CHAPTER IV

‘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, inThe 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 inRoman 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 toits 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. inScrib. 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 inPl. 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 thanPaul 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).

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 inPl. IVhas 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) ferramentumfecit 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.’

‘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 bylabrosum, andsumma parteI take to refer to the back part of the blade, and not to the back part of the instrument as a whole.RectumI 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 roundedthe 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.’

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

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

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

Probe pointed blade with two cutting edges.

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

II A. (a)Curved bistoury—‘Crow Bill.’

Greek, ὀξυκόρακον σμίλιον.

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

In Celsus the instrument appears under the termcorvus. 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 dissectsout 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 thehairs 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 shapewe 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,’orἀγκύλος, ‘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-likeportion 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 ὁμοίωςἑκατέρωθεν, 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.’

‘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.’

‘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. InPl. X, fig. 5is shown a bronze pair from the Naples Museum, found in Pompeii.

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 eyedprobe (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 specillopatet. 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.’

‘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 usesbaca(sic), a berry, andbacula, little berry, and in theAdditamenta(I. viii. 21, ed. Rose) he uses the transliterationpyrena 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. 3shows a rather longer specimen from the Naples Museum. A variety with non-tapered ends is seen inPl. X, fig. 1. It is also from the Naples Museum.Pl. XI, fig. 4shows 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:

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