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  SURGICAL INSTRUMENTS
  IN GREEK AND ROMAN TIMES


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


  WITH ILLUSTRATIONS


  OXFORD
  AT THE CLARENDON PRESS
  1907




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




PREFACE


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

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

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

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

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

The books from which I have drawn most information are Brunner's _Die
Spuren der römischen Ärzte auf dem Boden der Schweiz_, Deneffe's _Étude
sur la Trousse d'un Chirurgien Gallo-Romain du III{e} Siècle_, Adams'
translation of Paulus Aegineta, and the papers of Vulpes in the volume for
1851 of the _Memorie della Regale Accademia Ercolanese di Archeologia_.

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

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

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

  HARTLEPOOL,
  _April 19, 1907_.




CONTENTS


                                                                     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--Paré--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--
  κοπάριον--μήλη--ὑπάλειπτρον--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

  ÉTUI, 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 Föes (1595), Van der Linden (1665), Kühn
(Leipzig, 1821). Later editions are the text with a French translation by
Littré (10 vols., 1849-61), a scholarly edition by Ermerins with a Latin
rendering (1859-64), and an excellent translation of the genuine works of
Hippocrates by the world-famous Dr. Adams of Banchory (Sydenham Soc.
Trans., 1849). The best edition, however, is the edition of Kuehlewein,
begun in 1894 and at present in course of publication by Teubner, Leipzig.
The later volumes have not yet appeared. For the portion of the text which
is not contained in the first two volumes of Kuehlewein I have relied on
the edition of Kühn for most of the readings, although occasionally those
of Van der Linden or Föes are to be preferred. The references given are to
the volumes and pages of Kühn's edition, but in this edition indications
are given of the corresponding localities in the other editions so that
cross-references to these can easily be made. There seems to be a
different arrangement in different editions of Föes, for Liddell and Scott
say the references in their Lexicon are to the pages in Föes but they do
not correspond in any way to the pagination of the edition before me
(Frankfort, 1595).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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




CHAPTER II

MATERIAL, EXECUTION, AND ORNAMENTATION


_Steel and Iron._

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

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

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

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

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

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

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

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

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


_Bronze._

Although, as I have shown, iron and steel were largely used in the
manufacture of instruments, fortunately for us bronze was the metal
usually selected, for thus many instruments have withstood the lapse of
time which would otherwise have been oxidized out of existence. Copper is
much more easily got from ore than iron, and consequently it was the first
to be used by man, and very early the advantage of combining it with tin
to form bronze was found out. Bronze was used by the Egyptians 6,000 years
ago, and the Phoenicians, who got it from them, passed it on to the whole
of Europe. The quantity of tin in the bronze is very constantly about
7-1/2 per cent.

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

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

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

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

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

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


_Tin._

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


_Lead._

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


_Gold._

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


_Silver._

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

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


_Horn._

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

Scribonius Largus (_Compositiones_, vii) says:

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


_Wood._

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


_Bone and Ivory._

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

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


_Stone._

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


_Execution and Ornamentation._

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

Hippocrates points out the necessity for this:--

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

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

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

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

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

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


_Preservation._

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

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


_Finds of Instruments._

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

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

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

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

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

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

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

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




CHAPTER III

KNIVES


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

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

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

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

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

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


_The Blade._

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

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

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

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

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

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

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

    'Incise the outer integument between the ribs with a bellied scalpel.'

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


_Scarificator for wet cupping._

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

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

Paul says he prefers a single scalpel.

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


_Straight sharp-pointed bistoury._

Greek, σκολοπομαχαίριον, σκολόπιον; Latin, _scalpellus_.

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

    [1] So says Briau (_Paul D'Egine_, p. 97), but it seems more likely to
    be derived from σκόλοψ '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 σκολόπιον which also occurs pretty often.

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


  I. A (_b_) _Straight blade cutting on one side, blunt-pointed._

  (α) Novacula or razor (Greek ξυρόν, diminutive ξύριον).
  (β) Blunt-pointed bistoury.
  (γ) 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 περὶ κουρᾶς καὶ ξυρήσεως. 'These things,' he says, 'have
been introduced into medicine as a means of evacuation and as remedies in
chronic diseases.'

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

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

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

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

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

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

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

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

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


  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):

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

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

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


_Phlebotome._

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


_The 'Katias.'_

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

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

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

The Latin version of Moschion has:

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

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

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

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

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

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

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

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


_Spathion and Hemispathion._

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

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

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

Again, Paul (VI. lxxviii) says:

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

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

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

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

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

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


_Polypus Knife._

Greek, πολυπικὸν σπαθίον, πολυποδικὸν σπαθίον; Latin, _ferramentum acutum
modo spathae factum_.

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

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

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

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

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

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

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

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

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

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


_Lithotomy Knife._

Greek, λιθοτόμον (τό); Latin, _scalpellus_.

In describing lithotomy Paul says:

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

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

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

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

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

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

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

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

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

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

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


_Perforator for the foetal cranium._

Greek, ἐμβρυοτόμον.

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

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

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

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


_Probe pointed blade with two cutting edges._

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


II A. (_a_) _Curved bistoury--'Crow Bill.'_

Greek, ὀξυκόρακον σμίλιον.

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

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

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

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

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


_Pterygium Knife._

Greek, πτερυγοτόμος, ὁ; Latin, _scalpellus_.

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

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


_Knife for plastic operation on the eyelid._

Greek, ἀναρραφικὸν σμιλίον.

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

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

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

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


_Uvula Knife._

Greek, σταφυλοτόμον.

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

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

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


_Blade curved on the flat.--Tonsil Knife._

Greek, ἀγκυλοτόμον (ἀγκύλη, 'bend of elbow,' _or_ ἀγκύλος, 'crooked').

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

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

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


_Curved blade cutting on one side, blunt-pointed.--Fistula Knife._

Greek, συριγγοτόμον, from σῦριγξ, 'a fistula.'

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

Secondly, Paul (VI. lxxviii) says:

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

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

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

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


_Curved blade cutting on two edges._

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

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

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

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


_Shears._

Greek, ψαλίς; Latin, _forfex_.

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

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

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

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

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

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

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




CHAPTER IV

PROBES


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

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 μήλη dicitur.' Thus it meant a
probe or sound.

μήλη is probably derived from μῆλον, an apple or fruit, from the olivary
enlargement at the end of a sound.

The term ὑπάλειπτρον, which is frequently used by Hippocrates, originally
meant an ointment spatula, being derived from ὑπαλείφω, 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 κοπάριον 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 κόπανον, 'pestle,' κοπανιστήριον, 'mortar,' and κοπανίζω,
'bray,' and κοπτάριον, a medicament pounded in a mortar (Dioscorides, iv.
190). The exact significance of the term κοπάριον 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 κοπάριον for the word μήλη, 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 (διὰ τετρημένου κοπαρίου) Briau
translates it by 'au moyen du manche percé d'un scalpel', an expression
which is meaningless to a surgeon. Briau evidently thinks it is derived
from κόπτω, 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
κοπάριον, however, was the same as the μήλη or specillum it was evidently
used for cutting with, as well as for cutting upon', and on one occasion
(Paul, VI. lxxx) he translates κοπάριον 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 κοπάριον is only
a late Greek term for the earlier μήλη, 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 σμίλη, 'scalpel,' and μήλη, 'probe,' are
distinct, but the inferior reading σμήλη is frequent in both codices and
texts as a bastard, for σμίλη is often written σμήλη incorrectly, and μήλη
often becomes σμήλη, just as μικρός is written σμικρός. Thus in Paul (VI.
viii), where the author is describing the eversion of the eyelid by means
of the olivary point of a probe (τῷ πυρῆνι τῆς μήλης), four codices and
the Aldine and Basle texts read σμήλης, two codices read σμύλης, one reads
μήλης, four μίλης, and Briau reads σμίλης. 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 πυρήν, 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 ἀπυρηνομήλη or
ἀπυρομήλη. 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' (πυρῆνα μὲν μήλης
    ἐπιδέχεται ἢ βραχύ τι τούτου παχύτερον).

Here Kühn translates πυρῆνα 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' (τὸ μῆκος πυρῆνος).

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 (πυρηνοσμήλης),
and similarly after removal of sebaceous cysts from the lid, levigated
salts may be applied on the nucleus (τὸν πυρῆνα τῆς μήλης).

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 (πυρῆνος μήλης), and
again (II. iv. 14) he directs us to use it for application of pomade to
the face (πυρῆνι μήλης). 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, ἀπυρηνομήλη, ἀπυρομήλη; 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 Musée de Cinquantenaire, Brussels. It was found with other probes in
an étui. 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, διπύρηνος μήλη, ἀμφίσμιλος.

A slender sound with slight olivary enlargement at either end is very
frequently mentioned under the name διπύρηνος μήλη by Galen. He also calls
it ἀμφίσμιλος. Thus he says:

    Καί σοι διχόθεν ἔστι διεμβάλλειν αὐτοῦ τι τῶν παρασκευασμένων λεπτὸν
    εἴτε ἀμφίσμιλον, εἴτε διπύρηνον ὀνομάζειν ἐθέλεις, εἰ δέ τι λεπτότερον
    δέῃ καὶ μηλωτίδα (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' (διπυρήνῳ εὐκαμπεῖ), 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' (Διαπυρίνον ἢ μηλωτίδα ἤ τι τοιοῦτον
    λεπτὸν ὄργανον πεπυρωμένον εἴρουσι τῷ τόπῳ ὅθεν ἡ θρὶξ ἢ αἱ τρίχες
    ἐκομίσθησαν).

Here Briau reads πυρῆνα (an olivary point), but the balance of the
evidence of the codices is in favour of διαπυρίνον, 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 (διπυρήνου τρήματι), and we
    push the other end of the probe (τὸ ἕτερον πέρας τοῦ διπυρήνου)
    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, ὑπάλειπτρον, σπαθομήλη; 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 στρόγγυλον μήλην, the other μήλη πλατεῖα. 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
(μαλάξας ἐπὶ τῆς χειρὸς διὰ σπαθομήλης).

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 (τῇ
σπαθομήλῃ).

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 (σπαθομήλην πλατεῖαν) 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' (τοῦ πλάτεος τῆς μήλης).

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, _Löffelsonde_.

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 Vendée in
1847. Among a number of colour pots and alabaster mortars for rubbing down
and mixing colours was an étui 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] Blümner, _Technologie und Terminologie der Gewerbe und Künste bei
    Griechen und Römern_, 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, μηλωτίς, -ίδος, μηλωτρίς, ἀπυρομήλη, τῇ πυρῆνα μὴ ἐχούσῃ τούτεστι τῇ
μηλωτρίδι (Galen, Lexicon); ὠτογλυφίς, μήλην ἐξωτίδα (Galen, Lexicon);
Latin, _oricularium specillum_ (Celsus); _auriscalpium_ (Scrib. Largus);
German, _Ohrlöffel_.

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' (κυαθίσκῳ στενῷ μικρῷ μηλωτρίδος).

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' (κυαθίσκου
    μήλης).

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 (καὶ ὅταν
    ἀφαιρῇς τὸ αἷμα τῇ μήλῃ μὴ κάρτα πιέζειν ὡς μὴ φλάσις προσγίνηται)
    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
    opposée à celle qui sert comme sonde, c'est-à-dire son extrémité
    large, l'autre bout étant 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 κυαθίσκον 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:

    Ἀπυρομήλῃ· τῇ πυρῆνα μὴ ἐχούσῃ τούτεστι τῇ μηλωτρίδι.

    '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 (τῷ ὀξεῖ τῆς μηλωτίδος). 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' (καὶ μηλωτρίδα).

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' (ἐκ τῆς μηλωτῆς).

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 (μηλωτίδα) 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 (ὑποβάλλοντες κοπάριον ἢ
    μηλωτίδα) 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, τραυματικὴ μήλη; 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' (κυαθίσκου τραυματικῆς
    μηλωτίδος).

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 μήλην ἰσχυράν is stated to mean τὴν τραυματικὴν μήλην. 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 (ὅσον πυρηνομήλης) from the part
    called the iris and in the direction of the outer canthus, then mark
    with the olivary end of the couching needle (πυρῆνι παρακεντηρίου) 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 (καὶ ἀναστρέψαντες τὴν ἀκμὴν
    στρογγύλην κατὰ τὸ πέρας ὑπάρχουσαν τοῦ κεντηρίου), 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 Paré. 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, ὀφθαλμικὴ μήλη.

In Hippocrates (ii. 100) we find an ophthalmic probe mentioned.

    Λεπίδος μῆλαι τρεῖς τῷ πλατεῖ καὶ ἀλήτου σητανίου κόλλης, πάντα ταῦτα
    λεῖα τρίψας, καταπότια ποιήσας δίδου.

    '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 μῆλαι τρεῖς τῷ πλατεῖ means τῷ κυαθίσκῳ
ὀφθαλμικῆς μήλης. 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, βλεφαρόξυστον; 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' (διὰ τοῦ βλεφαροξύστου καλουμένου, 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, γράφιον, γραφεῖον, γραφίς; 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 (γραφείῳ
ἀνάλαβε) 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 (γραφίῳ) 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 Musée 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
    σταφύλωμα 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
(μήλην κασσιτερίνην ἐπ' ἄκρου τετρημένην), 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' (διὰ
    τετρημένου κοπαρίου ἢ διπυρήνου).

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 Paré
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, κυαθίσκος; 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, γλωσσοκάτοχος.

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 (γλωσσοκατόχῳ).

Pl. XX, fig. 6 shows one of six bronze tongue depressors, burnished like
small mirrors, from the Lépine collection (Védrènes, _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.

    Καὶ ὑπάλειπτρον καθιέναι καὶ ἀναστομοῦν καὶ τῷ γε δακτύλῳ ὡσαύτως
    λειοῦν.

Soranus (II. x) describes plugging for uterine haemorrhage by means of the
sound:

    Καὶ τρυφερὸν ἔριον ἑνί τινι τῶν εἰρημένων χυλῶν διάβροχον διὰ δακτύλου
    ἢ μήλης παρεντιθέσθω τῷ στόματι τῆς ὑστέρας. καὶ πολὺ μᾶλλον ἐντεῦθεν
    τῆς αἱμορραγίας ὑπαρχούσης.

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 (περὶ μήλην) 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 (μήλην ὑπαλειπτρίδα) 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 (μήλας διαπύρους
ἐμβάλλοντα).

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 (ὑπάλειπτρον) 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, διαστομωτρίς, μήλην τὴν διαστέλλουσαν--τὸν διαστολέα (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 μήλη 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 (προσθέτων) 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
Védrènes 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 (τῇ μήλῃ τῇ κασσιτερίνῃ ἢ
    μολυβδαίνῃ), 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, μήλη δικροῦς, χηλή.

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: ἔπειτα χηλὴν ὑποθεὶς ὑπὸ
τὸν γαργαρεῶνα ἀντερείδων ἕλκειν ἔστ' ἂν ἐξειρύσῃς τὸν πώλυπον). In
Galen's _Lexicon_ we find χηλή explained as meaning a notched probe, split
like a hoof at the point (μήλην δικροῦν, κατὰ τὸ ἀκρὸν ἐκτετμημένην
ἐμφερῶς χηλῇ). And again under the heading δικροῦν he gives τὸ οἷον
δίκρανον, ὅπερ καὶ δισχιδὲς ὀνομάζουσι τὸ δὲ αὐτὸ καὶ δηλοῖ, '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
(χορδήν) 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 (μήλῃ τῇ ἐντετμημένῃ),
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 Λ. The Aldine edition has ψ. 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 (δι' ἐξυμενιστήρων) 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, ὑδροκηλικὸν κοπάριον.

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 (ἐξυμενίσαντες τῷ τε
    ὑδροκηλικῷ κοπάριω καὶ τῷ σμιλίῳ), 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' (ὑδροκηλικοῖς ἐπικαμπέσι κοπαρίοις).

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, ἄγκιστρον, ἀγκυρομήλη; 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 (καὶ ἀγκίστρῳ
    καταπείροντες περὶ τὰ μέσα τὸ πτερύγιον), we gently make traction on
    it' (_Tet._ II. iii. 60).

Paul also says:

    'Seizing the pterygium with a hook with a small curve, (ἀγκίστρῳ
    μικροκαμπεῖ ἀναδειξάμενοι) 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 (ἄγκιστρον) 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, τυφλάγκιστρον; 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
    (τυφλαγκίστρῳ) 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 (τυφλάγκιστρον)
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:

    Ἐνδέχεται δὲ καὶ χωρὶς βελόνης ἀγκίστρῳ διατρήτῳ γενέσθαι τὴν
    ἐγχείρησιν, ὡς ἐπὶ τῶν περὶ τὰς καρωτίδας ἀρτηρίας νεύρων εἴωθε
    ποιεῖσθαι (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, ξύστρα. 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, σταφυλεπάρτης.

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"' (σταφυλεπάρτου).

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, τριχολαβίς, τριχολάβιον (== τριχολαβίδιον); 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 (τριχολαβίῳ)
    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} siècle_, 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
(τριχολαβίῳ), 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, πολυποξύστης.

Galen (_Med. Sec. Loc._ xii. 685) alludes to the method of extraction of
polypus from the nose by means of a forceps (ἔπειτα λαβιδίῳ ἐξαίρει), 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 (ἕτερον πολυποξύστην), and with the end of it
    (ἐπάκμου αὐτοῦ ξυστηρίου) bring away what remains, by stretching,
    twisting, and scraping it strongly.'

Ξυστήριον 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, μύδιον, μύγδιον, σαρκολαβίς, σαρκολάβος; 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 μυτίλοι, vulgo μύδια (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:

    Μυδίῳ πλατυστόμῳ συλλαβὼν τὴν νύμφην διὰ τῆς εὐωνύμου χειρὸς
    ἀποτεινέτω τῇ δὲ δεξιᾷ ἀποτεμνέτω παρὰ τοὺς ὀδόντας τοῦ μυδίου.

    '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):

    Μυδίῳ κατασχόντες τὸ περιττὸν τῆς νύμφης ἐκτέμνομεν σμίλῃ.

    'Seizing the hypertrophied portion of the clitoris with a vulsellum,
    excise it with a scalpel.'

Aetius (xvi. 107) also says:

    Ὥσπερ οὖν ἐπὶ τῆς νύμφης προείρηται σχηματίζειν χρὴ τὴν γυναῖκα καὶ
    μυδίῳ ἀποτείνειν τὴν ὑπεροχὴν καὶ τῷ πολυπικῷ σπαθίῳ ἐκβάσεως ὅλον τὸ
    περιττὸν ἀφαιρεῖν.

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 (μυδίῳ) and cut
    off' (vi. 74).

In the corresponding passage in Paul (VI. xvii) another name for the
vulsellum is used, viz. σαρκολάβος:--'granuloma of the inner canthus we
seize with vulsella and excise' (σαρκολάβῳ). In treating of epulis he
again uses the same term: 'Epulis we seize with vulsella and excise'
(σαρκολάβῳ).

In Moschion (II. xxx), in the chapter 'De Haemorrhoidibus quae in matrice
nascuntur', we find a Latin transliteration of the two terms μύδιον and
σαρκολάβος 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 μύδιον, and the added 'vel sarcolabo' is simply a gloss, for
the terms μύδιον and σαρκολάβος 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' (ἡ ἐπουλὶς μυδιοσκέλλῳ ἀποταθεῖσα ἐκτεμνέσθω σμιλαρίῳ στενῷ,
    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 (coudée 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 (βλεφαροκατόχῳ μυδίῳ, τοῦτ'
ἔστι πρὸς τὴν περιφέρειαν τοῦ βλεφάρου ἐσχατισμένῳ ἀνατείναντες τὸ
περιττὸν δέρμα, σμιλίῳ ἀποκόπτουσι). It may be noted that this coudée 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, σταφυλάγρα.

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 (τὴν σταφυλάγραν) 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 σταφυλάγρα 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 (σταφυλάγρᾳ) 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, σταφυλοκαύστης.

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 (τοῦ σταφυλοκαύστου τὰς
κοιλότητας), 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 (τὰς κοιλίας σταφυλοκαύστου) 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 (τῷ αἱμορροϊδοκαύστῃ ἢ τῷ
    σταφυλοκαύστῃ), we surround them close to the jaws of the instrument
    (πρὸς τὰ χείλη) 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 τῷ αἱμορροϊδοκαύστῃ, and
Cornarius and Dalechamps reject the words τῷ αἱμορροϊδοκαύστῃ ἢ τῷ
σταφυλοκαύστῃ 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, ὁ ἀκανθοβόλος.

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' (τοῖς ἰδίως ἀκανθοβόλοις
    προσαγορευομένοις ἐξέλκομεν).

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 (τριχολαβίῳ)'. A
forceps of the epilation type, but angled in its length, is figured by
Védrènes. 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, σικύα, κύαθος; 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 σικύα signify a gourd. The usual theory as
to its action was that in a diseased part there was a vicious πνεῦμα 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 (ἐπίπεδα τὰ χείλεα) and sometimes concave (σεσιμωμένα τὰ
χείλεα). 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 (κεραμεοῦν κοῦφον) and adapted to the
    side (ἁρμόζον τῇ πλευρᾷ), or bronze with flat lips (πρηνῆ τὰ χείλεα)
    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:
ἄνδρ' εἶδον πυρὶ χαλκὸν ἐπ' ἀνέρι κολλήσαντα '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 κλυστήρ, the uterine μητρεγχύτης,
and the bladder injector is called καθετήρ. In x. 328 we find all these
three terms used in one paragraph:

    Ἐς ταῦτα μὲν γὰρ διὰ =κλυστῆρος= εἰς μήτραν δὲ διὰ =μητρεγχυτῶν= τῶν
    ἐπιτηδείων τι φαρμάκων ἐνίεμεν ὥσπερ γε καὶ εἰς κύστιν διὰ τῶν
    εὐθυτρήτων καθετήρων.

The different varieties of injection apparatus which are specially named
are as follows:

    (1) Rectal: Greek, κλυστήρ, -ῆρος; Latin, _clyster_.

    (2) Vaginal: Greek, μητρεγχύτης; Latin, _clyster_.

    (3) Uterine: Greek, μητρεγχύτης; Latin, _clyster_.

    (4) Bladder: Greek, εὐθύτρητος καθετήρ; Latin, _clyster_.

    (5) Nasal: Greek, ῥινεγχύτης; Latin, _rhinenchytes_.

    (6) Ear: Greek, ὠτεγχύτης; Latin, _oricularius clyster_.

    (7) Sinus: Greek, πυουλκός; 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 (τρεῖς κότυλοι), 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 (τὸ κέρας τοῦ κλυστῆρος) 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, μητρεγχύτης.

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 (καθετήρ). 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, εὐθύτρητος καθετήρ.

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 εὐθύτρητος καθετήρ, 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, φῦσα.

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 (φῦσαν χαλκευτικήν) 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, ῥινεγχύτης; 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 (ῥινεγχύτης), 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, πυουλκός.

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 (πυουλκόν),
    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
    (πυουλκῷ), 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, ὠτεγχύτης, ὠτικὸς κλυστήρ; 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 (καλάμῳ ἢ πτίλῳ ἢ καυλῷ παχεῖ καὶ ἐπιμήκει).

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:

    Χαλκοῦν καλαμίσκον ... καθίσομεν ἔχοντα τὴν ἐκτομὴν παραπλησίαν τοῖς
    γραφικοῖς καλάμοις.

    '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' (ἐντιθέναι μοτὸν κασσιτέρινον κοῖλον).


_Tubes to prevent Contractions and Adhesions._

Greek, μοτὸς μολυβοῦς; 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, γραφικὸς κάλαμος; 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 (καλαμίσκον) 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, πτίλον.

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, καυτήριον, καυτήρ, καυτηρίδιον σιδήρεον; 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' (σιδήρια). 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, ξυράφιον.

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 (μαχαιρωτῷ καυτῆρι)' (VI. lxii).

Galen, speaking of cancer, says, 'Some use heated razor blades
(ξυραφίοις), 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 (τριαίνῃ ἢ τριαινοειδεῖ καυτηρίῳ), 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, πυρηνοειδὲς καυτήριον.

Malignant polypus of the nose is removed, says Paul (VI. xxv), with
olivary pointed cauteries (πυρηνοειδὲς καυτήριον); 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 Paré 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 (αἰγιλωπικοῖς
καυτηρίοις) 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 Γ (γαμμοειδῶν καυτήρων) and two cautery knives, we must first
    burn the scrotum through with the Γ-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' (ὡς ἐπὶ ὀβολοῦ μικροῦ).


_Lunated Cautery._

Greek, μηνοειδὲς καυτήριον.

Paul says in cases of sloughing of the prepuce we must cut it off, and if
there be haemorrhage we must use lunated cauteries (μηνοειδέσι
καυτηρίοις). 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 (ἡλωτούς) cauteries heated in the fire, and afterwards
    burn the triangle with gamma-shaped cauteries, and afterwards level
    the triangle with cauteries shaped like bricks (πλινθωτοῖς) or lentils
    (φακωτοῖς).'

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 (προμήκη). For thus they pass more
    readily through' (iii. 151).

Galen has a long note in explanation of this term:

    Φαλακρὰ κέκληκε τὰ περιφέρειαν ἔχοντα κατὰ τὸ πέρας οἷον οἱ κατὰ τὰς
    μασχάλας ἔχουσι πυρίνας ἤτοι τὰ διαπύρινα καλούμενα καὶ αἱ
    σπαθομήλαι, προμήκη δὲ τὰ τούτοις ἐναντίως διακείμενα προσηγόρευσεν,
    ὧν οὐκ ἔστι περιφερὲς τὸ πέρας ἀλλ' ὀξύτεραν περ' ἐμπλήρωμα
    παραπλήσιόν πως τοῖς εἰς τὰς παρακεντήσεις ἐπιτηδείοις ὀργάνοις.

    'He (Hippocrates) calls φαλακρά (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 προμήκη, 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 (σφηνίσκοισι σιδηρίοισι).


_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' (καυτῆρα χρὴ ποιήσασθαι οἷον καλαμίσκον φραγμίτην,
    σιδήριον δὲ ἐναρμόσαι καλῶς ἁρμόζον).

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'(ὅταν οὕτως ἔχῃ, ἐνθέντα χρὴ σύριγγα καῦσαι σιδηρίοισιν ἢ
    τριοσὶν ἢ τέσσαρσιν) (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 (πυξίνοισιν
ἀτράκτοισι βάπτων ἐς ἔλαιον ζέον) (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 (ἴσκαι) 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 μύκης, a fungus, is used--ἢ μύκησιν ὀκτὼ
ἐσχάρας καῦσαι (or with fungi burn eight scars).




CHAPTER VIII

BONE AND TOOTH INSTRUMENTS


_Raspatory._

Greek, ξυστήρ; 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 (ἐπιξύσαι). 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' (ὑπὸ τοῦ ξυστῆρος) (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 (ξυστήριον) 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, ἐκκοπεύς; 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' (ἐκκοπεῦσι) (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 (τῷ ἐκκοπεῖ), 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 ἐκκοπέων ἀντιθέτων.

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_' (ἀντιβαλλομένων δυοῖν
    ἀλλήλοις ἐκκοπέων ὡς ἔθος).

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 (δι'
    ἐκκοπέων), taking care that the instrument called 'meningophylax' (q.
    v.), or another chisel, be put under the clavicle (μηνιγγοφύλακος ἢ
    ἑτέρου ἐκκοπέως) to steady it' (VI. xciii).

The phrase δι' ἐκκοπέων ἀντιθέτων, which Paul uses in describing the
treatment of a fistula leading to carious bone, is translated by Briau--'à
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 (καὶ ἀντίθετον τούτῳ δεύτερον).


_Gouge._

Greek, κυκλίσκος, κοιλισκωτὸς ἐκκοπεύς, κυκλισκωτὸς ἐκκοπεύς, σκυλισκωτὸς
ἐκκοπεύς; 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'
(τῶν κοίλων ἐκκοπέων οὓς καὶ κυκλίσκους ὀνομάζουσιν, x. 445).

Paul (VI. xc) says:

    'And if the bone be weak, naturally, or from the fracture, we cut it
    out with gouges (σκυλισκωτοῖς), 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, φακωτός.

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 (φακωτός) 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, σφῦρα; 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 (σφῦρα) 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. Paré 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, ἐπίκοπον, 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'
    (κατ' ἐπικόπου σανιδίου τινὸς ἢ σκληροῦ δέρματος).

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:

    Χρώμενος ἐπικόπῳ, καλέσαι γὰρ οὕτως οὐδὲν χεῖρον ἔστιν ὁμοίως τοῖς
    ἀνατομικοῖς τε καὶ χειρουργοῖς τὸ στήριγμα τῶν ὑποβεβλημένων τῇ τομῇ
    τῶν σωμάτων (ii. 685).


_Meningophylax._

Greek, μηνιγγοφύλαξ; 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
(μηνιγγοφύλακα).'

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; μηνιγγοφύλακα
    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, τρύπανον; 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' (τρυπάνοις) (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 (τερέτρῳ χρὴ
περικόπτειν τὰ γυμνά).

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, τρύπανον ἀβάπτιστον; 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 (ἀβάπτιστα τρύπανα), 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 (περιτρυπήσαντες ἀβαπτίστοις τοῖς
    λεγομένοις), 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, πρίων, μαχαιρωτὸς πρίων (as if from μαχαιρόω); 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 (πρίων) 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:

    Ἤδη καὶ τῶν πριόνων τε καὶ χοινικίδων χειρουργίαι, κτλ.

    '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 (μαχαιρωτῶν
πριόνων).' There is an example of this form of saw in the Guildhall
Museum, London.


_Trephine._

Greek, τρύπανον, πρίων, πρίων χαρακτός, χοινικίς, ὀρθοπρίων; Latin,
_modiolus_.

The ancient trephine is referred to by Hippocrates, who mentions a saw
(πρίων and πρίων χαρακτός) 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
    (πρίων), being heated by the circular motion (περιόδου) 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
    (πρίονι χρὴ χαρακτῷ ἐμπρίειν), and in doing so must take out the
    trephine (πρίονα), and examine with a probe and by other means along
    the track of the trephine' (πέριξ κατὰ τὴν ὁδὸν τοῦ πρίονος).

In injuries to the head in young people (iii. 371) he mentions a small
trephine (σμικρὸν τρύπανον), so that apparently several sizes were
available. Hippocrates, we have seen, uses the words πρίων and πρίων
χαρακτός to denote the trephine. Galen always uses χοινικίς, but in his
Lexicon he gives two other words, viz. ὀρθοπρίονι and περητηρίῳ,
ostensibly from the works of Hippocrates:

    Ὀρθοπρίονι--τῇ χοινικίδι.

    περητηρίῳ--τρυπάνῳ τῷ εὐθεῖ καὶ ὀξεῖ, ἔστι γὰρ καὶ ἕτερον ἡ χοινικίς.

These terms do not, however, occur in any extant Hippocratic writings,
unless, as seems possible to me, the latter term περητηρίῳ be a _var.
lect._ for the obscure word τρυγλητηρίῳ applied to τρύπανον 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' (χοινικίσιν); 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 χοινικίς is derived from χοινίκη and χνόη, 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 χοινικίδα 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, λεπτὸν τρύπανον.

Galen (xii. 821) says that Archigenes in cases of fistula lachrymalis
perforated the nasal bone with a small drill (λεπτὸν τρύπανον), and Paul
(VI. xxii) says:

Some, after excision of the flesh, use a perforator (τρύπανον) 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, μοχλίσκος, ἀναβολεύς.

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 (σιδήρια) are to be prepared like the
    levers (οἱ μοχλοί) 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 (τῷ λεγομένῳ μοχλίσκῳ). 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 Paré 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, ὀστάγρα.

Galen (x. 450) says, in comminuted fracture of the skull we must make a
way for the lenticular with the bone forceps (διὰ τῆς ὀστάγρας); 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' (ὀδοντάγρα ἢ ὀστάγρα).

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 (ὀδοντάγρας ἢ ὀστάγρας). 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
    (κιρσουλκῷ) 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, ὀδοντάγρα, ῥιζάγρα.

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 ῥιζάγρα. Paulus Aegineta (VI.
xxvii) bids us scarify down to the socket and loosen the tooth gradually
by shaking with a tooth extractor (ὀδοντάγρα) and extract it.
Supernumerary teeth are, if fast, to be rasped down with a graving tool;
if loose, to be extracted with tooth forceps (διὰ τῆς ὀδοντάγρας). 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 (ὀστάγρας ἢ ὀδοντάγρας). 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. (ὀδοντάγρα ἢ ὀστάγρα). 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 (ὀδοντάγρας ἢ ῥιζάγρας).


_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, ξυστήριον, σμιλίον, σμιλιώτον (sc. ὄργανον); 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 (ξυστηρίῳ) 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
(τῶν σμιλιωτῶν).


_File._

Greek, ῥινάριον, ῥίνη, ῥινίον; 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:
σιδήριον ἐποίησα ῥινίον πυρηνοειδές (xiv. 871).

Aetius copies Galen's chapter word for word (II. iv. 30). Paul (VI.
xxviii) says the file (ῥινάριον) 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, βελουλκόν (sc. ὄργανον).

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
    (βελουλκοῦ), 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 βελουλκοῦ
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, ὑποσπαθιστήρ, σπαθιστήρ.

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 (ὑποσπαθιστήρ), 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 ὑποσπαθιστήρ. The
operation is mentioned by Epiphanius, a bishop of Alexandria in the fourth
century, by whom the instrument is referred to as σπαθιστήρ.


_Impellent._

Greek, διωστήρ.

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 (διωστῆρος), 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'
    (τὴν θήλειαν τοῦ διωστῆρος καθέντες καὶ ἐναρμόσαντες ὠθήσομεν τὸ βέλος
    εἰ δὲ αὐλὸν τὸν ἄρρενα).

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 Paré 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, κυαθίσκος Διοκλεῖος.

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 Διοκλείου κυαθίσκον 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 Hôpital
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 manœuvre of pushing back, by means of a catheter, a
stone impacted in the urethra. Rufus of Ephesus (Περὶ λιθιώσης κύστεως)
says of impacted urethral calculus: 'Those that are stuck fast push back
with the catheter if you prefer not to do lithotomy' (ἐρείδοντας οὖν εἰ μὴ
θέλοις τέμνειν ἀπῶσαι τῷ αὐλίσκῳ). 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 (καθετήρ). The word Rufus uses puts it beyond
doubt that a hollow tube is meant, or we might have argued that καθετήρ
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 (μήλωσις) 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, λιθουλκός; 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
λιθουλκός, 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'
    (τοῦ λιθουλκοῦ) (VI. lx).

Adams translates λιθουλκός by 'forceps for extracting stone', but this is
not quite a justifiable translation. The instruments whose names end in
-ουλκός, and which are derived from ἕλκω, are certainly in many instances
forceps, e. g. βελουλκός, a forceps for extracting weapons, but in other
cases they are as certainly not. I need only refer to ἐμβρυουλκός, which
is conclusively described as a hook for extracting the dead foetus. Thus
while it is possible that the λιθουλκός 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 λιθολάβος,
which has a more definite meaning. The majority of words compounded of
-λάβος means some variety of forceps, e. g. σαρκολάβος, 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 λιθολάβος 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 λιθοτόμος 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, ἑδροδιαστολεύς, μικρὸν διόπτριον, κατοπτήρ.

The earliest mention of the rectal speculum is to be found in the treatise
on fistula by Hippocrates:

    Ὕπτιον κατακλίνας τὸν ἄνθρωπον κατοπτῆρι κατιδὼν τὸ διαβεβρωμένον τοῦ ἀρχοῦ.

    '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"' (τῷ
    ἑδροδιαστολεῖ (τῷ μικρῷ διοπτρίῳ λέγω) διαστεῖλαι τὴν ἕδραν ὡς γυναικεῖον κόλπον).

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 κατοπτήρ, in contradistinction
to the vaginal speculum which was called διόπτρα. In Galen's Lexicon they
are explained as follows:

    Κατοπτῆρι, τῷ καλουμένῳ ἑδροδιαστολεῖ, ὥσπερ γε καὶ διόπτρα ὁ γυναικῶν διαστολεύς.

    '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, διόπτρα; 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 Περὶ
διοπτρισμοῦ. 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 (διόπτρα)
    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 (τοῦ τῆς διόπτρας λωτοῦ) 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 (τὸν κοχλίον) 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 (τῶν
    ἐμπλησμάτων τοῦ λωτοῦ) 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, ἐμβρυουλκός; 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 (καταπείρειν δὲ καὶ ἀντίθετον τούτῳ δεύτερον), 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 (τῷ ἑλκυστῆρι) 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 Bibliothèque Nationale.


_Cranioclast._

Greek, πίεστρον, ἐμβρυοθλάστης, θλάστης;

The cranioclast is mentioned by Hippocrates (ii. 701).

    Σχίσαντα τὴν κεφαλὴν μαχαιρίῳ ξυμπλάσαι ἵνα μὴ θραύσῃ τῷ πιέστρῳ καὶ
    τὰ ὀστέα ἕλκειν τῷ ὀστεουλκῷ.

    '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 πιέστρῳ defined as τῷ ἐμβρυοθλάστῃ
καλουμένῳ. 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 (μηχαναῖς) 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 μηχαναῖς 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 (καὶ περὶ
    ξύστραν περιειλίξας γυπὸς δέρμα ἢ ὑμένα, διαξύειν τὸ στόμα τῶν μητρέων).

ξύστρα 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, ἐμβρυοσφάκτης; 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;
    ἐμβρυοσφάκτην 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 ἐμβρυοσφάκτης (_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 (δύο ἑκτέας), 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, βάλανος, πεσσόν, πεσσός; 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 (βάλανον ἐνθεὶς κερατίνην). 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, σπόγγος; 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:

    Ὁπότε τρυφερὸν καὶ καθαρὸν σπογγάριον ἐπιμήκες ὡσαύτως διάβροχον ὡς
    ἐσωτάτω παρεντιθέναι προσήκει.


_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
(ὠμολίνου), 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 χορδή, 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, ἀγκτήρ; 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; ἀγκτῆρας 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 ἀγκτῆρας) 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 (ἀγκτῆρσι καὶ ῥαφαῖς). 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 ἀγκτῆρσι, the codices of Paul almost
unanimously have ἀγκίστροις. 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 (ταινίαν) 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, ἠθμός, κυρτίς; 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 (διὰ κυρτίδων τῶν
κοχλιῶν). The word κυρτίς literally means a basket or wicker eel-trap.
Here it must mean a strainer.


_Mortar and Pestle._

Greek, ἰγδίον, mortar: δοῖδυξ, 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:

    Ἐν μολυβδίνῳ ἰγδίῳ καὶ μολυβδίνῳ δοίδυκι λειώσας.

    '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, ἀκόνη; 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:

    Τό γε μὴν τῆς Ναξίας ἀκόνης ἀπότριμμα ψυκτικὸν εἶναι φασὶν ὥστε καὶ
    τιτθοὺς παρθένων καὶ παίδων ὄρχεις προστέλλειν. τῆς ἐλαιακόνης δὲ τὸ
    ἀπότριμμα ῥυπτικὸν ὑπάρχον ἀλωπεκίαις ἁρμόττει.

    '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:

    Ἡ δὲ σμύρις ῥυπτικὴν ἔχουσα δύναμιν ὀδόντας σμήχει.

    '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

ÉTUI, 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 étui 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 Bosséaz 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 Musée 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 × 18
cm. outside measurement, and 7 × 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, coudé 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. Étui 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 Bosséaz and Allaz. Étui for probes, seal for
medicament pots, vulsella.

_Sierre._ Four spoon probes, spatula probe, large needle.

_Schaffhausen._ Probe from Schleitheim.

_Zürich_ (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 (Zürich). 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, étui, 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 estremità 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 à Herculanum et Pompeï. (_Gazette
Médicale_, 1867, xxii. pp. 491-94.)

SCOUTETTEN.--Histoire des instruments de chirurgie trouvés à Herculanum et
à Pompeï. (_France Médicale_, 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.--Über Pincetten alter Völker. (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 Général du Musée National de Naples. (Naples, 1900.)

MONACO.--Les monuments du Musée National de Naples.

MONACO.--Specimens of domestic articles from the Naples Museum (Naples,
n.d.).

LINDENSCHMIDT.--Die Altertümer unserer heidnischen Vorzeit, Bd. iv. Heft
iii.

Anzeiger für schweizerische Geschichte and Altertumskunde, Jahrgang 1857,
No. 3.

ULRICH.--Jahrbücher des Vereins für Altertumsfreunde in den Rheinländen,
xiv. 1849.

ULRICH.--Catalogue of the Collection of the Antiquarian Society of Zürich
(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 römischen Aerzte auf dem Boden der Schweiz.
(Zürich, 1894.)

ANONYMOUS.--Un hôpital militaire romain. Zürich. (A sketchy pamphlet
published as an advertisement by the town of Baden.)

Mitteilungen der Antiquarischen Gesellschaft, Zürich.--References of
interest occur in the following volumes: vol. vii, Meyer, Geschichte der
XI. und XXI. Legion; vol. ix, Mommsen, Die Schweiz in römischer Zeit (15);
vol. xii, Die römischen Ansiedelungen in der Ostschweiz (19. M. B.); vol.
xiv, Bochat, Recherches sur les antiquités d'Yverdon; vol. xvi, Römische
Alterthümer aus Vindonissa; Römische Ansiedelungen in der Ostschweiz, ii;
vol. xvi, Bursian, Aventicum Helvetiorum, Mosaikbild von Orbe.

TOLOUSE.--Recherches historiques et archéologiques sur divers points du
vieux Paris (Mémoires de la Société 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 médicales, 1870.

MCKAY.--History of ancient Gynaecology, 1901.

LAMBROS.--Περὶ σικυῶν καὶ σικυάσεως παρὰ τοῖς ἀρχαίοις. 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.

  Étui, 168.

  Excavator, dental, 138.


  Fibula, 162, 164.

  File, 139.

  Fillet, 36, 156, 164.

  Finds, 20.

  Fistula knife, 47.

  Forceps, blacksmith's, 136.
    bone, 135.
    coudée, 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.

  Löffelsonde, 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.

  Paré, 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

  ἀβάπτιστος, 129.

  ἄγκιστρον, 85.

  ἀγκτήρ, 162.

  ἀγκυλοτόμος, 47.

  ἀγκυρομήλη, 85.

  αἱμορροϊδοκαύστης, 99.

  ἀκανθοβόλος, 100.

  ἀκόνη, 166.

  ἀμφίσμιλος, 56.

  ἀναβολεύς, 133.

  ἀναρραφικός, 45.

  ἀντίθετος, 123.

  ἀπυρομήλη, 63.

  ἄτρακτος, 120.

  αὐλίσκος, 145.


  βάλανος, 159.

  βελουλκόν, 139.

  βλεφαροκάτοχος, 97.

  βλεφαρόξυστον, 71.


  γαμμοειδής, 118.

  γαστρώδης, 28.

  γλωσσοκάτοχος, 79.

  γραφεῖον, 72.

  γραφικός, 114.

  γράφιον, 72.

  γραφίς, 72.


  διαπύρηνος, 56.

  διαστελλούσας, 81.

  διαστολεύς, 81.

  διαστομωτρίς, 81.

  δικροῦς, 83.

  διόπτρα, 151.

  διόπτριον, 149.

  διοπτρισμός, 150.

  διωστήρ, 141.

  δοῖδυξ, 165.


  ἑδροδιαστολεύς, 149.

  ἐκκοπεύς, 122.

  ἐλαιακόνη, 167.

  ἐμβρυοθλάστης, 154.

  ἐμβρυοσφάκτης, 157.

  ἐμβρυοτόμον, 43.

  ἐμβρυουλκός, 152.

  ἐξωτίς, 63.

  ἐπίκοπον, 125.


  ἠθμός, 165.

  ἡλωτός, 118.

  ἡμισπάθιον, 38.


  θλάστης, 154.


  ἰγδίον, 165.

  ἴσκαι, 120.


  καθετήρ, 105, 145.

  καθιάς, 36.

  καλαμίσκος, 112.

  κάλαμος, 114.

  κατειάδιον, 36.

  κατιάδιον, 36.

  κατοπτήρ, 149.

  καυτήρ, 116.

  καυτηρίδιον, 116.

  καυτήριον, 116.

  κιρσουλκός, 136.

  κλυστήρ, 105.

  κοιλισκωτός, 123.

  κότυλος, 106.

  κυαθίσκος, 64, 77, 142.

  κύαθος, 101.

  κυκλίσκος, 123.

  κυκλισκωτός, 123.

  κυρτίς, 165.


  λιθοτόμον, 40.

  λιθουλκός, 5, 147.


  μάχαιρα, 27.

  μαχαίριον, 27.

  μαχαιρίς, 27.

  μήλη
    διαστέλλουσα, 81.
    δικροῦς, 83.
    ἐντετμημένη, 83.
    ἐξωτίς, 63.
    ἰσχυρά, 69.
    ὀφθαλμική, 71.
    τραυματική, 68.

  μηλωτίς, 63.

  μηλωτρίς, 63.

  μηνιγγοφύλαξ, 126.

  μηνοειδής, 118.

  μητρεγχύτης, 107.

  μοτός, 113.

  μοχλίσκος, 133.

  μύδιον, 94.

  μυδιόσκελλον, 96.

  μύκης, 120.


  ξυράφιον, 117.

  ξυστήρ, 121.

  ξυστήριον, 94, 121, 138.

  ξύστρα, 88, 157.


  ὀδοντάγρα, 136.

  ὄνυξ, 31.

  ὀξυβελής, 32.

  ὀξυκόρακος, 43.

  ὀρείχαλκος, 14.

  ὀρθοπρίων, 131.

  ὀστάγρα, 135.

  ὀφθαλμικός, 71.


  πεσσόν, 159.

  πεσσός, 159.

  πίεστρον, 154.

  πλινθωτός, 118.

  πολύκμητος, 10.

  πολυπικός, 39.

  πολυποδικός, 39.

  πολυποξύστης, 94.

  πρίων, 130.

  προμήκης, 119.

  πρόσθετον, 82.

  πτερυγοτόμος, 44.

  πτίλον, 111, 115.

  πυουλκός, 109.

  πυρήν, 53.

  πυρηνοσμήλη, 55.


  ῥινάριον, 139.

  ῥινεγχύτης, 109.

  ῥίνη, 139.

  ῥινίον, 139.


  σαρκολάβος, 94.

  σίδηρος, 10.

  σικύα, 101.

  σκολόπιον, 28.

  σκολοπομαχαίριον, 28.

  σκυλισκωτός, 123.

  σμήλη, 52.

  σμιλάριον, 38.

  σμίλη, 27, 52.

  σμιλίον, 45.

  σμιλιωτός, 138.

  σμύρις, 167.

  σπαθίον, 38.

  σπαθιστήρ, 140.

  σπόγγος, 161.

  σταφυλάγρα, 97.

  σταφυλεπάρτης, 89.

  σταφυλοκαύστης, 98.

  σταφυλοτόμον, 46.

  στηθοειδής, 27.

  συριγγοτόμον, 47.

  σῦριγξ, 47, 120.

  σφηνίσκος, 119.

  σφῦρα, 125.


  τέρετρον, 127.

  τραυματικός, 68.

  τρίαινα, 117.

  τριχολάβιον, 90.

  τριχολαβίς, 90.

  τρύπανον, 126.

  τυφλάγκιστρον, 87.


  ὑδροκηλικός, 85.

  ὑπαλειπτρίς, 51.

  ὑπάλειπτρον, 51.

  ὑποσπαθιστήρ, 140.


  φακωτός, 118.

  φαλακρός, 118.

  φλεβοτόμον, 32.

  φλεβοτόμος, 32.

  φῦσα, 108.


  χαρακτός, 131.

  χηλή, 83.

  χοινικίς, 131.


  ψαλίς, 49.


  ὠτεγχύτης, 110.

  ὠτικός, 110.

  ὠτογλυφίς, 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   Bibliothèque 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 Védrènes


[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 Védrènes
  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 Védrènes
  3. 12{cm}     Saint-Germain
  4. 12{cm}          "
  5. 7{cm},5    Naples
  6. 11{cm},5   After Védrènes


[Illustration: PLATE XXI]

   _Size of
  originals._   _Museum._

  1. 15{cm}     After Védrènes
  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 Védrènes


[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 Védrènes
  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 Védrènes


[Illustration: PLATE LI]

   _Size of
  originals._   _Museum._

  1. 21{cm}     Naples
  2. 3{cm},3    After Védrènes
  3, 4.           "   Albucasis


[Illustration: PLATE LII]

   _Size of
  originals._           _Museum._

  1. 6{cm}              Cologne
  2. 3{cm}              Toulouse
  3. 2{cm} × 4{cm},2    Author's
  4. 4{cm},4 × 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} × 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}.