probe pointed bistoury, 43. - - Pterygotome, 44. - - Pumice, 71. - - Pyulcus, 109. - - - Quill, 111, 115. - - - Ram's head, 19, 79. - - Rasp, 139. - - Raspatory, 121, 138. - - Razor, 29. - - Rectal tube, 113. - - Reed, 114, 120. - - Retractor, 83. - - Rhases, 8. - - Ring knife, 31, 157. - - Rufus of Ephesus, 3. - - Rugine, 94, 121. - - - Saw, 130. - - Scaler, dental, 138. - - Scalpel, 24. - - Scarfication lancet, 28. - - Scolopomachaerion, 28. - - Scoop of Diocles, 142. - lithotomy, 27, 146. - - Screw probe, 68. - - Scribonius Largus, 6. - - Scultetus, 8. - - Seal of oculist, 171. - - Sequestrum forceps, 135. - - Serpent, 18, 164, 172. - - Serres fines, 162. - - Shaving, 29, 90. - - Shears, 49. - - Sieve, 165. - - Silver, 16. - - Sinus irrigator, 109. - knife, 47. - - Smelting iron, 10. - - Solder, 25. - - Soranus, 3. - - Sound, 51. - bladder, 145. - uterine, 79. - - Spathion, 38. - - Spathomele, 58. - - Spatula probe, 58. - double, 79. - - Specillum, 51. - - Speculum, rectal, 149. - vaginal, 150, 158. - - Spiral ornamentation, 17, 61. - - Sponge, 161. - - Spoon of probe, 61, 63, 71, 77. - for pouring collyria, 78. - - Steel, 10. - - Stone, 17. - - Strainer, 165. - - Strigil, 88, 157. - - Stump forceps, 136. - - Stylet for destroying foetus, 157. - - Stylus, 72. - - Sutures, 161. - - Syphon, 143. - - Syringe, aspiration, 109. - aural, 110. - nasal, 109. - - Syringotome, 47. - - - Tempering steel, 10. - - Tents, sponge, 161. - - Theodorus Priscianus, 6. - - Tin, 15. - - Tongs, smith's, 136. - - Tongue depressor, 59, 79. - tie guard, 62. - - Tonsil knife, 47. - - Tooth elevator, 134, 138. - excavator, 138. - file, 139. - forceps, 136. - powder, 167. - scaler, 138. - - Traction hook, 152, 157. - - Trephine, 131. - - Tube for ascites and empyema, 112. - for drinking by, 115. - - Tube for guarding cautery, 120. - for preventing adhesion, 113 - for removing warts, 115. - - - Unguent spatula, 58, 7 - - Uterine curette, 157. - dilator, 81. - douche, 107. - prolapse, 159. - sound, 54, 60, 79. - tube, 113. - - Uvula, forceps for cauterizing, 98. - forceps for crushing, 97. - knife, 46. - spoon for cauterizing, 89. - - - Vaginal douche, 107. - fumigation, 158. - medicament tube, 113. - pessary, 159. - - Varix extractor, 135. - - Vindicianus Afer, 6. - - Vulsellum, 94. - - - Weapon, extraction of, 68, 83, 114, 127, 138, 139, 141. - forceps, 139. - - Wood, 16. - - - Y-shaped retractor, 83. - - - - -II. LATIN INDEX - - - Abaptista, 129. - - Acus, 69, 74. - - Anuloculter, 81, 157. - - Asperatum specillum, 71. - - Auriscalpium, 68. - - Aversum specillum, 65. - - - Baca, 58. - - Bacula, 53. - - - Calamus scriptorius, 114. - - Clyster, 105. - - Corvus, 44. - - Cos, 166. - - Cribrum, 165. - - Cucurbitula, 101. - - Cultellus, 30. - - Culter, 30. - - - Ferramentum acutum in modo spathae factum, 39. - crassitudinis modicae prima parte tenui, 148. - cuius tertiam digiti partem, &c., 112. - factum ad similitudinem Graecae litterae Y, 84. - quo in sectione calculus protrahitur, 146. - quod a similitudine corvum vocant, 44. - rectum in summa parte labrosum, &c., 41. - - Ferrum candens, 116. - - Fibula, 162. - - Ficulneum folium, 71. - - Fistula aenea, 112. - - Fistula fictilis, 120. - plumbea, 112. - - Flebotomum, 33. - - Forfex, 49. - - - Hamulus, 85. - - Hamus, 85, 87. - - - Ligula, 77. - - Lima, 139. - - Limula, 139. - - - Malleolus, 125. - - Membranae custos, 126. - - Meningophylax, 126. - - Modiolus, 131. - - Mortarium, 165. - - - Novacula, 30. - - Nucleus, 53. - - - Organon, 150. - - - Pessulum, 159. - - Pessum, 159. - - Pessus, 159. - - Phlebotomum, 37. - - Pilum, 165. - - - Rhinenchytes, 16, 109. - - Rudicula, 58. - - - Sarcolabos, 95. - - Scalpellus vel scalpellum, 27, 40. - - Scalper, 121, 122, 123, 138. - - Scalprum, 121, 122. - - Serrula, 130. - - Spathomela, 58. - - Specillum, 51. - - Speculum magnum, 150. - - Spiculum aeneum, 157. - - Spongia, 161. - - Stilus, 72. - - Strigilis, 88. - - Stylus, 72. - - - Terebella, 126. - - Terebra, 126. - - - Uncus, 146, 152, 154. - - - Vulsella, 90, 94, 136. - - - - -III. GREEK INDEX - - - [Greek: abaptistos], 129. - - [Greek: ankistron], 85. - - [Greek: ankter], 162. - - [Greek: ankylotomos], 47. - - [Greek: ankyromele], 85. - - [Greek: haimorrhoidokaustes], 99. - - [Greek: akanthobolos], 100. - - [Greek: akone], 166. - - [Greek: amphismilos], 56. - - [Greek: anaboleus], 133. - - [Greek: anarrhaphikos], 45. - - [Greek: antithetos], 123. - - [Greek: apyromele], 63. - - [Greek: atraktos], 120. - - [Greek: auliskos], 145. - - - [Greek: balanos], 159. - - [Greek: beloulkon], 139. - - [Greek: blepharokatochos], 97. - - [Greek: blepharoxyston], 71. - - - [Greek: gammoeides], 118. - - [Greek: gastrodes], 28. - - [Greek: glossokatochos], 79. - - [Greek: grapheion], 72. - - [Greek: graphikos], 114. - - [Greek: graphion], 72. - - [Greek: graphis], 72. - - - [Greek: diapyrenos], 56. - - [Greek: diastellousas], 81. - - [Greek: diastoleus], 81. - - [Greek: diastomotris], 81. - - [Greek: dikrous], 83. - - [Greek: dioptra], 151. - - [Greek: dioptrion], 149. - - [Greek: dioptrismos], 150. - - [Greek: dioster], 141. - - [Greek: doidyx], 165. - - - [Greek: hedrodiastoleus], 149. - - [Greek: ekkopeus], 122. - - [Greek: elaiakone], 167. - - [Greek: embryothlastes], 154. - - [Greek: embryosphaktes], 157. - - [Greek: embryotomon], 43. - - [Greek: embryoulkos], 152. - - [Greek: exotis], 63. - - [Greek: epikopon], 125. - - - [Greek: ethmos], 165. - - [Greek: helotos], 118. - - [Greek: hemispathion], 38. - - - [Greek: thlastes], 154. - - - [Greek: igdion], 165. - - [Greek: iskai], 120. - - - [Greek: katheter], 105, 145. - - [Greek: kathias], 36. - - [Greek: kalamiskos], 112. - - [Greek: kalamos], 114. - - [Greek: kateiadion], 36. - - [Greek: katiadion], 36. - - [Greek: katopter], 149. - - [Greek: kauter], 116. - - [Greek: kauteridion], 116. - - [Greek: kauterion], 116. - - [Greek: kirsoulkos], 136. - - [Greek: klyster], 105. - - [Greek: koiliskotos], 123. - - [Greek: kotylos], 106. - - [Greek: kyathiskos], 64, 77, 142. - - [Greek: kyathos], 101. - - [Greek: kykliskos], 123. - - [Greek: kykliskotos], 123. - - [Greek: kyrtis], 165. - - - [Greek: lithotomon], 40. - - [Greek: lithoulkos], 5, 147. - - - [Greek: machaira], 27. - - [Greek: machairion], 27. - - [Greek: machairis], 27. - - [Greek: mele] - [Greek: diastellousa], 81. - [Greek: dikrous], 83. - [Greek: entetmemene], 83. - [Greek: exotis], 63. - [Greek: ischyra], 69. - [Greek: ophthalmike], 71. - [Greek: traumatike], 68. - - [Greek: melotis], 63. - - [Greek: melotris], 63. - - [Greek: meningophylax], 126. - - [Greek: menoeides], 118. - - [Greek: metrenchytes], 107. - - [Greek: motos], 113. - - [Greek: mochliskos], 133. - - [Greek: mydion], 94. - - [Greek: mydioskellon], 96. - - [Greek: mykes], 120. - - - [Greek: xyraphion], 117. - - [Greek: xyster], 121. - - [Greek: xysterion], 94, 121, 138. - - [Greek: xystra], 88, 157. - - - [Greek: odontagra], 136. - - [Greek: onyx], 31. - - [Greek: oxybeles], 32. - - [Greek: oxykorakos], 43. - - [Greek: oreichalkos], 14. - - [Greek: orthoprion], 131. - - [Greek: ostagra], 135. - - [Greek: ophthalmikos], 71. - - - [Greek: pesson], 159. - - [Greek: pessos], 159. - - [Greek: piestron], 154. - - [Greek: plinthotos], 118. - - [Greek: polykmetos], 10. - - [Greek: polypikos], 39. - - [Greek: polypodikos], 39. - - [Greek: polypoxystes], 94. - - [Greek: prion], 130. - - [Greek: promekes], 119. - - [Greek: prostheton], 82. - - [Greek: pterygotomos], 44. - - [Greek: ptilon], 111, 115. - - [Greek: pyoulkos], 109. - - [Greek: pyren], 53. - - [Greek: pyrenosmele], 55. - - - [Greek: rhinarion], 139. - - [Greek: rhinenchytes], 109. - - [Greek: rhine], 139. - - [Greek: rhinion], 139. - - - [Greek: sarkolabos], 94. - - [Greek: sideros], 10. - - [Greek: sikya], 101. - - [Greek: skolopion], 28. - - [Greek: skolopomachairion], 28. - - [Greek: skyliskotos], 123. - - [Greek: smele], 52. - - [Greek: smilarion], 38. - - [Greek: smile], 27, 52. - - [Greek: smilion], 45. - - [Greek: smiliotos], 138. - - [Greek: smyris], 167. - - [Greek: spathion], 38. - - [Greek: spathister], 140. - - [Greek: spongos], 161. - - [Greek: staphylagra], 97. - - [Greek: staphylepartes], 89. - - [Greek: staphylokaustes], 98. - - [Greek: staphylotomon], 46. - - [Greek: stethoeides], 27. - - [Greek: syringotomon], 47. - - [Greek: syrinx], 47, 120. - - [Greek: spheniskos], 119. - - [Greek: sphyra], 125. - - - [Greek: teretron], 127. - - [Greek: traumatikos], 68. - - [Greek: triaina], 117. - - [Greek: tricholabion], 90. - - [Greek: tricholabis], 90. - - [Greek: trypanon], 126. - - [Greek: typhlankistron], 87. - - - [Greek: hydrokelikos], 85. - - [Greek: hypaleiptris], 51. - - [Greek: hypaleiptron], 51. - - [Greek: hypospathister], 140. - - - [Greek: phakotos], 118. - - [Greek: phalakros], 118. - - [Greek: phlebotomon], 32. - - [Greek: phlebotomos], 32. - - [Greek: physa], 108. - - - [Greek: charaktos], 131. - - [Greek: chele], 83. - - [Greek: choinikis], 131. - - - [Greek: psalis], 49. - - - [Greek: otenchytes], 110. - - [Greek: otikos], 110. - - [Greek: otoglyphis], 63. - - - - - OXFORD - PRINTED AT THE CLARENDON PRESS - BY HORACE HART, M.A. - PRINTER TO THE UNIVERSITY - - - - -[Illustration: PLATE I] - - _Size of - originals._ _Museum._ - - 1. 7{cm},5 British - 2. 6{cm} " - 3. 9{cm},5 " - - -[Illustration: PLATE II] - - _Size of - originals._ _Museum._ - - 1. 5{cm},2 Saint-Germain - 2. 6{cm} " - 3. 10{cm} " - 4. 11{cm},5 " - 5. 10{cm},5 " - 6. 8{cm},7 Puy-en-Velay - 7. 6{cm} Saint-Germain - - -[Illustration: PLATE III] - - _Size of - originals._ _Museum._ - - 1. 7{cm},5 British - 2. 8{cm},5 " - 3. 12{cm},2 Author's - - -[Illustration: PLATE IV] - - _Size of - original._ _Museum._ - - 43 x 33{cm} Athens - - -[Illustration: PLATE V] - - _Size of - originals._ _Museum._ - - 1. 14{cm},3 British - 2. 12{cm},3 " - 3. 17{cm} Naples - 4. 15{cm},5 " - 5. 17{cm} " - 6. 18{cm} " - - -[Illustration: PLATE VI] - - _Size of - originals._ _Museum._ - - 1. 15{cm} Naples - 2. 14{cm} Charleroi - - -[Illustration: PLATE VII] - - _Size of - originals._ _Museum._ - - 1. Modern catalogue - 2. 9{cm},5 Cologne - 3. 7{cm},8 Author's - 4. 10{cm},7 " - 5. 11{cm} Shrewsbury - 6. 7 After Heister - - -[Illustration: PLATE VIII] - - _Size of - originals._ _Museum._ - - 1. 15{cm} Montauban - 2. 13{cm},5 Bibliotheque Nationale - 3. 12{cm} Naples - 4, 5, 6. Hypothetical - 7. After Albucasis - 8. 14{cm} Orfila - - -[Illustration: PLATE IX] - - _Size of - originals._ _Museum._ - - 1. After Heister - 2, 3, 4. " Albucasis - 5. 10{cm} Baden - 6. 7{cm} After Vedrenes - - -[Illustration: PLATE X] - - _Size of - originals._ _Museum._ - - 1. 15{cm},7 Naples - 2. 6{cm},5 Thorwaldsen - 3. 17{cm},6 Naples - 4. 13{cm},5 Author's - 5. 10{cm} Naples - - -[Illustration: PLATE XI] - - _Size of - originals._ _Museum._ - - 1. 11{cm},2 Author's - 2. 8{cm} Baden - 3. 10{cm},2 Author's - 4. 18{cm} Author's - 5. 12{cm} Saint-Germain - - -[Illustration: PLATE XII] - - _Size of - original._ _Museum._ - - 1. 14{cm},5 Naples - 2. 18{cm} Author's - 3. 17{cm},2 Author's - 4. 18{cm} Athens - - -[Illustration: PLATE XIII] - - _Size of - originals._ _Museum._ - - 1. 18{cm},5 Naples - 2. 16{cm} Mainz - 3. 17{cm} Athens - 4. 20{cm} Author's - - -[Illustration: PLATE XIV] - - _Size of - originals._ _Museum._ - - 1. 17{cm} Naples - 2. 11{cm} Author's - 3. 15{cm},8 " - 4. 15{cm},5 Mainz - 5. 12{cm} Author's - - -[Illustration: PLATE XV] - - _Size of - originals._ _Museum._ - - 1. 17{cm},2 Author's - 2. 13{cm} " - 3. 16{cm} Naples - 4. 14{cm} Author's - 5. 13{cm},8 Baden - - -[Illustration: PLATE XVI] - - _Size of - originals._ _Museum._ - - 1. 15{cm},3 After Vedrenes - 2. 8{cm},7 Saint-Germain - 3. 6{cm} " - 4. 7{cm} " - 5. 7{cm} " - 6. 6{cm} " - 7. 12{cm},7 Author's - - -[Illustration: PLATE XVII] - - _Size of - originals._ _Museum._ - - 1. 11{cm},5 Baden - 2. 12{cm},5 Author's - 3. 14{cm} " - 4. 7{cm} " - 5. 10{cm},5 " - 6. 12{cm},5 Naples - - -[Illustration: PLATE XVIII] - - _Size of - originals._ _Museum._ - - 1. 11{cm},2 Author's - 2. 10{cm},8 " - 3. 18{cm},4 " - 4. 20{cm} " - 5. 10{cm},5 " - 6. 10{cm},5 " - 7. 14{cm} " - 8. 16{cm},7 " - - -[Illustration: PLATE XIX] - - _Size of - originals._ _Museum._ - - 1. 7{cm},8 Naples - 2. 12{cm},2 " - 3. 14{cm},2 " - 4. 17{cm},5 British - - -[Illustration: PLATE XX] - - _Size of - originals._ _Museum._ - - 1. 17{cm},5 Naples - 2. 11{cm},4 After Vedrenes - 3. 12{cm} Saint-Germain - 4. 12{cm} " - 5. 7{cm},5 Naples - 6. 11{cm},5 After Vedrenes - - -[Illustration: PLATE XXI] - - _Size of - originals._ _Museum._ - - 1. 15{cm} After Vedrenes - 2. 6{cm} Saint-Germain - 3. 18{cm},2 Author's - 4. 4{cm} Saint-Germain - 5. 8{cm} Author's - 6. 10{cm},2 " - - -[Illustration: PLATE XXII] - - _Size of - originals._ _Museum._ - - 1. 12{cm} British - 2. 7{cm},5 " - 3. 13{cm},2 " - 4. 14{cm} " - 5. 10{cm} " - - -[Illustration: PLATE XXIII] - - _Size of - originals._ _Museum._ - - 1. 14{cm},2 Author's - 2. 16{cm},8 Saint-Germain - 3. 12{cm},8 British - 4. 5{cm},6 Saint-Germain - - -[Illustration: PLATE XXIV] - - _Size of - originals._ _Museum._ - - 1. 14{cm},8 Saint-Germain - 2. 11{cm},5 " - 3. 10{cm},8 " - 4. 15{cm},5 Author's - 5. 17{cm} Naples - - -[Illustration: PLATE XXV] - - _Size of - originals._ _Museum._ - - 1. 21{cm} Author's - 2. 13{cm},3 After Vedrenes - - -[Illustration: PLATE XXVI] - - _Size of - originals._ _Museum._ - - 1. 17{cm} Naples - 2. 9{cm},5 Author's - 3. 8{cm} Naples - 4. 6{cm} Guildhall - 5. 6{cm},9 Author's - 6. 15{cm} Naples - - -[Illustration: PLATE XXVII] - - _Size of - originals._ _Museum._ - - 1. 15{cm},5 Toulouse - 2. 4{cm},8 Saint-Germain - 3. 5{cm},5 Mainz - 4. 11{cm},8 Thorwaldsen - 5. 11{cm},8 Saint-Germain - - -[Illustration: PLATE XXVIII] - - _Size of - originals._ _Museum._ - - 1. 12{cm},4 British - 2. 10{cm},5 Naples - 3. 12{cm} Author's - - -[Illustration: PLATE XXIX] - - _Size of - originals._ _Museum._ - - 1. 17{cm} Toulouse - 2. 5{cm},8 Saint-Germain - 3. 5{cm} Mainz - 4. 10{cm} Naples - - -[Illustration: PLATE XXX] - - _Size of - originals._ _Museum._ - - 1. 19{cm} British - 2. 18{cm} " - - -[Illustration: PLATE XXXI] - - _Size of - originals._ _Museum._ - - 1. 19{cm} Toulouse - 2. 20{cm},2 Basle - - -[Illustration: PLATE XXXII] - - _Size of - originals._ _Museum._ - - 1. 15{cm},2 After Vedrenes - 2. 12{cm},5 Vienna - 3. 11{cm} Naples - - -[Illustration: PLATE XXXIII] - - _Size of - original._ _Museum._ - - 14{cm},5 Athens - - -[Illustration: PLATE XXXIV] - - _Size of - original._ _Museum._ - - 10{cm},2 British - - -[Illustration: PLATE XXXV] - - _Size of - original._ _Museum._ - - 15{cm} Naples - - -[Illustration: PLATE XXXVI] - - _Size of - originals._ _Museum._ - - 1. 2{cm},8 Mainz - 2. After Alpinus - 3. 3{cm} Mainz - - -[Illustration: PLATE XXXVII] - - 1. After Alpinus - 2. " Hero - 3. " Heister - - -[Illustration: PLATE XXXVIII] - - _Size of - originals._ _Museum._ - - 1. 13{cm} Naples - 2. 5{cm},5 Baden - 3, 4, 5. After Hero - - -[Illustration: PLATE XXXIX] - - _Size of - originals._ _Museum._ - - 1. 17{cm} Naples - 2. 9{cm} " - 3. 12{cm} " - - -[Illustration: PLATE XL] - - _Size of - originals._ _Museum._ - - 1. 25{cm} Naples - 2, 3. After Vidius - 4. 15{cm},5 Toulouse - - -[Illustration: PLATE XLI] - - _Size of - originals._ _Museum._ - - 1. 15{cm},5 Naples - 2. 8{cm},5 Cologne - 3. 11{cm} British - - -[Illustration: PLATE XLII] - - _Size of - originals._ _Museum._ - - 1. 18{cm} Guildhall - 2. 15{cm} " - 3, 4, 5. After Vidius - - -[Illustration: PLATE XLIII] - - _Size of - original._ _Museum._ - - 21{cm} Naples - - -[Illustration: PLATE XLIV] - - -[Illustration: PLATE XLV] - - _Size of - originals._ _Museum._ - - 1. 26{cm},5 Naples - 2. 20{cm} " - 3. 15{cm} Mainz - 4. Hypothetical - - -[Illustration: PLATE XLVI] - - _Size of - originals._ _Museum._ - - 1. 15{cm} Naples - 2. 11{cm},5 " - 3. 11{cm},5 " - - -[Illustration: PLATE XLVII] - - _Size of - original._ _Museum._ - - 23{cm} Naples - - -[Illustration: PLATE XLVIII] - - _Size of - original._ _Museum._ - - 23{cm} Athens - - -[Illustration: PLATE XLIX] - - _Size of - original._ _Museum._ - - 31{cm},5 Naples - - -[Illustration: PLATE L] - - _Size of - originals._ _Museum._ - - 1. 17{cm} Naples - 2. 15{cm},3 After Vedrenes - - -[Illustration: PLATE LI] - - _Size of - originals._ _Museum._ - - 1. 21{cm} Naples - 2. 3{cm},3 After Vedrenes - 3, 4. " Albucasis - - -[Illustration: PLATE LII] - - _Size of - originals._ _Museum._ - - 1. 6{cm} Cologne - 2. 3{cm} Toulouse - 3. 2{cm} x 4{cm},2 Author's - 4. 4{cm},4 x 2{cm},5 " - 5. 5{cm} Guildhall - 6. 4{cm} " - 7. 7{cm} " - 8. 3{cm},6 " - - -[Illustration: PLATE LIII] - - _Size of - originals._ _Museum._ - - 1. 18{cm} Naples - 2. 17{cm} " - - -[Illustration: PLATE LIV] - - _Size of - original._ _Museum._ - - - 13{cm} x 7{cm},5 Naples - - - - -Transcriber's Notes: - -Passages in italics are indicated by _italics_. - -Gesperrt passages are indicated by =gesperrt=. - -Superscripted characters are indicated by {superscript}. - -The original text includes Greek characters. 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