Surgical Instruments in Greek and Roman Times

CHAPTER V

FORCEPS

Epilation Forceps.

Greek, t?????a??, t????????? (== t?????a?d???); Latin, vulsella.

The removal of the hair from the face for cosmetic purposes is a custom which has come down to us from prehistoric times, and seems to have been very prevalent among all primitive races. In the bronze age the method by which this was accomplished seems to have been to fix the hairs with a broad jawed forceps and cut them off close to the skin by means of a knife or ‘razor’. Thus did primitive men ‘shave’, and very often in early bronze age graves in Scandinavia and in the Swiss lake-dwelling excavations these forceps and razors are found together. No doubt also epilation proper was practised occasionally, but the majority of the prehistoric forceps are not for epilation but for fixing the hairs to allow the knife to divide them close to the skin. At a later time, with the more common use of steel, the Greeks and Romans shaved as we do, and epilation proper was practised for removing superfluous hairs from the face and also to remove trichiasis. Aristophanes, a contemporary of Hippocrates (Ran. 516, Lys. 89, 151), Persius (iv. 37) and Juvenal (vii. 114) refer to the depilation of the pubes as being common among certain classes, and the early Christian Fathers deplore the practice. See also the remarks of Suetonius on the conduct of Domitian (xxii). Prosper Alpinus, who visited Egypt in the sixteenth century and wrote an interesting book on the state of medicine in that country, found the custom still prevalent among the Egyptian women, and thus explains the object with which it was practised (Medicina Aegyptiorum, cap. III. xv):

A pulveribus, qui Aegyptiis fere toto anno ventorum terraeque siccitatis occasione perpetuo familiares existunt, atque ab assiduis sudoribus quibus coeli calore omnia corpora continue abundant, illuvieque quadam immunda redduntur, atque foetentia, ex quo pleraque ipsorum et foetere et pediculis abundare solent. Balneis omnes hi populi utuntur familiarissime pro corporum abstersione, maximeque mulieres, quibus curae magis est corpora ipsarum pulchriora facere ipsorum, illuviem et foetorem corrigentes, ut cariores sint suis viris. Eae etenim saepissime corpora in iis lavant, at mundant ab illuvie, perlotaque variis ornant odoribus ut recte unguentis oleant. Ac veluti Italae mulieres atque aliarum multarum etiam nationum ad capillorum facieique omne cultum adhibent studium, ita Aegyptiae capillorum cultum negligunt ex consuetudine omnes capillos in bursam serico panno paratam concludentes, ac ad pudendorum abditarumque corporis partium ornatum omnem diligentiam adhibent. Pudendis igitur tota cura in balneis ab iis adhibetur. Ea siquidem in primis lavant, pilisque nudant, locaque pudendorum perpetuo glabra gestant, turpeque ibi est mulierum pilis obsitam vulvam habere. Demum lotas eas partes glabrasque effectas variis unguentis etiam exornant.

The custom survived in France and Italy in the sixteenth century.

Epilation as a purely surgical operation was frequently necessary for the trichiasis consequent on the granular ophthalmia which was so common among the Romans. Paul (VI. xiii) says:

‘Turn the eyelid outwards and, with an epilation forceps (t?????a??) dragging out the offending hairs, either one, or two, or three or whatever number there are. Then apply a heated olivary probe or an aural probe or some such slender instrument to the place from whence the hair or hairs have been removed.’

The numbers of toilet epilation forceps which have been found are enormous. Moreover, forceps of exactly similar form were in use in every household as accessories of the lamp for raising and snuffing the wick, and artisans used them also for the finer manipulations of their crafts; so that by far the largest number of forceps of this type are not surgical instruments, but household implements. However, we have plenty of specimens from purely surgical finds.

Of the surgical instruments all forms agree in having no teeth. The simplest form consists of a strip of metal bent on itself straight as in Pl. XXVI, fig. 3, or with the jaws turned inwards, as in Pl. XXVI, fig. 5. These are often pocket forceps. A ‘pocket-companion’, consisting of a toilet forceps, an ear-pick and a nail-cleaner, such as is seen in Pl. XXVI, fig. 4, is a common object in museums, such as the Guildhall Museum, where this object is. A variety of epilation forceps with rounded legs is seen in Pl. XXVI, fig. 2. Several of these have been obtained from purely surgical finds. Others are formed by sawing a bar of bronze up its centre, as in the specimen shown in Pl. XXVI, fig. 1, which is 13 cm. 4 mm. long, and with jaws 10 mm. broad. It is from the Naples Museum.

This is the form most typical of the surgical epilation forceps. Several of this type were found in the grave of the oculist Gaius F. Severus at Rheims (Pl. XXVI, fig. 6). They are very large powerful instruments, from 15 to 16 cm. long, and with jaws 7 to 8 mm. in breadth (Deneffe, Oc. du 3^e siÈcle, ii. 1-8). This form was no doubt used as a dissecting forceps or tumour vulsellum as well as for epilation, but the typical tumour forceps was toothed, and it is convenient to classify all those of the untoothed type as epilation forceps.

Other epilation forceps, which are however more likely to be toilet articles, have the jaws of extreme breadth, as in Pl. XXVII, fig. 3 from the Mainz Museum. It has a sliding catch. They are evidently intended to remove a considerable number of hairs at once, or to fix them while they were cut with razor or shears.

It is certain, however, that in addition to these broader forceps a variety with quite narrow blades was used, as Paul (VI. xxiv) tells us that stones, &c. may be removed from the ear with epilation forceps (t?????a??), and again in fracture of the nose Paul (VI. xxiv) says that splinters of detached bone are to be removed with these forceps. We have several forceps of this type. There are in the Naples Museum three, one from Pompeii, two from Herculaneum (Deneffe). One from my own collection is shown in Pl. XXVI, fig. 2. The points are narrow and rounded.

A very interesting form is seen in Pl. XXVII, fig. 4, which shows a forceps in the Thorwaldsen Museum, Copenhagen. It is 12 cm. long, of which 6 cm. of the upper end are solid and round. The remainder of the length is occupied by the blades of the forceps, each 5 mm. broad, except for 12 mm. at the extremity, where it expands into a leaf-shaped portion, 10 mm. broad in its broader part. These leaf-shaped expansions oppose each other accurately, and on the narrow part of the blade above them there slides a rectangular catch which serves to clamp the blades and fix them like the jaws of a vice.

The surgical epilation forceps is, as we have seen, usually a simple instrument. Occasionally we meet with a forceps combined with some other instrument. These are, as a rule, toilet articles. A pocket ear-scoop and epilation forceps combined was found in Paris. Precisely similar articles of steel may be bought in chemists’ shops to-day. Another has a small unguent spatula combined with a forceps, while others carry olivary probes. There are several of these in the St-Germain-en-Laye Museum (Pl. XXVII, figs. 5, 2). One from Melos, in the Athens Museum, has a porte-caustique.

Polypus Forceps.

Greek, p???p???st??.

Galen (Med. Sec. Loc. xii. 685) alludes to the method of extraction of polypus from the nose by means of a forceps (?pe?ta ?a?d?? ??a??e?), and from what Paul says it would seem that there was a special polypus instrument, consisting of a forceps at one end and a rugine at the other. After describing extraction by means of a knife and scoop he says:

‘If, however, any part of the tumour be left behind, we take another polypus eradicator (?te??? p???p???st??), and with the end of it (?p???? a?t?? ??st?????) bring away what remains, by stretching, twisting, and scraping it strongly.’

??st????? means a small rugine, but stretching and twisting can only be done with a forceps. Rare as the combination of an antique forceps with another instrument is, we have one example of the combination of a rugine and a forceps, and, as it is admirably adapted for the extraction of nasal polypus, I think we are quite justified in considering it to be the instrument indicated by Paul. This instrument was found in the grave of the Paris surgeon. It is elegantly formed and is of one piece of bronze sawn down the middle. The upper part is surmounted by a rugine strongly curved, pointed at the tip and cutting on one edge. The rugine measures 3 cm. in length, and 5 mm. in breadth (Deneffe, Tr. d’un Chir., pl. v, fig. 1) (Pl. XXVII, fig. 1).

Tumour Vulsellum (Myzon).

Greek, ?d???, ??d???, sa????a??, sa???????; Latin, myzon, sarcolabon, vulsella.

The form vulsellum has got so well established by usage in modern medical writings that it would seem pedantic to write ‘vulsella forceps’, but so far as I am aware it is not a form which has any classical authority. The classical usage is vulsella, -ae, feminine. I shall follow custom and use the modern term when using it as an English word.

The myzon, or tumour forceps, was a toothed instrument of the dissecting forceps type. Ducange says it takes its name from the shells which are called ?t????, vulgo ?d?a (mussels). It was used whenever it was desired to make traction on any object—such as a tumour—to excise it, or to raise and fix a piece of skin. Aetius (xvi. 106) says:

??d?? p?at?st?? s???a?? t?? ??f?? d?? t?? e?????? ?e???? ?p?te???t? t? d? de??? ?p?te??t? pa?? t??? ?d??ta? t?? ?d???.

‘Seizing the clitoris with a broad jawed vulsellum in the left hand, put it on the stretch, and with the right cut it off close to the teeth of the instrument.’

Paul gives pretty much the same instructions (VI. lxx):

??d?? ?atas???te? t? pe??tt?? t?? ??f?? ??t???e? s???.

‘Seizing the hypertrophied portion of the clitoris with a vulsellum, excise it with a scalpel.’

Aetius (xvi. 107) also says:

?spe? ??? ?p? t?? ??f?? p??e???ta? s??at??e?? ??? t?? ???a??a ?a? ?d?? ?p?te??e?? t?? ?pe????? ?a? t? p???p??? spa??? ???se?? ???? t? pe??tt?? ?fa??e??.

Cf. also Paul, VI. lxxi and again Aetius (iv. ii. 3).

Again Aetius says:

‘If there is a large and malignant excrescence in the angle of the orbit, the enlarged part must be seized with vulsella (?d??) and cut off’ (vi. 74).

In the corresponding passage in Paul (VI. xvii) another name for the vulsellum is used, viz. sa???????:—‘granuloma of the inner canthus we seize with vulsella and excise’ (sa??????). In treating of epulis he again uses the same term: ‘Epulis we seize with vulsella and excise’ (sa??????).

In Moschion (II. xxx), in the chapter ‘De Haemorrhoidibus quae in matrice nascuntur’, we find a Latin transliteration of the two terms ?d??? and sa??????? side by side:

Myzo vel sarcolabo haemorrhoides teneantur ita ut in aliquantum extensas scalpello prius radices earum scarifes, et in aliquantum artifex sarcolabo convertat.

Here, in all probability, Soranus, from whom Moschion is copying, has simply used ?d???, and the added ‘vel sarcolabo’ is simply a gloss, for the terms ?d??? and sa??????? are synonymous. However this part of Soranus is lost. Extant specimens of the vulsellum are common. A simple variety is formed by folding a plate of bronze on itself, as in Pl. XXVIII, fig. 1, which shows a specimen in the British Museum. The jaws are finely toothed.

More usually the myzon is formed by sawing a plate of bronze partly along its midline as in Pl. XXIX, fig. 2, which is taken from the find of the oculist Severus.

An interesting variation is seen in the specimen shown in Pl. XXVIII, fig. 3 which is from my own collection. The line of junction of the jaws instead of being in the median plane is sloping. The object of this arrangement is not quite clear. A small variety of the vulsellum is referred to by Aetius:

‘Epulis we seize with a small vulsellum and excise with a small scalpel’ (? ?p????? ?d??s????? ?p?ta?e?sa ??te??s?? s??a??? ste??, vii. 24, 25).

We have one or two of these instruments. They remind one of fixation forceps. I illustrate one in Pl. XXIX, fig. 3. It is from the Mainz Museum. There are four similar ones in the Frankfort Historical Museum. The specimen shown in Pl. XXVIII, fig. 2, from the Naples Museum, is interesting as being stamped with the name of the maker, Acachcolus.

We have now to consider an interesting variation produced by extending the extremity of the blade to one side so as to increase the width of the blade (coudÉe type). This is a rare type.

Pl. XXIX, fig. 1 represents one of two from the find of the surgeon of Paris. It is 17 cm. long, and the legs of the forceps are 8 mm. wide. The jaws debouch to one side at an obtuse angle for a distance of 2 cm. and end in a fairly sharp point. The jaw is thus increased to 2 cm. in breadth. They are finely toothed. They are concave internally and convex externally. The other forceps was 14·5 cm. long and 8 mm. wide. The Museum at Naples has a forceps of this type, but having a sliding ring to fix the jaws after they have been applied (Pl. XXIX, fig. 4).This angled type of forceps may be the one referred to by Paul in his description of the plastic operation on the eyelid for trichiasis (VI. viii), when he directs us to raise the redundant skin of the lid with a fixation forceps and cut it off with a scalpel (?efa???at??? ?d??, t??t' ?st? p??? t?? pe??f??e?a? t?? ?ef???? ?s?at?s??? ??ate??a?te? t? pe??tt?? d??a, s???? ?p???pt??s?). It may be noted that this coudÉe type of forceps has considerable affinity with the type of forceps presently to be described for strangling haemorrhoids and the relaxed uvula, the only essential difference being that the blades are not crossed here.

Uvula Forceps.

Greek, staf?????a.

In Aetius (II. iv. 12) we have an interesting description of the amputation of the uvula by first crushing it in a forceps so as to prevent haemorrhage and then cutting it off:

‘Then inserting a vulsellum and making traction on it, the uvula crusher (t?? staf?????a?) is fitted on about the middle of the uvula or a little below it, and then it is pulled and twisted (by the vulsellum). By the torsion it becomes lifeless and, as it were, snared off; it curls up, becomes livid and comes off without much effusion of blood. Wherefore it is well to wait some time and hold it till the patient can stand it no longer, and then cut it off—the cut being made close to the vulsellum but nearer the tip than to it.’

The staf?????a therefore corresponds in its action to a pile-crusher. This instrument I believe to be represented by the type of forceps shown in Pl. XXX, fig. 1. It is in the British Museum. The two branches of the forceps cross like scissor blades, and at their ends the jaws are formed in such a way as to project forwards and enclose a cavity 1 cm. deep and 18 mm. long. Over all the forceps is 18 cm. long. The jaws are finely toothed. There is in the same museum another instrument similar in all respects except that it is 1 cm. shorter, and that in each blade, which is 16 mm. long (Pl. XXX, fig. 2), there is a small hole near the proximal end. A posterior view of a similar instrument is seen in Pl. XXXI, fig. 1. It is from the find of the surgeon of Paris. A similar specimen is in the Mainz Museum.

Pl. XXXII, fig. 3 shows a smaller specimen from the Naples Museum. It is 11 cm. in length. A large powerful variety with a different arrangement of the handles is seen in Pl. XXXI, fig. 2 from a specimen in the Antiquarian Museum at Basle. It is 20 cm. long.

A forceps which I take to be a staphylagra occurs on the coins of Atrax in Thessaly (circa 400 B. C.). The forceps stands alongside a bleeding cup.

The object of the holes in several of the specimens is to permit the insertion of a cord to bind the jaws firmly together, and thus keep up the strangulation of the part for some time, as Aetius directs. The application of a ligature in this way would, of course, not be possible while the instrument was applied to the uvula, but the following passage from Leonidas (Paul, vi. 79) shows that the uvula crusher was also used to clamp piles in the same way:

‘Having seized the haemorrhoids and held them there for some time with the uvula crusher (staf??????) he cuts them off with a scalpel.’

In such a case the application of a cord to clamp the jaws together would be a distinct convenience. The short variety is more suitable for external operations, as for haemorrhoids; the long variety for manipulations in the throat.

Hippocrates mentions the uvula crusher as one of the instruments necessary for the outfit of the physician (i. 63).

Forceps for applying Caustic to Uvula.

Greek, staf????a?st??.

A remarkable variety of forceps, of which there is only one extant specimen (which is in the Vienna Museum) is shown in Pl. XXXII, fig. 2. It is formed of two branches which cross and are fixed by a rivet near the middle of the instrument. The jaws are 3·5 cm. long, concave internally, and fit accurately together, enclosing an oval cavity 1 cm. in diameter. This forceps is, I believe, the one which Paul describes as used for destroying the uvula with caustic. He says (VI. xxi) that if from timidity the patient decline excision of the uvula, we are to take the caustic used for operations on the eyelids, or some such caustic, and fill with it the hollows of the caustic holder for the uvula (t?? staf????a?st?? t?? ?????t?ta?), and directing the patient to gape wide, and getting the tongue pressed down with a tongue depressor, we open the instrument sufficiently and grasp with it as much of the uvula as we cut off in the other operation. The medicament must neither be of too liquid consistence, lest it run down from the uvula and burn the adjoining parts, nor very hard, that it may quickly act on the uvula. And if from one application the uvula becomes black this will be sufficient, but if not, we must use it again. In VI. lxxix he says that some, filling the hollows of the staphylocaustes (t?? ?????a? staf????a?st??) with caustic, burn off haemorrhoids in the same way as they do the uvula. An interesting use of this instrument is mentioned by the same author in the chapter above referred to, while describing the method of treating haemorrhoids by the ligature:

‘By means of the forceps for applying caustic to haemorrhoids, or the forceps for applying caustic to the uvula (t? a??????d??a?st? ? t? staf????a?st?), we surround them close to the jaws of the instrument (p??? t? ?e???) with a five-ply thread of lint, and strangle the haemorrhoids separately with this ligature.’

It would seem then that, just as there was a long instrument for crushing the uvula and a short one for crushing haemorrhoids, there were corresponding instruments for cauterizing these parts, probably differing from each other only in the length of the handle.

The passage above quoted has given much trouble to the scribes and commentators apparently from a lack of knowledge of the instrument referred to. About a third of the codices omit t? a??????d??a?st?, and Cornarius and Dalechamps reject the words t? a??????d??a?st? ? t? staf????a?st? as superfluous and interpolated. Apparently they were unaware that both instruments were forceps of similar principle but different lengths, and quite suitable for putting a haemorrhoid on the stretch. The reason why these instruments are preferred, for this purpose, to the staphylagra is apparently that not being toothed like the latter instrument they would be both less painful and less likely to cause bleeding.

Pharyngeal Forceps.

Greek, ? ??a???????.

Paul (VI. xxxii) describes a forceps for removing foreign bodies from the pharynx:

‘Prickles, fish-bones and other substances are swallowed in eating and stick in different places. Wherefore such as can be seen we are to extract with the special fish-bone forceps’ (t??? ?d??? ??a???????? p??sa???e??????? ??????e?).

This is the only reference to the acanthobolus I have met with, and it gives us no information as to the appearance of the instrument. It is noteworthy, however, that Paul in his chapter on the removal of spiny bodies from the pharynx is copying Aetius, and the instrument Aetius names is an epilation forceps. He says ‘bones stick near the tonsil or back of the pharynx and can be seen, and if a considerable part projects out of the tonsil it can be removed with an epilation forceps (t?????a??)’. A forceps of the epilation type, but angled in its length, is figured by VÉdrÈnes. It was found in Pompeii. This forceps is eminently suitable for pharyngeal work (Pl. XXXII, fig. 1). Albucasis figures an acanthobolus with an up-and-down, not lateral, movement.

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