CHAPTER III

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.’

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 gotmainly 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 bya 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).

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 westernprovinces, 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 anair de famillewhich 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 entitledMes fouilles dans le sol du vieux Paris(Paris, 1888). In 1892 the find was fully described by Professor Deneffe of Ghent, in theRevue Archéologique, under the title ‘Notice descriptive sur une trousse de médecin auIIImesiècle’, and reprinted, with photogravures, in 1893 in a monographÉtude sur la trousse d’un chirurgien Gallo-Romain duIIImesiècle(Antwerp, 1893). It is convenient to refer to this find as that of the ‘Surgeon ofParis’. 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 theAnnales 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 ofLes Oculistes Gallo-Romaine auIIImesiècle(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 200A. D.The objects mentioned are still theprivate 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.

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 inPlates 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 inPl. 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 withwhich 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. Anex vototablet found on the site of the temple of Aesculapius on the Acropolis at Athens shows a box of scalpels, among which are some interesting forms (Pl. IV). The scalpels, it will be noted, are arranged head and tail alternately. A few varieties are actually described in detail in the classical authors, and, by piecing together other references to particular instruments and drawing inferences from the various uses to which we find them put, we are able to describe a surprisingly large number of forms. The sixteenth-century writers, such as Paré, and seventeenth-century writers, such as Scultetus, illustrate with great confidence many of the cutting instruments mentioned by ancient writers, but it is easy to show that in several instances they are wrong, and, therefore, I have drawn on them as little as possible.

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

Ordinary Scalpel.

The ordinary scalpel had apparently a straight, sharp-pointed blade. The word which Galen, Aetius, and Paulus Aegineta use to denote scalpel is σμίλη. Latin authors usescalpellus, the diminutive ofscalper. 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 inPl. V, figs. 1 and 2from 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 inPl. 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.’

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 toPl. V, fig. 3in 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 treatiseDe 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 toa cutting instrument sufficiently indicates its shape. It takes its name from its similarity to the beak of a snipe, which is long and slender[1]. We find it used by Galen (xi. 1011) for dissecting out warts, excising caruncles from the inner canthus, puncturing the foetal cranium in obstructed labour, &c.

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

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

Razor.

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

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

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

A large scalpel of this form from the Naples Museum is shown inPl. 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 theculter, butculteris not a term applied by any Latin author to a surgical instrument, nor iscultellus, 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 domesticculterorcultellusis shown inPl. 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.’

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

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

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

Galen’s knife for opening the vertebral canal.

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

Καθίημι τὸ πρόμηκες μαχαίριον, οὕτω γὰρ αὐτὸ καλῶ δύο πλευρὰς ὀξείας ἔχον ἐπὶ τοῦ πέρατος εἰς μίαν κορυφὴν ἀνηκοῦσας.‘I push in the ‘long scalpel’, for thus I describe the one with two cutting edges meeting in one at the tip.’

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 (seep. 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 arecertain 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.’

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 arecertain 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 theIliad, 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 curvedbistoury; 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,scalpellumnempe minus et maius; vulguslancettaseadem nominant. Serviunt eadem, praesertim minora, venis incidendis, quare phlebotoma Graecis vocantur; sed et abscessibus aperiendis, imprimis maiora; ideoque Gallis etiamlancettes a l’abscesappellari consueverunt.

A bronze blade of this shape is shown inPl. 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 (seePl. 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 atall, 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 theGentleman’s Magazine(1862, pt. ii. p. 677):

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