CHAPTER VII

‘It is necessary to insert a leaden tube, similar in shape to the largest dilator but hollow so as to contain substances, and the width of the bore will be the same as that used for ulcers, in order that the mouth of the tent may be smooth and do no damage, and it will be prepared like the wooden dilators. When the tent has been prepared fill it with rubbed down mutton fat, and when ready extract the wooden dilator and insert the leaden one.’

This leaden dilator is referred to over and over again by Hippocrates. There are in the Naples Museum three of these metal tubes. They are of bronze. One is 18 cm. long, 14 mm. wide at one end, narrowing gradually to 6 mm. at the point (Pl. XXXIX, fig. 1).

Calamus Scriptorius.

Greek, γραφικὸς κάλαμος; Latin,calamus scriptorius.

The writing pen reed is frequently referred to as an implement of minor surgery.

Alexander Trallianus (IV. viii) says that a calamus scriptorius whose joints have been removed may be used as an insufflator. Celsus (VII. v) says that when a weapon buried in the flesh has barbs too strong to be broken with forceps they may be shielded with split writing reeds, and the weapon thus withdrawn:

Fissis scriptoriis calamis contegenda, ac, ne quid lacerent, sic evellenda sunt.

Paul says ‘Some apply a tube (καλαμίσκον) round about the barbs’ (VI. lxxxviii).

Celsus (III) mentions a narrow tube of this sort for drinking water through in cases of nocturnal thirst.

Paul (VI. xxiv and III. xxiii) says that foreign bodies may be sucked from the ear with a reed.

Quill.

Greek, πτίλον.

Galen (x. 1011) says that warts may be extracted by means of quills of feathers.

Paul quotes this (VI. lxxxvii):

‘Some, among whom are Galen, advise us to scarify round the wart with the quill of a hard feather, such as those of old geese or of eagles, and to push it down so as to remove the wart from its roots. Others do the same with a copper or iron tube.’

Aretaeus says a quill may be used for blowing powder into the pharynx (408, vol. ii).

CAUTERIES

Cautery.

Greek, καυτήριον, καυτήρ, καυτηρίδιον σιδήρεον; Latin,Ferrum candens.

The cautery was employed to an almost incredible extent in ancient times, and surgeons expended much ingenuity in devising different forms of this instrument. A considerable number of these shapes are definitely mentioned. The cautery is nearly always spoken of as made of iron. Bronze becomes too soft to act well as a cautery, so that even the earliest references to the cautery in the authentic Hippocratic writings refer to cauteries as ‘the irons’ (σιδήρια). It is true, of course, that in special cases bronze was used—and Priscianus recommends a cautery of gold or silver for stopping haemorrhage from the throat (Logicus, xxii)—but iron was the usual thing, and in spite of the enormous numbers of cauteries which must have existed only a very few have come down to us, as the iron has perished. The cautery was employed for almost every possible purpose, as a ‘counter-irritant’, as a haemostatic, as a bloodless knife, as a means of destroying tumours, &c.

The following passage is interesting as showing its application in two of these capacities (Aet. IV. iv. 45):

‘I put the patient lying on her back, then I incise the sound part of the breast outside the cancer and burn the incision with cauteries until the eschar produced stops the flow of blood. By and by I incise again and dissect the depth of the breast and again burn the incision; and often repeat the same, both cutting and cauterizing to stop the haemorrhage, for then the danger of a rush of bleeding is avoided, and after the amputation is completed I again burn all the parts to desiccation. The first cauterization is for the sake of stopping the haemorrhage, the second for eradicating all traces of the disease.’

Cautery Knife.

Greek, ξυράφιον.

Paul on several occasions mentions the use of the cautery knife. In radical cure of hydrocele, as an alternative to the excision of the sac by the knife, he explains how it may be done with the cautery, and says, ‘Afterwards, when the whole is laid bare, we stretch it with hooks and remove it with a sword-shaped cautery (μαχαιρωτῷ καυτῆρι)’ (VI. lxii).

Galen, speaking of cancer, says, ‘Some use heated razor blades (ξυραφίοις), at once cutting and burning’ (xiv. 786).

Trident Cautery.

For forming issues over the spleen Paul (VI. xlviii) says:

‘Some pick up the skin with hooks and push through it a long cautery, and repeat this three times so that there are six eschars. Marcellus, however, by using the instrument called a trident or trident-shaped cautery (τριαίνῃ ἢ τριαινοειδεῖ καυτηρίῳ), formed six eschars at one application.’

Vulpes describes an instrument of bronze which he considers to be a trident-shaped cautery. It was found along side an instrument which I take to be a phlebotome. If it is for the purpose described above by Paul it is unusual in being of bronze, and it must have lost a good part of its teeth.

Olivary Cautery.

Greek, πυρηνοειδὲς καυτήριον.

Malignant polypus of the nose is removed, says Paul (VI. xxv), with olivary pointed cauteries (πυρηνοειδὲς καυτήριον); and again, quoting Leonidas, he says empyema may be opened in the same way (VI. xliv).

The special cautery which was used for ‘aegilops’ (fistula lachrymalis) was probably an olivary pointed cautery, as the cautery recommended by both Scultetus and Paré for this is an olivary pointed one. Paul (VI. xxii) says, ‘Some after excision of the flesh use a perforator, and make a passage for the fluid or matter to the nose, but we are content withburning alone, using the cauteries for fistula lachrymalis (αἰγιλωπικοῖς καυτηρίοις) and burning down till a lamina of bone exfoliates.’

Gamma-shaped Cautery.

Paul (VI. lxii), describing the radical cure of hernia, says:

‘Wherefore having heated ten or twelve cauteries shaped like the Greek letter Γ (γαμμοειδῶν καυτήρων) and two cautery knives, we must first burn the scrotum through with the Γ-shaped ones, &c.’

Obol Cautery.

In the treatise on haemorrhoids (iii. 340) Hippocrates says:

‘I order, therefore, seven or eight instruments to be prepared, a palm long, and the thickness of a thick specillum, bent towards the end and flattened on the point like a small obol’ (ὡς ἐπὶ ὀβολοῦ μικροῦ).

Lunated Cautery.

Greek, μηνοειδὲς καυτήριον.

Paul says in cases of sloughing of the prepuce we must cut it off, and if there be haemorrhage we must use lunated cauteries (μηνοειδέσι καυτηρίοις). They both stop the haemorrhage and prevent the spreading of the sore (VI. lvii).

Nail, Tile and Button Cautery.

Treating of bubonocele, Paul says (VI. lxvi):

‘Make a triangular mark over the centre of it and apply to the mark nail-shaped (ἡλωτούς) cauteries heated in the fire, and afterwards burn the triangle with gamma-shaped cauteries, and afterwards level the triangle with cauteries shaped like bricks (πλινθωτοῖς) or lentils (φακωτοῖς).’

Cauteries of nail shape are also referred to by Hippocrates in the treatment of recurrent dislocation of the shoulder:

‘Raise up the skin. Burn with cauteries which are not thick nor much rounded but of an elongated shape (προμήκη). For thus they pass more readily through’ (iii. 151).

Galen has a long note in explanation of this term:

Φαλακρὰ κέκληκε τὰ περιφέρειαν ἔχοντα κατὰ τὸ πέρας οἷον οἱ κατὰ τὰς μασχάλας ἔχουσι πυρίνας ἤτοι τὰ διαπύρινα καλούμενα καὶαἱ σπαθομήλαι, προμήκη δὲ τὰ τούτοις ἐναντίως διακείμενα προσηγόρευσεν, ὧν οὐκ ἔστι περιφερὲς τὸ πέρας ἀλλ' ὀξύτεραν περ' ἐμπλήρωμα παραπλήσιόν πως τοῖς εἰς τὰς παρακεντήσεις ἐπιτηδείοις ὀργάνοις.‘He (Hippocrates) calls φαλακρά (globose) those having a ball at the tip, such as those for the axilla, which have olivary points and also those which are called double olivary probes and spathomeles. But those which are the reverse he calls προμήκη, i. e. those which have the end not globose but rather sharp, exactly like the instruments for paracentesis’ (xviii. 376).

‘He (Hippocrates) calls φαλακρά (globose) those having a ball at the tip, such as those for the axilla, which have olivary points and also those which are called double olivary probes and spathomeles. But those which are the reverse he calls προμήκη, i. e. those which have the end not globose but rather sharp, exactly like the instruments for paracentesis’ (xviii. 376).

In the Naples Museum there are three tile-shaped cauteries, one of iron and two of bronze. One of the latter is shown inPl. XL, fig. 1.

Wedge-shaped Cautery.

Hippocrates (iii. 223) says that the oblique veins of the head are to be burned with wedge-shaped cauteries (σφηνίσκοισι σιδηρίοισι).

Needle Cautery.

Celsus (VII. viii) says:

At ubi aures in viro puta, perforatae sunt et offendunt, traiicere id cavum celeriter candente acu satis est, ut leviter eius orae exulcerentur.

Treating of trichiasis he says (VII. vii. 8):

Si pili nati sunt qui non debuerunt tenuis acus ferrea, ad similitudinem spathae lata, in ignem coniicienda est; deinde candens, sublata, palpebra sic ut eius perniciosi pili in conspectum curantis veniant, sub ipsis pilorum radicibus ab angulo immittenda est, ut ea tertiam partem palpebrae transsuat; deinde iterum, tertioque usque ad alterum angulum; quo fit ut omnes pilorum radices adustae emoriantur.

This indicates a needle beaten out into the shape of one of our spuds for removing foreign bodies from the eye. The needle handles from the find of the oculist Severus are well adapted for this work, but are dealt with elsewhere (p. 69).

Cautery guarded by a Tube.

In the treatise on haemorrhoids (iii. 345) Hippocrates says:

‘We must make a [tubular] cautery like a writing reed and fit it to a well-fitting iron’ (καυτῆρα χρὴ ποιήσασθαι οἷον καλαμίσκον φραγμίτην, σιδήριον δὲ ἐναρμόσαι καλῶς ἁρμόζον).

Again, in the treatment of polypus of the nose, he says:

‘When that occurs we must insert a tube and cauterize with three or four irons’(ὅταν οὕτως ἔχῃ, ἐνθέντα χρὴ σύριγγα καῦσαι σιδηρίοισιν ἢ τριοσὶν ἢ τέσσαρσιν) (ii. 244).

Celsus says this tube may be a calamus or a tube of pottery:

Apud quosdam tamen positum est, vel fictilem fistulam vel enodem scriptorium calamum in narem esse coniiciendum, donec sursum ad os perveniat: tum per id tenue ferramentum candens dandum esse ad ipsum os (VII. xi).

Wood dipped in boiling Oil.

Hippocrates, in diseases of the liver, says that cauterization may be performed with boxwood spindles dipped in boiling oil (πυξίνοισιν ἀτράκτοισι βάπτων ἐς ἔλαιον ζέον) (ii. 482). Aetius (XII. iii) says that the root of the birthwort (aristolochia) may be used in the same way.

Ignited Fungi, &c.

In the passage in Hippocrates on cauterizing for disease of the liver, Hippocrates, as an alternative to the hot iron, says that eschars may be produced by fungi. This must mean that they were set on fire like the old moxa.

This is probably what is meant by Paul when, in treating of cauterizing over the stomach, he says (VI. xlix):

‘But some do not burn with iron but with the substances called iscae. The iscae (ἴσκαι) are spongy bodies forming on oaks and walnut trees, and are mostly used among the barbarians.’

Aetius (II. iii. 91) says iscae are the medullary wood of the walnut tree.

In Hippocrates (ii. 482) the word μύκης, a fungus, is used—ἢ μύκησιν ὀκτὼ ἐσχάρας καῦσαι (or with fungi burn eight scars).

BONE AND TOOTH INSTRUMENTS

Raspatory.

Greek, ξυστήρ; Latin,scalper excisorius,scalper medicinalis.

The raspatory or rugine consists of a blade of varying shape fixed at right angles to the shaft, and it is operated by pulling instead of by being driven forwards by striking or pushing. Although no ancient raspatory has been preserved to us we are quite familiar with the instrument, as it has been in continuous use throughout ancient and mediaeval times, and it is in use at the present day. The raspatory is the instrument upon which Hippocrates relies for eradicating fissured and contused bone in injury to the skull:

‘If you cannot discover whether the bone is broken or contused, or both the one and the other, nor can see the truth of the matter, you must dissolve black ointment and fill the wound with the solution, and apply a linen rag smeared with oil, and then a poultice of maza with a bandage; and on the next day, having cleaned out the wound, scrape the bone with the raspatory (ἐπιξύσαι). And if the bone is not sound but fractured and contused, the rest of the bone will be white when scraped, but the fracture and contusion, having imbibed the preparation, will appear black, while the rest of the bone is white. And you must again scrape more deeply the bone where it appears black, and if you thus remove the contusion and cause it to disappear you may conclude that there has been a contusion of the bone to a greater or less extent, which has occasioned the fracture that has disappeared under the raspatory’ (ὑπὸ τοῦ ξυστῆρος) (iii. 366).

From Galen we learn that there were different sizes and shapes of the raspatory (x. 445):

‘In simple fissure reaching to the second plate narrow raspatories are used, and they should be of different sizes to suit all cases. The affected bone being exposedsecundum artem, first the broader ones are to be used, then the smaller down to the narrowest. The narrowest are to be used in the diploe.’

Paul refers to a small raspatory (ξυστήριον) for use as a tooth scaler (q. v.). All the mediaeval writers figure numerous shapes of raspatories—many more than we use to-day, but all on the same principle as ours.

Chisel.

Greek, ἐκκοπεύς; Latin,scalper,scalprum planum.

The flat chisel is referred to by Celsus in his description of the levelling of an elevation on one side of a depressed fracture of the cranium:

Ergo, si ora alteri insedit, satis est id quod eminet plano scalpro excidere; quo sublato, iam rima hiat quantum curationi satis est (VIII. iv).

Numerous references occur in other authors. There is a fine example of a flat chisel in the Cologne Museum (Pl. XLI, fig. 2). It is all of steel, and delicately ornamented with spiral indentations. This interesting little instrument was found in the surgeon’s outfit already described, and is one of the best authenticated instruments—as regards its having been the property of a surgeon—we possess. The chisel figured by Vulpes, consisting of a cylindrical bronze handle and a flat blade, is, I believe, a variety of scalpel.

We have many interesting references to the use of the chisel in bone work. It was used as an osteotome to divide the bone in distorted union:

‘If the callus be of stony hardness incise the skin with a scalpel, and divide the union with chisels’ (ἐκκοπεῦσι) (Paul, VI. cix).

In the removal of supernumerary digits we are to cut away the flesh all round, and either chop the bone through with a chisel (τῷ ἐκκοπεῖ), or remove it by sawing (Paul,VI. xliii). In using the chisel as an osteotome one chisel was often placed behind the bone to steady it while it was being struck by another in front. This method of applying two chisels, which is only described by the Greek authors, is always referred to by the phrase ἐκκοπέων ἀντιθέτων.

The following passage from Galen fully describes the manipulation (ii. 687):

‘Separate off the membranes adhering to the bone, which being properly done, divide the bone of the rib by means of two chisels placed in opposition to each othersecundum artem’ (ἀντιβαλλομένων δυοῖν ἀλλήλοις ἐκκοπέων ὡς ἔθος).

The following passage from Paul shows the chisel used for a similar purpose:

‘If part of the clavicle is broken off and unconnected, and if we find it irritating the parts, we must make a straight incision with a scalpel and remove the broken portion and smooth it with chisels (δι' ἐκκοπέων), taking care that the instrument called ‘meningophylax’ (q. v.), or another chisel, be put under the clavicle (μηνιγγοφύλακος ἢ ἑτέρου ἐκκοπέως) to steady it’ (VI. xciii).

The phrase δι' ἐκκοπέων ἀντιθέτων, which Paul uses in describing the treatment of a fistula leading to carious bone, is translated by Briau—‘à l’aide de tenailles tranchantes’. It does seem here, and occasionally in other passages, as if the phrase might suggest ‘cutting forceps’, but we have no knowledge of such an instrument being used by surgeons in classical times, and the passages from Paul and Galen show that only two chisels are meant. We may compare the passage on extraction of the foetus in Paul (VI. lxxiv), where he directs a second hook to be fixed on opposite the first (καὶ ἀντίθετον τούτῳ δεύτερον).

Gouge.

Greek, κυκλίσκος, κοιλισκωτὸς ἐκκοπεύς, κυκλισκωτὸς ἐκκοπεύς, σκυλισκωτὸς ἐκκοπεύς; Latin,scalper excisorius.

The Greek writers frequently refer to the gouge. Celsus never does so by any special name, although it is evidentthat many of the manipulations he describes as being performed by the ‘scalper’, his general term for chisels of all kinds, could only be performed with gouges and not with flat chisels. The gouge was a favourite instrument of Galen’s, especially in injury to the skull. With it he removed pieces of fractured bone from the skull. He also used it to groove a path for the vertical cutting instrument called the lenticular (q. v.). He calls it a ‘hollow chisel’ (τῶν κοίλων ἐκκοπέων οὓς καὶ κυκλίσκους ὀνομάζουσιν, x. 445).

Paul (VI. xc) says:

‘And if the bone be weak, naturally, or from the fracture, we cut it out with gouges (σκυλισκωτοῖς), beginning first with the broader ones, and changing to the narrower, and then using those which are probe-like, striking gently with the mallet to prevent concussion of the head.’

The gouge is still familiar to us.

Lenticular.

Greek, φακωτός.

The lenticular of the ancients was a vertical chisel cutting on one edge and struck on the other by a hammer, while the end carried a rounded button, which being smooth did not injure the brain (Pl. XL, fig. 4). It takes its name from the lentil-like (φακωτός) shape of the button. Galen had a high appreciation of it, and gives a full description of its principle (x. 445), which is transcribed by Paul (VI. xc):

‘The method of operating with a sort of incisor called lenticular is greatly praised by Galen, being performed without drilling after the part has been grooved all round with gouges.’

Wherefore he says:

‘If you have once exposed the place, then applying the chisel, which has at its point a blunt (rounded), smooth, lentil-shaped knob, but which longitudinally is sharp, when you apply the flat part of the lenticular to the meninges divide the cranium by striking with the small hammer. For we have all that we require in such an operation, for the membrane, even if the operator were half asleep, couldnot be wounded, being in contact only with the flat part of the lenticular, and if it be adherent anywhere to the calvarium the flat part of the lenticular removes its adhesion without trouble. And behind it follows the incisor or lenticular itself, dividing the skull, so that it is impossible to discover another method of operating more free from danger or more expeditious.’

The earliest illustration of the lenticular I have been able to obtain is that given by Vidus Vidius (Pl. XL, fig. 2). It evidently is the same instrument as that described by Galen.

Hammer.

Greek, σφῦρα; Latin,malleolus.

I have already quoted passages where the hammer is referred to as being used in cranial surgery. Paul says: ‘When you apply the flat part of the lenticular to the meninges divide the skull by striking with a small hammer,’ and again in using gouges, ‘strike gently with hammer (σφῦρα) to avoid concussion of the head’ (VII. xc).

Paul and Celsus describe a method of extracting foreign bodies from the ear by laying the patient on a board and striking the under side with a mallet. Paré mentions a hammer made of lead, and Fabricius describes one padded with leather, but neither of these is described by the ancients. There is, however, a Roman hammer of lead from the excavation at Uriconium in the Shrewsbury Museum.

Block.

Greek, ἐπίκοπον, a butcher’s block.

The ancients frequently amputated parts by placing them on a block and striking them with a chisel. The mediaeval surgeons amputated parts as large as the forearm in this way, but the Greeks all describe amputation by knife and saw. We have reference to the ‘block’ in Greek literature, however. In describing the plastic removal of a portion of the scrotum Paul (VI. lxvii) says:

‘Leonidas, laying the patient on his back, cuts off the redundant portion upon a chopping block of any kind ofwood or stiff leather’ (κατ' ἐπικόπου σανιδίου τινὸς ἢ σκληροῦ δέρματος).

Galen uses the same word in the eighth book of his work on Practical Anatomy—apologizing somewhat for calling the article used by anatomists and surgeons by the undignified term of butcher’s block:

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

Meningophylax.

Greek, μηνιγγοφύλαξ; Latin,membranae custos.

The meningophylax was a small plate, which was inserted under a bone which was being cut in order to protect underlying structures. ‘In cutting or sawing the bone,’ says Paul (VI. lxxvii), ‘when any vital parts are situated below, such as the pleura, spinal marrow, or the like, we must use the instrument called the meningophylax for protecting them (μηνιγγοφύλακα).’

Celsus thus describes it (VIII. iii):

Factis foraminibus eodem modo media septa, sed multo circumspectius, excidenda sunt, ne forte angulus scalpri eandem membranam violet; donec fiat aditus, per quem membranae custos immittatur; μηνιγγοφύλακα Graeci vocant. Lamina aenea est, firma paulum resima, ab exteriore parte laevis; quae demissa sic ut exterior pars eius cerebro proprior sit, subinde ei subiicitur quod scalpro discutiendum est; ac si excipit eius angulum, ultra transire non patitur; eoque et audacius, et tutius, scalprum malleolo medicus subinde ferit, donec undique excisum os eadem lamina levetur, tollique sine ulla noxa cerebri possit.

Pl. XL, fig. 3shows a figure of the meningophylax from Vidius.

Drill.

Greek, τρύπανον; Latin,terebra,terebella.

There are, says Celsus, two kinds of drills. The first like those used by artisans and driven by a thong, the second with a guard to prevent the instrument from sinking too deeply into the bone. The drill was used in excisinga piece of the skull where the diseased portion was larger than could be comprehended by the modiolus of a trephine. The part to be removed was surrounded by perforations with the drill and the intervening spaces were divided with chisels or raspatories. Celsus says:

At si latius vitium est quam ut illo comprehendatur, terebra res agenda est. Ea foramen fit in ipso fine vitiosi ossis atque integri; deinde alterum non ita longe, tertiumque, donec totus is locus qui excidendus est his cavis cinctus sit. Atque ibi quoque, quatenus terebra agenda sit, scobis significat. Tum excisorius scalper ab altero foramine ad alterum malleolo adactus id quod inter utrumque medium est excidit; ac sic ambitus similis ei fit qui in angustiorem orbem modiolo imprimitur (VIII. iii).

Paul says:

‘If a weapon be lodged deep in bone of considerable thickness it may be bored out with drills’ (τρυπάνοις) (VI. lxxxviii).

Aretaeus (ed. Adams, p. 467) says that exposed bones are to be surrounded with perforations by means of the drill and thus reduced (τερέτρῳ χρὴ περικόπτειν τὰ γυμνά).

The boring parts of drills are not unfrequently found. The most ancient illustrations known to me of drills driven by thongs are in the work by Vidus Vidius (Chirurgia e Graeco in Lat. Conversa, V. Vidio. Florent. interprete c. nonn. eiusd. commentariis. Lutec. Paris., 1544).

Vidius shows three arrangements for driving these drills with thongs: the first method consists simply of a thong attached to the shaft of the drill (Pl. XLII, fig. 4); the second consists of a bow with the string of the bow wound once round the shaft (Pl. XLII, fig. 5); and the third consists of a crosspiece with a hole in the centre of it through which the shaft passes, and having strings from the end of the crosspiece to the top of the shaft (Pl. XLII, fig. 3). Primitive arrangements truly, yet all three methods of producing rotary motion are to be seen in use at the present day, and be it known that some of the most delicate boring performed by the hand of man at the present day is done with drills turned by the thong stretched across a bow.The latest developments in mechanical devices for drilling have failed to displace thong-driven drills for boring the holes in which the wheel spindles of the best hand-made chronometers move, and the spindles themselves are turned in chucks rotated not by belts in continuous rotary motion, but in alternating motion by means of a thong stretched across a bow. A bow of cane with a strong but fine thread, one turn of which is taken round the drill, is drawn backwards and forwards and rotates the drill with marvellous rapidity and accuracy. The bows used by watchmakers average about a foot along the string. Similar drills are used by engineers in turning out small work. The form with the crosspiece may be seen in use by travelling crockery menders, who drill holes in broken pottery and clamp the pieces with rivets. A turn or two of the string is made round the shaft, and the point of the drill being adjusted on the spot to be bored the crosspiece is gently pressed down by the first and third fingers, causing the shaft to rotate. When the thong has nearly uncoiled itself the pressure is slightly removed, the momentum causes the shaft to overrun and coil the thong in the opposite direction to which it originally was. The crosspiece is again depressed and the alternating rotation goes on without intermission, and the drill bores through the pottery. The travelling crockery mender is, in the northern towns of England, not an unusual sight squatting at work on the kerb. On the continent the ‘Rastelbinder’ is a regular domestic institution. Not only crockery but glass is readily drilled by these means, and one who has seen the rapidity with which these drills rotate can readily understand the necessity for the advice given both by Hippocrates and Celsus to frequently remove the drill and dip it in cold water, in case sufficient heat be generated by the friction to cause subsequent exfoliation of the neighbouring bone.

The remaining method of producing rotation by means of a string fixed to the shaft can be seen in use by boatmen when clearing water out of a boat with a mop,The mop is laid over the side of the boat. A few turns of a rope fixed to the shaft are made round it and the rope being pulled the shaft rotates. The momentum generated causes the shaft to overrun and the rope to coil itself in the reverse way to the original. This is repeated till the speed generated causes the water to fly off the mop by centrifugal motion.

The fire drill of the ancient Egyptians was turned by a bow, and it is interesting in connexion with the advice of Hippocrates to avoid generating too much heat in drilling the skull, and also because it helps to explain the construction of the instruments of Vidius. A sketch of an ancient fire drill found by Flinders Petrie (Ten Years Digging in Egypt) shows that the head of the drill was separate and the points were also removable.

Drill with Guard.

Greek, τρύπανον ἀβάπτιστον; Latin,terebra abaptista.

This is the second variety of drills described by Celsus. It had a collar which prevented it from sinking beyond a certain depth, so that in excising a piece of bone from the skull, which was the object for which it was used, there was little danger of its doing injury to the brain or its membranes:

Terebrarum autem duo genera sunt; alterum simile ei quo fabri utuntur; alterum capituli longioris, quod ab acuto mucrone incipit, deinde subito latius fit; atque iterum ab alio principio paulo minus quam aequaliter sursum procedit (VIII. iii).

Further on in the same passage Celsus states that they were to be frequently removed and dipped in water lest too great heat should be generated, so that they were evidently driven at a rapid rate with a thong like the other drills. They are not mentioned by Hippocrates, but Galen (x. 445) describes them:

‘In order to make less chance of error they have invented drills called abaptista (ἀβάπτιστα τρύπανα), which have a circular border a little above the sharp point of the drill.It is best to have several for every thickness of the calvarium; for thicker bone longer are required, for thinner bone shorter.’

Paul (VI. xc) says:

‘But if the bone is strong it is first to be perforated with that kind of perforators called abaptista (περιτρυπήσαντες ἀβαπτίστοις τοῖς λεγομένοις), which have certain eminences to prevent them sinking down to the membrane, and then with chisels we remove the bone not whole, but in pieces.’

The illustrations of drills given from Vidius (Pl. XLII) are really abaptista.

Saw.

Greek, πρίων, μαχαιρωτὸς πρίων (as if from μαχαιρόω); Latin,serrula.

The saw is very frequently mentioned in the description of operation on bone. Celsus (VII. xxxiii), in describing the amputation of a gangrenous limb, says:

Dein id serrula praecidendum est, quam proxime sanae carni etiam inhaerenti: ac tum frons ossis, quam serrula exasperavit, laevanda est.

And Paul says that in amputating a gangrenous limb the flesh ought to be retracted with a band lest it be torn by the saw. Saws were also used in cranial surgery. Hippocrates frequently mentions a saw (πρίων) in this connexion, but it is evident that he means the trephine, as he describes its circular motion. Paul, however, makes it quite clear that he means flat cranial saws, for he mentions both saws and trephines in one paragraph:

Ἤδη καὶ τῶν πριόνων τε καὶ χοινικίδων χειρουργίαι, κτλ.‘The method of operating with saws and trephines is condemned by the moderns as a bad one’ (VI. xc).

Ἤδη καὶ τῶν πριόνων τε καὶ χοινικίδων χειρουργίαι, κτλ.

‘The method of operating with saws and trephines is condemned by the moderns as a bad one’ (VI. xc).

Pl. XLI, fig. 3shows a surgical saw from the British Museum (No. 2,328). It is of bronze, and measures 112 mm. long, 3 cm. broad at one end, narrowing to 23 mm. at the other. There are surgical saws of steel in the Naples Museum. Many of the saws extant are for use as ‘frame’ saws. Others have the saw portion continuous with the handle, like a knife.Galen (xviii. 331) mentions these ‘knife-shaped’ saws: ‘For in this way each does not become so exactly smooth as with sword-shaped saws (μαχαιρωτῶν πριόνων).’ There is an example of this form of saw in the Guildhall Museum, London.

Trephine.

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

The ancient trephine is referred to by Hippocrates, who mentions a saw (πρίων and πρίων χαρακτός) having a circular motion (iii. 374):

‘In trephining you must frequently remove the trephine, on account of the heat in the bone, and plunge it in cold water. For the trephine (πρίων), being heated by the circular motion (περιόδου) and heating and drying the bone, burns it and makes a larger piece of bone exfoliate than would otherwise be necessary.’

And again:

‘You must saw the bone down to the meninges with a serrated trephine (πρίονι χρὴ χαρακτῷ ἐμπρίειν), and in doing so must take out the trephine (πρίονα), and examine with a probe and by other means along the track of the trephine’ (πέριξ κατὰ τὴν ὁδὸν τοῦ πρίονος).

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

Ὀρθοπρίονι—τῇ χοινικίδι.περητηρίῳ—τρυπάνῳ τῷ εὐθεῖ καὶ ὀξεῖ, ἔστι γὰρ καὶ ἕτερον ἡ χοινικίς.

Ὀρθοπρίονι—τῇ χοινικίδι.

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

These terms do not, however, occur in any extant Hippocratic writings, unless, as seems possible to me, the latter term περητηρίῳ be avar. lect.for the obscure word τρυγλητηρίῳapplied to τρύπανον in ii. 470 in the description of trephining a hole through a rib to drain an empyema. Galen held the trephine in little esteem. It must have been difficult to manufacture a satisfactory instrument of bronze. In x. 448 he says: ‘Some people, shall I call them rather cautious or rather timid, have used trephines’ (χοινικίσιν); and Paul, in a passage I have already quoted, says: ‘The mode of operating with saws and trephines is condemned by moderns as a bad one.’

The term χοινικίς is derived from χοινίκη and χνόη, the nave of a wheel. The Latin term for the trephine,modiolus, has the same meaning. Celsus graphically describes the trephine and the method of its application. From him we learn how the ancients solved the problem of the centre-pin, which is necessary until the toothed portion has begun to bite. In modern trephines this difficulty is got over by withdrawing the pin up the centre of the shaft. In mediaeval trephines it was solved by providing two instruments, a male and a female, the male with centre-pin being used till a circular track had been cut by the toothed ring, the female without pin being then used. In the time of Celsus the centre-pin was removable, being taken out after the instrument had begun to bite. From Celsus too we learn that the trephine was driven by a thong.

Celsus and Hippocrates both remark that, as in the case of the drill, it is necessary to dip the trephine in cold water at intervals in order to cool it, lest heat sufficient to injure the surrounding bone be generated. The thong manipulated by a bow would seem to be the method most applicable to an instrument like the trephine, which has a large boring radius, as slower motion is more easily produced by this arrangement than by one consisting of a cross-piece with thongs. Celsus says:

Exciditur vero os duobus modis: si parvulum est quod laesum est, modiolo, quem χοινικίδα Graeci vocant: si spatiosius, terebris. Utriusque rationem proponam. Modiolus ferramentum concavum teres est, imis oris serratum;per quod medium clavus, ipse quoque interiore orbe cinctus, demittitur. Terebrarum autem duo genera sunt: alterum simile ei quo fabri utuntur: alterum capituli longioris, quod ab acuto mucrone incipit, deinde subito latius fit; atque iterum ab alio principio paulo minus quam aequaliter sursum procedit. Si vitium in angusto est quod comprehendere modiolus possit, ille potius aptatur: et si caries subest, medius clavus in foramen demittitur; si nigrities, angulo scalpri sinus exiguus fit qui clavum recipiat ut, eo insistente, circumactus modiolus delabi non possit: deinde is habena, quasi terebra convertitur. Estque quidam premendi modus, ut et foret et circumagatur; quia si leviter imprimitur parum proficit, si graviter non movetur. Neque alienum est instillare paulum rosae vel lactis, quo magis lubrico circumagatur; quod ipsum tamen, si copiosius est, aciem ferramenti hebetat. Ubi iam iter modiolo impressum est, medius clavus educitur, et ille per se agitur: deinde, quum sanitas inferioris partis scobe cognita est, modiolus removetur.

Perforator for Fistula Lachrymalis.

Greek, λεπτὸν τρύπανον.

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

Some, after excision of the flesh, use a perforator (τρύπανον) and make a passage for the fluid or matter to the nose.

Albucasis figures a drill for this purpose which he says had a triangular iron point and a conical wooden handle.

In the find of instruments of the third-century oculist Severus is a drill which Deneffe regards as intended for this purpose. It is 6 cm. in length and 7 mm. on each of its four sides. One end is pointed, the other has a slit for a knife-blade. It is beautifully damascened with silver (Pl. II, fig. 7).

Bone Lever.

Greek, μοχλίσκος, ἀναβολεύς.

Instruments for levering fractured bones into position are described in several places. Hippocrates (iii. 117) says:

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