CHAPTER III

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KNIVES

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

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

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

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

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

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

The Blade.

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

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

I. Blade straight—
(A) Cutting on one side only (a) sharp-pointed, (b) blunt-pointed.
(B) Cutting on two edges (a) sharp-pointed, (b) blunt-pointed.
II. Blade curved—
(A) Cutting on one edge (a) sharp-pointed, (b) blunt-pointed.
(B) Cutting on two edges, sharp-pointed.

I. A (a) Straight blade cutting on one edge, sharp-pointed.
1. Ordinary scalpel.
2. Scalpel with tip turned back.
3. Bellied scalpel.
4. Scolopomachaerion.

Ordinary Scalpel.

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

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

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

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

???? s?? ? ???d?? t?? p???? e???? ? t??e?? de? eta?? t?? p?e???? st???e?de? a?a???d? t? p??t?? d??a.‘Incise the outer integument between the ribs with a bellied scalpel.’

St???e?d?? means rounded like the breast of a woman. Galen translates it in his lexicon t? s???? ?at???? ?ast??de?, ‘the bellied surgical knife.’ It is quite a serviceable instrument for several kinds of work, and it seems to have been a common form. Three out of the six scalpels depicted in the votive tablet from the Acropolis are of this form, and there are now in the Naples Museum four others of the same shape as the one described by Vulpes. These have blades of steel and handles of bronze. The figures of three of these (Pl. V, figs. 3-6), show the gradual evolution from a common scalpel into the bellied form. I have seen a scalpel with a blade similar to Pl. V, fig. 3 in use in Scotland for castrating piglings and calves.

Scarificator for wet cupping.

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

????? ??? ?pe???sa? ???a??? p??? t??t?, t??a s???a ?sa ?e??a?te? ???, ?p?? t? ?? ?p???? t?e?? ??????t? d?a???se??.

Paul says he prefers a single scalpel.

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

Straight sharp-pointed bistoury.

Greek, s????p?a?a?????, s????p???; Latin, scalpellus.

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

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

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

I. A (b) Straight blade cutting on one side, blunt-pointed.
(a) Novacula or razor (Greek ?????, diminutive ??????).
() Blunt-pointed bistoury.
(?) Ring knife for dismembering foetus.

Razor.

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

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

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

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

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

Another specimen also of this class, but with the blade so long in proportion to its width as to deserve the name of a blunt-pointed bistoury was excavated in a third-century graveyard at Stree, and is now in the Charleroi Museum. It is 14 cm. long by 1 cm. broad at the heel, widening gradually towards the point where it is 2 mm. broader than at the heel. The end of the blade is square (Pl. VI, fig. 2). An example of the domestic culter or cultellus is shown in Pl. VII, fig. 4. It is from a Roman camp at Sandy in Bedfordshire.In the curious pseudo-Hippocratic treatise (i. 463) a knife to fix on the thumb and dismember a foetus in utero is mentioned:

??e?? d? ??? p??? t? t??a?ta ?a? ????a ?p? t? da?t??? t? e????. ?a? d?e???ta ??e?e??e?? t?? ?e??a? ?t?.

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

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

I. B (a) Straight blade cutting on two edges, sharp-pointed.
(1) Galen’s ‘long’ dissecting knife.
(2) Phlebotome.
(3) Lithotome.
(4) Polypus knife.

Galen’s knife for opening the vertebral canal.

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

?a???? t? p????e? a?a?????, ??t? ??? a?t? ?a?? d?? p?e???? ??e?a? ???? ?p? t?? p??at?? e?? ?a? ????f?? ??????sa?.‘I push in the ‘long scalpel’, for thus I describe the one with two cutting edges meeting in one at the tip.’

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

Phlebotome.

Greek, f?e?t???, t? (sc. s?????), also f?e?t???, ? (Galen). ???e??? (sc. ???a???); Latin, phlebotomum (late), scalpellus.

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

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

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

???? ?e a?a?????? ???s? de? ???s?a? ?a? p??tes?, ??? ?p? p??t?? ????? pa?a??????e?, ?t?. (i. 60).

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

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

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

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

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

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

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

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

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

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

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

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

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

J. Corbet Anderson, in The Roman City at Wroxeter, p. 92, says it was embedded in the remains of a case in which it had been carried, and he gives an illustration of it (Pl. VII, fig. 5). A similar object is classified as a surgical instrument in the Louvre, but both these articles are I believe detached mirror handles. The passage quoted from Hippocrates shows that the ordinary phlebotome was not guarded in this way. A phlebotome of the principle of the fleam is figured by Albucasis and the method of using it in dividing the frontal vein by striking it with a comb is described. There is also a similar instrument in the Naples Museum, from Pompeii, which is classed as a veterinary instrument (Pl. VIII, fig. 3). It is probable, however, that such an instrument was used by Roman physicians, as the offices of surgeon and veterinarian were often held by the same individual in Roman times. It is not unlikely that the method is referred to by Antyllus in the passage beginning—p?t? ?? ?atape????te? p?t? d? ??ape????te? f?e?t??e? (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 ?atape????te?—cutting inwards—in cases where the vessels are deep, and ??ape????te?—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.’

?at??? -??d?? (?) (Soranus, II. xviii); ?a???? (Paul, VI. lxxiv); ?at??d??? (t?) (Aetius, II. iii. 2); ?ate??d??? (t?) (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:

?????? d? ? ??ast???e??? ?at??d? p??se???t?? d?a??e?? t? da?t??? p????????a?ta t? ????.

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 ?ate??d???, or the one called the scoop’ (t?????).

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 ?ate??d???, from ?at? and e?a 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 ?a????, one meaning of which is ‘to let blood’. The next writer who mentions it is Aetius (II. iii. 2, and again II. iv. 14), where he refers to its use in opening quinsy, in a chapter copied from Leonidas:

‘If the patient be adult make him sit down, and, opening his mouth, depress the tongue with a spatula or a tongue depressor, and open the abscess with a scalpel or katias’ (s??a??? ? ?at??d?).

Paul says that abscess of the womb is to be exposed with a speculum and opened with a scalpel or katias (spa??? ? ?at??d?). Paul also refers to it in perforating the foetal cranium in delivery obstructed through hydrocephaly (p???p??? spa??? ? ?a???d? ? s????p?a?a????) (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, spa???? (diminutive of sp???), ??sp?????; Latin, spatha.

On several occasions a knife called spa???? 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’ (spa??? ? ?at??d?).

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 (??spa??? ? spa??? s??????t??).

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

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

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

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

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

Polypus Knife.

Greek, p???p???? spa????, p???p?d???? spa????; 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 (p???p??? spa??? t? ??s???e?de? ??a??), we cut round the polypus or fleshy tumour, applying the point of the steel blade (t?? ???? t?? s?d????) to the part where it adheres to the nose. Afterwards turning the instrument end for end (??t?st???a?te?) we bring out the separated fleshy body with the scoop’ (t? ??a??s??).

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:—

?? d? e?????? t?? ?efa???? ?p?????t?? ? sf???s?? ?p?te???t?, d?? t?? ????t??? ? t?? p???p???? spa???? ???pt????? eta?? ???a??? ?a? t?? a???? da?t???? ?at? t?? ???es?? (xviii. 63).

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

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

Lithotomy Knife.

Greek, ????t??? (t?); Latin, scalpellus.

In describing lithotomy Paul says:

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

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

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

?a? e? ?? p???e???? e??, t? ?a? t?? a?a????? ?????e??, pep?es???? d? t? ?a? t?a?e?? te ?a? ?ap??? ?? ?????, ?? ?? ???sta s?f???? t? ????.

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

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

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

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

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

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

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

Perforator for the foetal cranium.

Greek, ????t???.

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

?? d? e?????? t?? ?efa???? ?p?????t?? ? sf???s?? ?p?te???t?, d?? t?? ????t??? ? t?? p???p???? spa???? ???pt????? eta?? ???a??? ?a? t?? a???? da?t???? ?at? t?? ???es??.

‘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, ??????a??? s?????.

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 (????????? s???? ? f?e?t?? ?? ???? ??e?e??). This undoubtedly refers to a curved scalpel, for the grappling hook was called ???a?.

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

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

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

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

Pterygium Knife.

Greek, pte????t???, ?; 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 (pte????t??) care being taken not to injure the lids.

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

Knife for plastic operation on the eyelid.

Greek, ??a??af???? s?????.

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’ (??a??af???? s?????) we make the first incision called the ‘arrow-shaped’ a little above the hairs which are normal, extending from canthus to canthus and penetrating only the depth of the skin. Afterwards we make the incision called the crescent-shaped, beginning at the same place as the former and carrying it upwards to such a height as to enclose the whole superabundant skin and ending in like manner as it did. Thus the whole skin within the incision will have the shape of a myrtle leaf. Having perforated the angle of this portion with a hook we dissect away the whole skin. Then washing away the clots with a sponge we unite the lips of the incision with three or four sutures’ (VII. viii).

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

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

Uvula Knife.

Greek, staf???t???.

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

‘Wherefore, having seated the patient in the sunlight and directed him to gape wide, we seize with the uvula forceps or a common tenaculum upon the elongated part and drag it downwards and excise it with the instrument called the uvula knife (staf???t??), 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, ??????t??? (??????, ‘bend of elbow,’ or ???????, ‘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 (??????t???) 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, s??????t???, from s?????, ‘a fistula.’

This was a falciform blade whose end was blunt, but the handle end was prolonged into a slender, rounded sound-like portion with a sharp point (Pl. IX, fig. 1). The narrow point was passed into a fistula, caught, and the whole instrument pulled outwards by means of it, thus dividing the overlying tissues with the falciform blade. This instrument remained in use till comparatively recent times. Heister figures a large number of varieties, and from him I have taken the figure shown, although it is also described and figured by Fabricius. The two following passages, taken in conjunction with each other, show that the classical instrument was of the form I have indicated. The first passage, from Galen, shows that the end of the blade was blunt, and that there was only one cutting side. The second, from Paul, shows that the blade was falciform and was operated in the manner I have stated. Galen (x. 415) says that in enlarging an abdominal wound we use a fistula knife (s??????t??). ‘But the scalpels which are two-edged or have a point are distinctly to be avoided’ (t? d' ?f??? t?? a?a????? ? ?at? t? p??a? ???a pa?t? t??p? fe??t?a).

Secondly, Paul (VI. lxxviii) says:

‘Having perforated the bottom of the fistula with the point of the falciform part of the syringotome (t?? d?ep???? t?? s??????t???) bring the instrument out of the anus and so divide all the intervening space with the edge of the falciform part’ (t? ??? t?? d?ep????).

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

????? d? ?? t? t??at? t?? s??????a??? d?ep???? t? ????? ??e??a?te?.

There was also a straight variety of the instrument (t? ?a???e?a ???? s??????t?a, 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:

???s?a? d' a?t?? ???sta t? ???t? ??e? ?e?a??e????? ????? ??at????e?, ?ste ?f????t??? ??e?? ?f?te?a? t?? te???sa? ??a?? ???? ?at? ?? t?? ?t??a? s???, ?at? d? t?? ??t??e????? ta?t? ???t??.

‘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 (e?? ?pe? ?st?? ?p?t?de??t?t? ??s??? ???t?, ii. 674).

Shears.

Greek, ?a???; Latin, forfex.

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

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

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

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

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

We have also two references in Paulus Aegineta. He says some of the moderns effect a cure of warty excrescences on the penis by a pair of shears (?a??d?, 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 (?a??d? ?p??? ? s???), and having secured the parts with sutures he effected healing with the treatment for recent wounds.

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


                                                                                                                                                                                                                                                                                                           

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