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
σμίλη. 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, μάχαιρα
or μαχαίριον, has a more definite meaning. It is from μάχαιρα, 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):
Ὅκως σοι ἡ ἔξοδος τοῦ πύους εὐρὺς ᾖ τάμνειν δεῖ μεταξὺ τῶν πλευρῶν
στηθοειδεῖ μαχαιρίδι τὸ πρῶτον δέρμα.
'Incise the outer integument between the ribs with a bellied scalpel.'
Στηθοειδής means rounded like the breast of a woman. Galen translates it
in his lexicon τῷ σμιλίῳ ἰατρικῷ γαστρωδεῖ, '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:
Τινὲς οὖν ἐπενόησαν ὄργανον πρὸς τοῦτο, τρία σμιλία ἴσα ζεύξαντες
ὁμοῦ, ὅπως τῇ μιᾷ ἐπιβολῇ τρεῖς γίνοιντο διαιρέσεις.
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 (καμπύλοις ἐξ ἄκρου μὴ λίην στενοῖς). Even if
καμπύλος 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, σκολοπομαχαίριον, σκολόπιον; Latin, _scalpellus_.
The etymology of the term σκολοπομαχαίριον 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.
[1] So says Briau (_Paul D'Egine_, p. 97), but it seems more likely to
be derived from σκόλοψ 'a spike'.
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 σκολόπιον 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._
(α) Novacula or razor (Greek ξυρόν, diminutive ξύριον).
(β) Blunt-pointed bistoury.
(γ) 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 περὶ κουρᾶς καὶ ξυρήσεως. '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:
Ἔχειν δὲ χρὴ πρὸς τὰ τοιαῦτα καὶ ὄνυχα ἐπὶ τῷ δακτύλῳ τῷ μεγάλῳ. καὶ
διελόντα ἐξενεγκεῖν τὰς χεῖρας κτλ.
'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):
Καθίημι τὸ πρόμηκες μαχαίριον, οὕτω γὰρ αὐτὸ καλῶ δύο πλευρὰς ὀξείας
ἔχον ἐπὶ τοῦ πέρατος εἰς μίαν κορυφὴν ἀνηκοῦσας.
'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 πρόμηκες 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, φλεβοτόμον, τὸ (sc. σμιλίον), also φλεβοτόμος, ὁ (Galen). ὀξυβελές
(sc. ὄργανον); 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:
Τοῖς γε μαχαιρίοις ὀξέσι δεῖ χρῆσθαι καὶ πλάτεσι, οὐκ ἐπὶ πάντων
ὁμοίως παραγγέλλομεν, κτλ. (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 (πλατυτέροις χρῆσθαι τοῖς μαχαιρίοις), 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 (ὀξυβελεῖ) which has been wound round with a rag, leaving
the breadth of the thumb nail at the point, be pushed in.'
Ὀξυβελής 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--ποτὲ μὲν καταπείροντες
ποτὲ δὲ ἀναπείροντες φλεβοτοῦμεν (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
καταπείροντες--cutting inwards--in cases where the vessels are deep, and
ἀναπείροντες--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.'_
Κατιάς -ιάδος (ἡ) (Soranus, II. xviii); καθιάς (Paul, VI. lxxiv);
κατιάδιον (τό) (Aetius, II. iii. 2); κατειάδιον (τό) (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:
Χόριον δὲ μὴ ἀναστομούμενον κατιάδι προσεχόντως διαιρεῖν τῷ δακτύλῳ
προκοιλάναντα τι μέρος.
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 κατειάδιον, or the one called the scoop'
(τορύνη).
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 κατειάδιον, from κατά and
εἴα 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 καθίημι, 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' (σμιλαρίῳ ἢ κατιάδι).
Paul says that abscess of the womb is to be exposed with a speculum and
opened with a scalpel or katias (σπαθίῳ ἢ κατιάδι). Paul also refers to it
in perforating the foetal cranium in delivery obstructed through
hydrocephaly (πολυπικῷ σπαθίῳ ἢ καθιάδι ἢ σκολοπομαχαιρίῳ) (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, σπαθίον (diminutive of σπάθη), ἡμισπάθιον; Latin, _spatha_.
On several occasions a knife called σπαθίον 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' (σπαθίῳ ἢ κατιάδι).
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 (ἡμισπαθίῳ ἢ σπαθίῳ συριγγοτόμῳ).
What the nature of the σπαθίον 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, πολυπικὸν σπαθίον, πολυποδικὸν σπαθίον; 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 (πολυπικῷ σπαθίῳ τῷ μυρσινοειδεῖ
ἀκμαίῳ), we cut round the polypus or fleshy tumour, applying the point
of the steel blade (τὴν ἀκμὴν τοῦ σιδήρου) to the part where it
adheres to the nose. Afterwards turning the instrument end for end
(ἀντιστρέψαντες) we bring out the separated fleshy body with the
scoop' (τῷ κυαθίσκῳ).
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:--
Εἰ δὲ μείζονος τοῦ κεφαλίου ὑπάρχοντος ἡ σφήνωσις ἀποτελοῖτο, διὰ τοῦ
ἐμβρυοτόμου ἢ τοῦ πολυπικοῦ σπαθίου κρυπτομένου μεταξὺ λιχανοῦ καὶ τοῦ
μακροῦ δακτύλου κατὰ τὴν ἔνθεσιν (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, λιθοτόμον (τό); Latin, _scalpellus_.
In describing lithotomy Paul says:
'We take the instrument called the lithotomy knife (τὸ καλούμενον
λιθοτόμον), 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:
Καὶ εἰ μὲν πρόχειρος εἴη, τῇ λαβῇ τοῦ μαχαιρίου ἐκβάλλειν, πεπιεσμένον
δὲ τῇ λαβῇ τραχείᾳ τε καὶ καμπύλῃ ἐξ ἄκρου, ὡς ἂν μάλιστα συμφέροι τῷ
ἔργῳ.
'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, ἐμβρυοτόμον.
A special instrument for perforating the foetal cranium is mentioned by
Soranus (II. viii. p. 366):
Εἰ δὲ μείζονος τοῦ κεφαλίου ὑπάρχοντος ἡ σφήνωσις ἀποτελοῖτο, διὰ τοῦ
ἐμβρυοτόμου ἢ τοῦ πολυπικοῦ σπαθίου κρυπτομένου μεταξὺ λιχανοῦ καὶ τοῦ
μακροῦ δακτύλου κατὰ τὴν ἔνθεσιν.
'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, ὀξυκόρακον σμίλιον.
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 (ὀξυκοράκῳ σμιλίῳ ἢ φλεβοτόμῳ ἐκ ῥιζῶν
ἐξελεῖν). This undoubtedly refers to a curved scalpel, for the grappling
hook was called κόραξ.
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, πτερυγοτόμος, ὁ; 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 (πτερυγοτόμῳ) 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, ἀναρραφικὸν σμιλίον.
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' (ἀναρραφικοῦ σμιλίου)
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, σταφυλοτόμον.
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 (σταφυλοτόμῳ), 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, ἀγκυλοτόμον (ἀγκύλη, 'bend of elbow,' _or_ ἀγκύλος, '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 (ἀγκυλοτόμον) 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, συριγγοτόμον, from σῦριγξ, '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 (συριγγοτόμῳ). 'But the scalpels
which are two-edged or have a point are distinctly to be avoided' (τὰ δ'
ἀμφήκη τῶν μαχαιρίων ἢ κατὰ τὸ πέρας ὀξέα παντὶ τρόπῳ φευκτέα).
Secondly, Paul (VI. lxxviii) says:
'Having perforated the bottom of the fistula with the point of the
falciform part of the syringotome (τοῦ δρεπάνου τοῦ συριγγοτόμου)
bring the instrument out of the anus and so divide all the intervening
space with the edge of the falciform part' (τῇ ἀκμῇ τοῦ δρεπάνου).
Another passage in the same chapter indicates that some of the
syringotomes had an eye in the instrument:
Τινὲς δὲ ἐν τῷ τρήματι τοῦ συριγγιακοῦ δρεπάνου τὸ λίνον ἐνείραντες.
There was also a straight variety of the instrument (τὰ καλούμενα ὀρθὰ
συριγγοτόμα, 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:
Χρῆσθαι δ' αὐτῆς μάλιστα τῷ κυρτῷ μέρει κεχαλκευμένης ὁμοίως
ἑκατέρωθεν, ὥστε ἀμφικύρτους ἔχειν ἀμφότερας τὰς τεμνούσας γραμμὰς
ἀλλὰ κατὰ μὲν τὴν ἑτέραν σιμῆς, κατὰ δὲ τὴν ἀντικειμένην ταύτῃ κυρτῆς.
'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 (εἰς
ὅπερ ἐστὶν ἐπιτηδειοτάτη μυρσίνη κυρτή, ii. 674).
_Shears._
Greek, ψαλίς; Latin, _forfex_.
Oribasius treats of cutting the hair as a regular medical procedure, in a
special chapter, περὶ κουρᾶς καὶ ξυρήσεως. 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 (ψαλίδι, 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 (ψαλίδι ἐπάκμῳ ἢ σμίλῃ), 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.