BONE AND TOOTH INSTRUMENTS
_Raspatory._
Greek, ξυστήρ; Latin, _scalper excisorius_, _scalper medicinalis_.
The raspatory or rugine consists of a blade of varying shape fixed at
right angles to the shaft, and it is operated by pulling instead of by
being driven forwards by striking or pushing. Although no ancient
raspatory has been preserved to us we are quite familiar with the
instrument, as it has been in continuous use throughout ancient and
mediaeval times, and it is in use at the present day. The raspatory is the
instrument upon which Hippocrates relies for eradicating fissured and
contused bone in injury to the skull:
'If you cannot discover whether the bone is broken or contused, or
both the one and the other, nor can see the truth of the matter, you
must dissolve black ointment and fill the wound with the solution, and
apply a linen rag smeared with oil, and then a poultice of maza with a
bandage; and on the next day, having cleaned out the wound, scrape the
bone with the raspatory (ἐπιξύσαι). And if the bone is not sound but
fractured and contused, the rest of the bone will be white when
scraped, but the fracture and contusion, having imbibed the
preparation, will appear black, while the rest of the bone is white.
And you must again scrape more deeply the bone where it appears black,
and if you thus remove the contusion and cause it to disappear you may
conclude that there has been a contusion of the bone to a greater or
less extent, which has occasioned the fracture that has disappeared
under the raspatory' (ὑπὸ τοῦ ξυστῆρος) (iii. 366).
From Galen we learn that there were different sizes and shapes of the
raspatory (x. 445):
'In simple fissure reaching to the second plate narrow raspatories
are used, and they should be of different sizes to suit all cases. The
affected bone being exposed _secundum artem_, first the broader ones
are to be used, then the smaller down to the narrowest. The narrowest
are to be used in the diploe.'
Paul refers to a small raspatory (ξυστήριον) for use as a tooth scaler (q.
v.). All the mediaeval writers figure numerous shapes of raspatories--many
more than we use to-day, but all on the same principle as ours.
_Chisel._
Greek, ἐκκοπεύς; Latin, _scalper_, _scalprum planum_.
The flat chisel is referred to by Celsus in his description of the
levelling of an elevation on one side of a depressed fracture of the
cranium:
Ergo, si ora alteri insedit, satis est id quod eminet plano scalpro
excidere; quo sublato, iam rima hiat quantum curationi satis est
(VIII. iv).
Numerous references occur in other authors. There is a fine example of a
flat chisel in the Cologne Museum (Pl. XLI, fig. 2). It is all of steel,
and delicately ornamented with spiral indentations. This interesting
little instrument was found in the surgeon's outfit already described, and
is one of the best authenticated instruments--as regards its having been
the property of a surgeon--we possess. The chisel figured by Vulpes,
consisting of a cylindrical bronze handle and a flat blade, is, I believe,
a variety of scalpel.
We have many interesting references to the use of the chisel in bone work.
It was used as an osteotome to divide the bone in distorted union:
'If the callus be of stony hardness incise the skin with a scalpel,
and divide the union with chisels' (ἐκκοπεῦσι) (Paul, VI. cix).
In the removal of supernumerary digits we are to cut away the flesh all
round, and either chop the bone through with a chisel (τῷ ἐκκοπεῖ), or
remove it by sawing (Paul, VI. xliii). In using the chisel as an
osteotome one chisel was often placed behind the bone to steady it while
it was being struck by another in front. This method of applying two
chisels, which is only described by the Greek authors, is always referred
to by the phrase ἐκκοπέων ἀντιθέτων.
The following passage from Galen fully describes the manipulation (ii.
687):
'Separate off the membranes adhering to the bone, which being properly
done, divide the bone of the rib by means of two chisels placed in
opposition to each other _secundum artem_' (ἀντιβαλλομένων δυοῖν
ἀλλήλοις ἐκκοπέων ὡς ἔθος).
The following passage from Paul shows the chisel used for a similar
purpose:
'If part of the clavicle is broken off and unconnected, and if we find
it irritating the parts, we must make a straight incision with a
scalpel and remove the broken portion and smooth it with chisels (δι'
ἐκκοπέων), taking care that the instrument called 'meningophylax' (q.
v.), or another chisel, be put under the clavicle (μηνιγγοφύλακος ἢ
ἑτέρου ἐκκοπέως) to steady it' (VI. xciii).
The phrase δι' ἐκκοπέων ἀντιθέτων, which Paul uses in describing the
treatment of a fistula leading to carious bone, is translated by Briau--'à
l'aide de tenailles tranchantes'. It does seem here, and occasionally in
other passages, as if the phrase might suggest 'cutting forceps', but we
have no knowledge of such an instrument being used by surgeons in
classical times, and the passages from Paul and Galen show that only two
chisels are meant. We may compare the passage on extraction of the foetus
in Paul (VI. lxxiv), where he directs a second hook to be fixed on
opposite the first (καὶ ἀντίθετον τούτῳ δεύτερον).
_Gouge._
Greek, κυκλίσκος, κοιλισκωτὸς ἐκκοπεύς, κυκλισκωτὸς ἐκκοπεύς, σκυλισκωτὸς
ἐκκοπεύς; Latin, _scalper excisorius_.
The Greek writers frequently refer to the gouge. Celsus never does so by
any special name, although it is 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'
(τῶν κοίλων ἐκκοπέων οὓς καὶ κυκλίσκους ὀνομάζουσιν, x. 445).
Paul (VI. xc) says:
'And if the bone be weak, naturally, or from the fracture, we cut it
out with gouges (σκυλισκωτοῖς), beginning first with the broader ones,
and changing to the narrower, and then using those which are
probe-like, striking gently with the mallet to prevent concussion of
the head.'
The gouge is still familiar to us.
_Lenticular._
Greek, φακωτός.
The lenticular of the ancients was a vertical chisel cutting on one edge
and struck on the other by a hammer, while the end carried a rounded
button, which being smooth did not injure the brain (Pl. XL, fig. 4). It
takes its name from the lentil-like (φακωτός) shape of the button. Galen
had a high appreciation of it, and gives a full description of its
principle (x. 445), which is transcribed by Paul (VI. xc):
'The method of operating with a sort of incisor called lenticular is
greatly praised by Galen, being performed without drilling after the
part has been grooved all round with gouges.'
Wherefore he says:
'If you have once exposed the place, then applying the chisel, which
has at its point a blunt (rounded), smooth, lentil-shaped knob, but
which longitudinally is sharp, when you apply the flat part of the
lenticular to the meninges divide the cranium by striking with the
small hammer. For we have all that we require in such an operation,
for the membrane, even if the operator were half asleep, could not be
wounded, being in contact only with the flat part of the lenticular,
and if it be adherent anywhere to the calvarium the flat part of the
lenticular removes its adhesion without trouble. And behind it follows
the incisor or lenticular itself, dividing the skull, so that it is
impossible to discover another method of operating more free from
danger or more expeditious.'
The earliest illustration of the lenticular I have been able to obtain is
that given by Vidus Vidius (Pl. XL, fig. 2). It evidently is the same
instrument as that described by Galen.
_Hammer._
Greek, σφῦρα; Latin, _malleolus_.
I have already quoted passages where the hammer is referred to as being
used in cranial surgery. Paul says: 'When you apply the flat part of the
lenticular to the meninges divide the skull by striking with a small
hammer,' and again in using gouges, 'strike gently with hammer (σφῦρα) to
avoid concussion of the head' (VII. xc).
Paul and Celsus describe a method of extracting foreign bodies from the
ear by laying the patient on a board and striking the under side with a
mallet. Paré mentions a hammer made of lead, and Fabricius describes one
padded with leather, but neither of these is described by the ancients.
There is, however, a Roman hammer of lead from the excavation at Uriconium
in the Shrewsbury Museum.
_Block._
Greek, ἐπίκοπον, a butcher's block.
The ancients frequently amputated parts by placing them on a block and
striking them with a chisel. The mediaeval surgeons amputated parts as
large as the forearm in this way, but the Greeks all describe amputation
by knife and saw. We have reference to the 'block' in Greek literature,
however. In describing the plastic removal of a portion of the scrotum
Paul (VI. lxvii) says:
'Leonidas, laying the patient on his back, cuts off the redundant
portion upon a chopping block of any kind of wood or stiff leather'
(κατ' ἐπικόπου σανιδίου τινὸς ἢ σκληροῦ δέρματος).
Galen uses the same word in the eighth book of his work on Practical
Anatomy--apologizing somewhat for calling the article used by anatomists
and surgeons by the undignified term of butcher's block:
Χρώμενος ἐπικόπῳ, καλέσαι γὰρ οὕτως οὐδὲν χεῖρον ἔστιν ὁμοίως τοῖς
ἀνατομικοῖς τε καὶ χειρουργοῖς τὸ στήριγμα τῶν ὑποβεβλημένων τῇ τομῇ
τῶν σωμάτων (ii. 685).
_Meningophylax._
Greek, μηνιγγοφύλαξ; Latin, _membranae custos_.
The meningophylax was a small plate, which was inserted under a bone which
was being cut in order to protect underlying structures. 'In cutting or
sawing the bone,' says Paul (VI. lxxvii), 'when any vital parts are
situated below, such as the pleura, spinal marrow, or the like, we must
use the instrument called the meningophylax for protecting them
(μηνιγγοφύλακα).'
Celsus thus describes it (VIII. iii):
Factis foraminibus eodem modo media septa, sed multo circumspectius,
excidenda sunt, ne forte angulus scalpri eandem membranam violet;
donec fiat aditus, per quem membranae custos immittatur; μηνιγγοφύλακα
Graeci vocant. Lamina aenea est, firma paulum resima, ab exteriore
parte laevis; quae demissa sic ut exterior pars eius cerebro proprior
sit, subinde ei subiicitur quod scalpro discutiendum est; ac si
excipit eius angulum, ultra transire non patitur; eoque et audacius,
et tutius, scalprum malleolo medicus subinde ferit, donec undique
excisum os eadem lamina levetur, tollique sine ulla noxa cerebri
possit.
Pl. XL, fig. 3 shows a figure of the meningophylax from Vidius.
_Drill._
Greek, τρύπανον; Latin, _terebra_, _terebella_.
There are, says Celsus, two kinds of drills. The first like those used by
artisans and driven by a thong, the second with a guard to prevent the
instrument from sinking too deeply into the bone. The drill was used in
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:
At si latius vitium est quam ut illo comprehendatur, terebra res
agenda est. Ea foramen fit in ipso fine vitiosi ossis atque integri;
deinde alterum non ita longe, tertiumque, donec totus is locus qui
excidendus est his cavis cinctus sit. Atque ibi quoque, quatenus
terebra agenda sit, scobis significat. Tum excisorius scalper ab
altero foramine ad alterum malleolo adactus id quod inter utrumque
medium est excidit; ac sic ambitus similis ei fit qui in angustiorem
orbem modiolo imprimitur (VIII. iii).
Paul says:
'If a weapon be lodged deep in bone of considerable thickness it may
be bored out with drills' (τρυπάνοις) (VI. lxxxviii).
Aretaeus (ed. Adams, p. 467) says that exposed bones are to be surrounded
with perforations by means of the drill and thus reduced (τερέτρῳ χρὴ
περικόπτειν τὰ γυμνά).
The boring parts of drills are not unfrequently found. The most ancient
illustrations known to me of drills driven by thongs are in the work by
Vidus Vidius (_Chirurgia e Graeco in Lat. Conversa_, V. Vidio. Florent.
interprete c. nonn. eiusd. commentariis. Lutec. Paris., 1544).
Vidius shows three arrangements for driving these drills with thongs: the
first method consists simply of a thong attached to the shaft of the drill
(Pl. XLII, fig. 4); the second consists of a bow with the string of the
bow wound once round the shaft (Pl. XLII, fig. 5); and the third consists
of a crosspiece with a hole in the centre of it through which the shaft
passes, and having strings from the end of the crosspiece to the top of
the shaft (Pl. XLII, fig. 3). Primitive arrangements truly, yet all three
methods of producing rotary motion are to be seen in use at the present
day, and be it known that some of the most delicate boring performed by
the hand of man at the present day is done with drills turned by the thong
stretched across a bow. The latest developments in mechanical devices for
drilling have failed to displace thong-driven drills for boring the holes
in which the wheel spindles of the best hand-made chronometers move, and
the spindles themselves are turned in chucks rotated not by belts in
continuous rotary motion, but in alternating motion by means of a thong
stretched across a bow. A bow of cane with a strong but fine thread, one
turn of which is taken round the drill, is drawn backwards and forwards
and rotates the drill with marvellous rapidity and accuracy. The bows used
by watchmakers average about a foot along the string. Similar drills are
used by engineers in turning out small work. The form with the crosspiece
may be seen in use by travelling crockery menders, who drill holes in
broken pottery and clamp the pieces with rivets. A turn or two of the
string is made round the shaft, and the point of the drill being adjusted
on the spot to be bored the crosspiece is gently pressed down by the first
and third fingers, causing the shaft to rotate. When the thong has nearly
uncoiled itself the pressure is slightly removed, the momentum causes the
shaft to overrun and coil the thong in the opposite direction to which it
originally was. The crosspiece is again depressed and the alternating
rotation goes on without intermission, and the drill bores through the
pottery. The travelling crockery mender is, in the northern towns of
England, not an unusual sight squatting at work on the kerb. On the
continent the 'Rastelbinder' is a regular domestic institution. Not only
crockery but glass is readily drilled by these means, and one who has seen
the rapidity with which these drills rotate can readily understand the
necessity for the advice given both by Hippocrates and Celsus to
frequently remove the drill and dip it in cold water, in case sufficient
heat be generated by the friction to cause subsequent exfoliation of the
neighbouring bone.
The remaining method of producing rotation by means of a string fixed to
the shaft can be seen in use by boatmen when clearing water out of a boat
with a mop, The mop is laid over the side of the boat. A few turns of a
rope fixed to the shaft are made round it and the rope being pulled the
shaft rotates. The momentum generated causes the shaft to overrun and the
rope to coil itself in the reverse way to the original. This is repeated
till the speed generated causes the water to fly off the mop by
centrifugal motion.
The fire drill of the ancient Egyptians was turned by a bow, and it is
interesting in connexion with the advice of Hippocrates to avoid
generating too much heat in drilling the skull, and also because it helps
to explain the construction of the instruments of Vidius. A sketch of an
ancient fire drill found by Flinders Petrie (_Ten Years Digging in Egypt_)
shows that the head of the drill was separate and the points were also
removable.
_Drill with Guard._
Greek, τρύπανον ἀβάπτιστον; Latin, _terebra abaptista_.
This is the second variety of drills described by Celsus. It had a collar
which prevented it from sinking beyond a certain depth, so that in
excising a piece of bone from the skull, which was the object for which it
was used, there was little danger of its doing injury to the brain or its
membranes:
Terebrarum autem duo genera sunt; alterum simile ei quo fabri utuntur;
alterum capituli longioris, quod ab acuto mucrone incipit, deinde
subito latius fit; atque iterum ab alio principio paulo minus quam
aequaliter sursum procedit (VIII. iii).
Further on in the same passage Celsus states that they were to be
frequently removed and dipped in water lest too great heat should be
generated, so that they were evidently driven at a rapid rate with a thong
like the other drills. They are not mentioned by Hippocrates, but Galen
(x. 445) describes them:
'In order to make less chance of error they have invented drills
called abaptista (ἀβάπτιστα τρύπανα), which have a circular border a
little above the sharp point of the drill. It is best to have several
for every thickness of the calvarium; for thicker bone longer are
required, for thinner bone shorter.'
Paul (VI. xc) says:
'But if the bone is strong it is first to be perforated with that kind
of perforators called abaptista (περιτρυπήσαντες ἀβαπτίστοις τοῖς
λεγομένοις), which have certain eminences to prevent them sinking down
to the membrane, and then with chisels we remove the bone not whole,
but in pieces.'
The illustrations of drills given from Vidius (Pl. XLII) are really
abaptista.
_Saw._
Greek, πρίων, μαχαιρωτὸς πρίων (as if from μαχαιρόω); Latin, _serrula_.
The saw is very frequently mentioned in the description of operation on
bone. Celsus (VII. xxxiii), in describing the amputation of a gangrenous
limb, says:
Dein id serrula praecidendum est, quam proxime sanae carni etiam
inhaerenti: ac tum frons ossis, quam serrula exasperavit, laevanda
est.
And Paul says that in amputating a gangrenous limb the flesh ought to be
retracted with a band lest it be torn by the saw. Saws were also used in
cranial surgery. Hippocrates frequently mentions a saw (πρίων) in this
connexion, but it is evident that he means the trephine, as he describes
its circular motion. Paul, however, makes it quite clear that he means
flat cranial saws, for he mentions both saws and trephines in one
paragraph:
Ἤδη καὶ τῶν πριόνων τε καὶ χοινικίδων χειρουργίαι, κτλ.
'The method of operating with saws and trephines is condemned by the
moderns as a bad one' (VI. xc).
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 (μαχαιρωτῶν
πριόνων).' There is an example of this form of saw in the Guildhall
Museum, London.
_Trephine._
Greek, τρύπανον, πρίων, πρίων χαρακτός, χοινικίς, ὀρθοπρίων; Latin,
_modiolus_.
The ancient trephine is referred to by Hippocrates, who mentions a saw
(πρίων and πρίων χαρακτός) having a circular motion (iii. 374):
'In trephining you must frequently remove the trephine, on account of
the heat in the bone, and plunge it in cold water. For the trephine
(πρίων), being heated by the circular motion (περιόδου) and heating
and drying the bone, burns it and makes a larger piece of bone
exfoliate than would otherwise be necessary.'
And again:
'You must saw the bone down to the meninges with a serrated trephine
(πρίονι χρὴ χαρακτῷ ἐμπρίειν), and in doing so must take out the
trephine (πρίονα), and examine with a probe and by other means along
the track of the trephine' (πέριξ κατὰ τὴν ὁδὸν τοῦ πρίονος).
In injuries to the head in young people (iii. 371) he mentions a small
trephine (σμικρὸν τρύπανον), so that apparently several sizes were
available. Hippocrates, we have seen, uses the words πρίων and πρίων
χαρακτός to denote the trephine. Galen always uses χοινικίς, but in his
Lexicon he gives two other words, viz. ὀρθοπρίονι and περητηρίῳ,
ostensibly from the works of Hippocrates:
Ὀρθοπρίονι--τῇ χοινικίδι.
περητηρίῳ--τρυπάνῳ τῷ εὐθεῖ καὶ ὀξεῖ, ἔστι γὰρ καὶ ἕτερον ἡ χοινικίς.
These terms do not, however, occur in any extant Hippocratic writings,
unless, as seems possible to me, the latter term περητηρίῳ be a _var.
lect._ for the obscure word τρυγλητηρίῳ applied to τρύπανον in ii. 470 in
the description of trephining a hole through a rib to drain an empyema.
Galen held the trephine in little esteem. It must have been difficult to
manufacture a satisfactory instrument of bronze. In x. 448 he says: 'Some
people, shall I call them rather cautious or rather timid, have used
trephines' (χοινικίσιν); and Paul, in a passage I have already quoted,
says: 'The mode of operating with saws and trephines is condemned by
moderns as a bad one.'
The term χοινικίς is derived from χοινίκη and χνόη, the nave of a wheel.
The Latin term for the trephine, _modiolus_, has the same meaning. Celsus
graphically describes the trephine and the method of its application. From
him we learn how the ancients solved the problem of the centre-pin, which
is necessary until the toothed portion has begun to bite. In modern
trephines this difficulty is got over by withdrawing the pin up the centre
of the shaft. In mediaeval trephines it was solved by providing two
instruments, a male and a female, the male with centre-pin being used till
a circular track had been cut by the toothed ring, the female without pin
being then used. In the time of Celsus the centre-pin was removable, being
taken out after the instrument had begun to bite. From Celsus too we learn
that the trephine was driven by a thong.
Celsus and Hippocrates both remark that, as in the case of the drill, it
is necessary to dip the trephine in cold water at intervals in order to
cool it, lest heat sufficient to injure the surrounding bone be generated.
The thong manipulated by a bow would seem to be the method most applicable
to an instrument like the trephine, which has a large boring radius, as
slower motion is more easily produced by this arrangement than by one
consisting of a cross-piece with thongs. Celsus says:
Exciditur vero os duobus modis: si parvulum est quod laesum est,
modiolo, quem χοινικίδα Graeci vocant: si spatiosius, terebris.
Utriusque rationem proponam. Modiolus ferramentum concavum teres est,
imis oris serratum; per quod medium clavus, ipse quoque interiore
orbe cinctus, demittitur. Terebrarum autem duo genera sunt: alterum
simile ei quo fabri utuntur: alterum capituli longioris, quod ab acuto
mucrone incipit, deinde subito latius fit; atque iterum ab alio
principio paulo minus quam aequaliter sursum procedit. Si vitium in
angusto est quod comprehendere modiolus possit, ille potius aptatur:
et si caries subest, medius clavus in foramen demittitur; si
nigrities, angulo scalpri sinus exiguus fit qui clavum recipiat ut, eo
insistente, circumactus modiolus delabi non possit: deinde is habena,
quasi terebra convertitur. Estque quidam premendi modus, ut et foret
et circumagatur; quia si leviter imprimitur parum proficit, si
graviter non movetur. Neque alienum est instillare paulum rosae vel
lactis, quo magis lubrico circumagatur; quod ipsum tamen, si copiosius
est, aciem ferramenti hebetat. Ubi iam iter modiolo impressum est,
medius clavus educitur, et ille per se agitur: deinde, quum sanitas
inferioris partis scobe cognita est, modiolus removetur.
_Perforator for Fistula Lachrymalis._
Greek, λεπτὸν τρύπανον.
Galen (xii. 821) says that Archigenes in cases of fistula lachrymalis
perforated the nasal bone with a small drill (λεπτὸν τρύπανον), and Paul
(VI. xxii) says:
Some, after excision of the flesh, use a perforator (τρύπανον) and make a
passage for the fluid or matter to the nose.
Albucasis figures a drill for this purpose which he says had a triangular
iron point and a conical wooden handle.
In the find of instruments of the third-century oculist Severus is a drill
which Deneffe regards as intended for this purpose. It is 6 cm. in length
and 7 mm. on each of its four sides. One end is pointed, the other has a
slit for a knife-blade. It is beautifully damascened with silver (Pl. II,
fig. 7).
_Bone Lever._
Greek, μοχλίσκος, ἀναβολεύς.
Instruments for levering fractured bones into position are described in
several places. Hippocrates (iii. 117) says:
'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 (σιδήρια) are to be prepared like the
levers (οἱ μοχλοί) 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.'
In a note to this passage Galen (xviii. 593) says:
'It is evident that the instruments described resemble those of stone
cutters, not in size but in principle. For the instruments prepared by
us for levering bone are similar in size to those used for levering
out teeth. But for levering bones several ought to be prepared,
differing from each other in length as well as breadth and thickness
at the point, by which means they may afford their greatest effect.'
Paul (VI. cvi) gives us some additional information:
'Of whatever bones therefore we endeavour to replace the protruded
ends, we must not meddle with them when in a state of inflammation.
But on the first day before inflammation has come on, or about the
ninth day after inflammation has gone off, we may set them with an
instrument called the lever (τῷ λεγομένῳ μοχλίσκῳ). It is an
instrument of steel about seven or eight fingers' breadth in length,
of moderate thickness that it may not bend during the operation, with
its extremity sharp, broad, and somewhat curved.'
There are two bone levers in the Naples Museum, both of bronze. Pl. XLI,
fig. 1 shows one of them (No. 78,012). It is 15·5 cm. in length, and with
its ends flattened, and curved, and pointed, as described by Paul. The
other instrument is of similar shape, but is somewhat less in size. The
concave surface at one end is smooth, at the other ridged like a file.
It may be remarked, that though the similarity in form to the instruments
figured by Paré as in use in his time for levering up depressed bones
shows that these are undoubtedly bone levers, it is quite possible, from
what Galen says, that they may also have been used for levering out teeth.
The smooth end also corresponds to the description of the meningophylax,
so that it is possible it may have been used in that capacity also.
_Bone Forceps._
Greek, ὀστάγρα.
Galen (x. 450) says, in comminuted fracture of the skull we must make a
way for the lenticular with the bone forceps (διὰ τῆς ὀστάγρας); and in
depressed fracture Paul (VI. xc) says:
'If the bone is strong it is first to be perforated with the drills
called abaptista and the fractured bone is to be removed in fragments,
with the fingers if possible, if not, with a tooth forceps or a bone
forceps' (ὀδοντάγρα ἢ ὀστάγρα).
Soranus (lxiv. p. 366) says that in impaction of the foetal cranium the
head may be opened with a sharp instrument and the pieces of the skull
removed with tooth or bone forceps (ὀδοντάγρας ἢ ὀστάγρας). Aetius copies
this (IV. iv. 24) and so does Paul (VI. lxxiv).
An excellent specimen of the sequestrum forceps was found in the house of
the physician at Pompeii, and is now in the Museum at Naples (No. 78,029).
It is formed of two crossed branches moving on a pivot. The handles are
square, the jaws are curved, and have across the inside of them parallel
grooves which oppose each other accurately (Pl. XLIII). It is classed in
the catalogue as an instrument for crushing calculus of the bladder. This
is, however, not a manipulation which is described by the ancients. The
only case in which splitting of calculi is referred to is in Celsus, and
then a chisel is used.
_Varix Extractor._
An instrument, apparently a forceps, for extracting varicose veins in
segments is mentioned by Galen:
'And with regard to varices in the legs, first having mapped them out
on the surface with scarifications, then setting about the operation,
taking hold of the skin we divide it first. Then pulling up the varix
with a hook we tie it, and, doing this at all the cuts in the skin,
and cutting the ends, we either remove it with a varix extractor
(κιρσουλκῷ) or, taking hold of it with a doubled thread, we draw it
through the channel of the varix after the manner of flaying' (xiv.
790).
Celsus (VII. xxxi) directs us to expose the vein and raise it by a blunt
hook at intervals of four finger breadths, and divide the vein at one hook
and pull the vein out at the next place. Galen, however, indicates that
there was a special instrument for the purpose, and this can scarcely have
been anything else than a forceps of some kind. The operation must have
been excessively painful. Pliny (xi. 104) remarks that C. Marius was the
only man who had undergone it in the upright position.
_Blacksmith's Tongs._
Latin, _vulsella quali fabri utuntur_.
For replacing a protruding bone in a case of compound fracture Celsus
(VIII. x) says that a forceps such as smiths use may be employed:
Tum ipsum recondendum est; ac, si id manus facere non potest, vulsella
quali fabri utuntur iniicienda est, recte se habenti capiti ab ea
parte qua sima est; ut ea parte qua gibba est eminens os in suam sedem
compellat.
'Then it is to be replaced, and if that cannot be done by hand the
forceps such as smiths use is to be inserted, the head being kept
straight by the snub-nosed part so that the curved part forces the
bone into position.'
The blacksmith's tongs is very frequently represented in ancient art. Pl.
XLII, fig. 2 shows a forceps from Roman London in the Guildhall Museum.
_Tooth and Stump Forceps._
Greek, ὀδοντάγρα, ῥιζάγρα.
The ancients regarded tooth extraction as an operation to be avoided
wherever possible. Caelius Aurelianus says death had followed in some
cases, and that in the temple of Apollo at Delos there hung a tooth
forceps of lead as a reminder for operators to exert little force in tooth
extraction (_Pass. Tard._ II. iv). Scribonius Largus (_Comp._ liii) is
equally pessimistic:
Ad dentium dolorem quamvis plurimi dicant forcipes remedium esse,
multa tamen citra hanc necessitatem scio profuisse.
Celsus (VII. xii) says extraction may result in injury to the temples and
eyes, and fracture or dislocation of the jaw may occur. He recommends
therefore to free the tooth all round down to the socket, then to shake it
repeatedly till it has been thoroughly loosened, and remove it with
fingers or forceps. If the tooth be hollow, it should be plugged with lint
or lead to prevent it breaking under the forceps. The tooth should be
pulled out straight, lest the alveolus be broken. Stumps are to be removed
with the forceps which the Greeks call ῥιζάγρα. Paulus Aegineta (VI.
xxvii) bids us scarify down to the socket and loosen the tooth gradually
by shaking with a tooth extractor (ὀδοντάγρα) and extract it.
Supernumerary teeth are, if fast, to be rasped down with a graving tool;
if loose, to be extracted with tooth forceps (διὰ τῆς ὀδοντάγρας). There
is no ancient forceps which can with certainty be set down as a tooth
forceps, although some have looked upon the Pompeian forceps (see p. 135)
as a tooth extractor. Although its shape is not otherwise unsuitable for
this purpose its jaws are not particularly well adapted for seizing a
tooth, as they are not hollowed inside. It may be noted that the tooth
forceps was evidently a 'universal', as no special variety is ever
mentioned beyond the two I have given--'tooth' and 'stump'. Whatever the
shape of the Graeco-Roman forceps was it seems to have been a handy
instrument for many different manipulations. Soranus (ii. 63) says that in
impaction of the foetal cranium we may open the head and remove the bones
with a bone forceps or a tooth forceps (ὀστάγρας ἢ ὀδοντάγρας). Paul (VI.
xc) says that in fracture of the skull the fragment is to be surrounded
with perforations by the drill and finally separated with chisels, the
chips being removed with the fingers or with tooth forceps, bone forceps,
&c. (ὀδοντάγρα ἢ ὀστάγρα). Again in ch. lxxxviii he says that if the shaft
of a weapon imbedded in the flesh be broken off, the weapon may be
extracted with a tooth forceps or a stump forceps (ὀδοντάγρας ἢ ῥιζάγρας).
_Tooth Elevator._
In a note on a passage in Hippocrates describing the lever for replacing
the protruding end of a fractured bone, Galen mentions an instrument for
levering teeth. He says the instruments for levering the bone are of the
same size as the instrument for levering teeth (xviii. 593). As we know
from Paul (VI. cvi) that these bone levers were seven or eight finger
breadths in length, we may take this as the length of the tooth elevator.
_Tooth Scalers._
Greek, ξυστήριον, σμιλίον, σμιλιώτον (sc. ὄργανον); Latin, _scalper
medicinalis_.
Paul (VI. xxviii) mentions a small raspatory used for removing tartar from
teeth:
'The scaly concretions which adhere to teeth we may remove with the
scoop of a specillum, or with a scaler (ξυστηρίῳ) or a file.'
Scribonius Largus (_Comp._ liii) mentions an excavator:
Itaque cum etiam exesus est aliqua ex parte, tum non suadeo protinus
tollendum, sed excidendum scalpro medicinali, qua cavatus est, quod
sine ullo fit dolore, reliqua enim solida pars eius et speciem et usum
dentis praestabit.
Marcellus conveys this passage entire (_De Med._ xii).
Paul (VI. xii) says supernumerary teeth may be cut down with excavators
(τῶν σμιλιωτῶν).
_File._
Greek, ῥινάριον, ῥίνη, ῥινίον; Latin, _lima_, _limula_.
In compound fracture with protrusion of bone Celsus says:
'Should any small piece of bone protrude, if it is blunt it should be
reduced to its place. If it is sharp its point should first be cut off
if it is long, and if short it should be filed. "In either case it
should be smoothed with the raspatory."' (Si longius est,
praecidendum; si brevius, limandum, et utrumque scalpro laevandum.)
The application of the raspatory to smooth the bone after the use of the
file shows that it must have been more of the nature of a rasp than a file
which was used for bones. Scribonius Largus speaks of a wood file or rasp
used in reducing a hart's horn to powder (_Comp._ cxli):
Ad lumbricos satis commode facit et santonica herba, quae non viget,
et cornum cervinum limatum lima lignaria.
Files were largely used in dental work. All the surgeons state that where
a tooth projects above its fellows it should be filed down; Galen says
that for this purpose he has invented an olivary pointed file of steel:
σιδήριον ἐποίησα ῥινίον πυρηνοειδές (xiv. 871).
Aetius copies Galen's chapter word for word (II. iv. 30). Paul (VI.
xxviii) says the file (ῥινάριον) may be used to remove tartar from teeth.
There are several files of steel in the Naples Museum which are classed
among the surgical instruments. Many Roman files of steel which have been
found in London are now in the Guildhall Museum. Some of these have
transverse edges like our own files. Other extant specimens have coarse
frets on them, like our wood rasps. Pl. XLII. fig. 1 shows one in the
Guildhall collection, which is of the rasp variety.
_Forceps for extracting Weapons._
Greek, βελουλκόν (sc. ὄργανον).
Paul has a most interesting chapter on the extraction of weapons, and in
it he mentions a special instrument for extracting weapons, evidently a
forceps:
'If the head of the weapon has fixed in the flesh, it is to be drawn
out with the hands, or by laying hold of the appendage which is called
the shaft, if it has not fallen off. This part is commonly made of
wood. When it has fallen off we make the extraction by means of a
tooth forceps, or a stump forceps, or a forceps for extracting weapons
(βελουλκοῦ), or any other convenient instrument. And sometimes we make
an incision in the flesh around it in the first place, if the wound do
not admit the instrument' (VI. lxxxvii).
It is true that etymologically we are only entitled to translate βελουλκοῦ
by 'weapon-extractor', but its association with the other two forceps
shows pretty conclusively that a forceps is meant, and Celsus says weapons
are to be extracted with the forceps under similar conditions. In the
picture of Aeneas wounded, found in a house at Stabiae and now in the
Naples Museum, the surgeon, Iapix, is engaged in extracting a weapon from
the wound in the thigh of the hero. The instrument he is using is a long
forceps with crossed legs (Pl. XLIV).
_Periosteal Elevator for the Pericranium._
Greek, ὑποσπαθιστήρ, σπαθιστήρ.
The hypospathister was an elevator for separating the pericranium from the
calvarium. It gave the name to a formidable operation in which it was
used, viz. hypospathismus. This operation is described by Galen, Aetius,
and Paul, by the latter (VI. vi) best of all. Paul is the only one who
mentions the instrument by name. The operation consisted in making three
vertical incisions, one down each side of the forehead and one down the
centre. Next the skin was raised along with the pericranium from the whole
of the front of the forehead with the hypospathister (ὑποσπαθιστήρ), and
the vessels lying in the raised flaps were subcutaneously divided by a
knife passed under them, with its back to the skull. The elevator by which
the pericranium was separated is called by Paul ὑποσπαθιστήρ. The
operation is mentioned by Epiphanius, a bishop of Alexandria in the fourth
century, by whom the instrument is referred to as σπαθιστήρ.
_Impellent._
Greek, διωστήρ.
In his chapter on the extraction of weapons, one of the most remarkable
chapters in the whole of his works, Paul mentions an impellent for forcing
an arrow head through a part so as to extract it at the side opposite to
that by which it went in.
'If the head of the weapon has passed to the other side and it is
found impossible to extract it by the way it entered, having divided
the parts opposite we extract it through the middle of them, either
extracting it in the manner spoken of (i. e. with forceps), or we make
an opening by means of the weapon itself, pushing it by the shaft, or,
if that has come away, by an impellent instrument (διωστῆρος), taking
care not to divide a nerve, artery, vein, or any important part; for
it would be malpractice if, in extracting the weapon, we should do
more mischief than the weapon itself had done. If the weapon has a
tang, which is ascertained by examination with the probe, having
introduced the female part of the impellent instrument and engaged it,
we push the weapon forwards, or, if it has a socket, the male part'
(τὴν θήλειαν τοῦ διωστῆρος καθέντες καὶ ἐναρμόσαντες ὠθήσομεν τὸ βέλος
εἰ δὲ αὐλὸν τὸν ἄρρενα).
Impellents formed an important part of the armamentarium of the surgeon,
at least down to the time of Scultetus, and in his works and in those of
Albucasis and Paré there are numerous figures of these instruments. None
of these quite agree with the idea of the instrument which one gathers
from Paul's description. It would seem to have been a very simple affair,
probably a plain rod of metal pointed at one end and hollowed at the
other, the pointed end being introduced into the socket of an arrow where
it possessed one, the hollow end being fitted over the tip of the tang in
cases where the arrow was tanged.
_Arrow Scoop._
Greek, κυαθίσκος Διοκλεῖος.
A scoop for extracting arrow heads is thus described by Celsus (VII. v):
Latum vero telum, si conditum est, ab altera parte educi non expedit,
ne ingenti vulneri ipsi quoque ingens vulnus adiiciamus. Evellendum
est ergo genere quodam ferramenti quod Διοκλείου κυαθίσκον Graeci
vocant, quoniam auctorem Dioclem habet: quem inter priscos maximosque
medicos fuisse iam posui. Lamina, vel ferrea vel etiam aenea, ab
altero capite duos utrimque deorsum conversos uncos habet; ab altero
duplicata lateribus, leviterque extrema in eam partem inclinata quae
sinuata est, insuper ibi etiam perforata est. Haec iuxta telum
transversa demittitur; deinde ubi ad imum mucronem ventum est paulum
torquetur, ut telum foramine suo excipiat; quum in cavo mucro est, duo
digiti subiecti partis alterius uncis simul et ferramentum id
extrahunt et telum.
'But a broad weapon if buried should not be extracted from a counter
opening, lest to one large wound we add another; therefore it is to be
extracted with a special variety of instrument which the Greeks call
the Scoop of Diocles, since Diocles invented it. I have already stated
that he was one of the most eminent of the old practitioners. Its
blade of iron, or even of bronze, has at one end two hooks, one at
each side turned backwards. At the other end it is folded over at the
sides, and the end is slightly curved up towards that part which is
bent. Moreover in it there is a perforation. This is introduced
crosswise near the weapon, then when it comes near the point it is
twisted a little so that it receives the point in the hole. When the
weapon is in the cavity two fingers placed under the hooks at the
other end simultaneously extract both the instrument and the weapon.'
This description seems very definite until we attempt to reconstruct the
instrument, when it becomes evident that more than one construction may be
put on some parts of it. Pl. XLV, fig. 4, shows the instrument as
conceived by me.