BONE AND TOOTH INSTRUMENTS

Raspatory.

Greek, ??st??; 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:

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

Paul refers to a small raspatory (??st?????) 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, ????pe??; 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:

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:

In the removal of supernumerary digits we are to cut away the flesh all round, and either chop the bone through with a chisel (t? ????pe?), 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 ????p??? ??t???t??.

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

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

The phrase d?' ????p??? ??t???t??, 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 (?a? ??t??et?? t??t? de?te???).

Gouge.

Greek, ?????s???, ?????s??t?? ????pe??, ?????s??t?? ????pe??, s????s??t?? ????pe??; Latin, scalper excisorius.

The Greek writers frequently refer to the gouge. Celsus never does so by any special name, although it is evident that 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’ (t?? ?????? ????p??? ??? ?a? ?????s???? ???????s??, x. 445).

Paul (VI. xc) says:

The gouge is still familiar to us.

Lenticular.

Greek, fa??t??.

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 (fa??t??) 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):

Wherefore he says:

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, sf??a; 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 (sf??a) 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, ?p???p??, 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:

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:

Meningophylax.

Greek, ??????f??a?; 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 (??????f??a?a).’

Celsus thus describes it (VIII. iii):

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

Drill.

Greek, t??pa???; 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 excising a 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:

Paul says:

Aretaeus (ed. Adams, p. 467) says that exposed bones are to be surrounded with perforations by means of the drill and thus reduced (te??t?? ??? pe????pte?? t? ????).

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, t??pa??? ??pt?st??; 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:

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:

Paul (VI. xc) says:

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

Saw.

Greek, p????, a?a???t?? p???? (as if from a?a????); 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:

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 (p????) 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:

Pl. XLI, fig. 3 shows 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 (a?a???t?? p??????).’ There is an example of this form of saw in the Guildhall Museum, London.

Trephine.

Greek, t??pa???, p????, p???? ?a?a?t??, ????????, ????p????; Latin, modiolus.

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

And again:

In injuries to the head in young people (iii. 371) he mentions a small trephine (s????? t??pa???), so that apparently several sizes were available. Hippocrates, we have seen, uses the words p???? and p???? ?a?a?t?? to denote the trephine. Galen always uses ????????, but in his Lexicon he gives two other words, viz. ????p????? and pe??t????, ostensibly from the works of Hippocrates:

These terms do not, however, occur in any extant Hippocratic writings, unless, as seems possible to me, the latter term pe??t???? be a var. lect. for the obscure word t?????t???? applied to t??pa??? 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’ (???????s??); 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 ???????? is derived from ??????? and ????, 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:

Perforator for Fistula Lachrymalis.

Greek, ?ept?? t??pa???.

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

Some, after excision of the flesh, use a perforator (t??pa???) 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, ????s???, ??a??e??.

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

‘In those cases of fracture in which the bones protrude and cannot be restored to their place, the following mode of reduction may be practised: pieces of steel (s?d???a) are to be prepared like the levers (?? ?????) which the cutters of stone make use of, one being rather broader and the other narrower, and there should be at least three, or even more, so that you may use those that suit best, and then along with extension we must use these as levers, applying the under surface of the piece of iron to the under fragment of bone, and the upper surface to the upper bone, and in a word we must operate powerfully with the lever as we would do upon a stone or a log. The pieces of steel should be as strong as possible so that they may not bend.’