CHAPTER IX

‘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. 1shows 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 areundoubtedly 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.’

‘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. 2shows a forceps from Roman London in the Guildhall Museum.

Tooth and Stump Forceps.

Greek, ὀδοντάγρα, ῥιζάγρα.

The ancients regarded tooth extraction as an operation tobe 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 (seep. 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 ἢὀδοντάγρας). 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. 1shows 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 ofweapons, 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 pericraniumwas 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.’

‘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.

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. SeePl. 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 thesize 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).

‘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 thebreadth. 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.’

‘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 inPl. IV; and in the marbleex vototablet 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 asthe 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).

‘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).

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 hingein 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.’

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. 1shows 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 prunascalefacere (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.

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 prunascalefacere (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 is0·09 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 inPl. 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.’

‘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:

Back to Index Next