John Stewart Milne

“ Soranus (II. xviii) says if a stone is the cause of dystocia we must push it out of the neck of the bladder into the bladder with a catheter (καθετήρ) . The word Rufus uses puts it beyond doubt that a hollow tube is meant, or we might have argued that καθετήρ did not necessarily mean a hollow tube, since Hippocrates uses it in the sense of a uterine plug (ii. 830) . Yet strange to say, the sensation conveyed to the hand and ear on striking a stone with a metal instrument is nowhere definitely given as a cardinal symptom by a classical writer. ”

“ The surgical instruments we meet with are, as a rule, of bronze. Not that the Greeks and Romans did not make many of their instruments of iron and steel, but the iron has mainly perished while more of the bronze has persisted. Long before the date of the earliest medical writings, Greece had passed into the iron age. The Homeric poems picture a civilization in the state of transition from a bronze to an iron period, and weapons such as sword, axe, and spear, are frequently described as made of iron. ”

“ Ligulae are found in enormous numbers and in very great variety. They are toilet articles for extracting from tubes and boxes ointment, the various salves, balsams, and powders which entered into the mysteries of the Roman lady’s toilet. The ligula is therefore not strictly speaking a surgical instrument, but as it was used by the laity, and no doubt also by physicians, for making applications to affected as well as to unaffected parts, and as it is often found associated with surgical instruments, it is advisable to bring it within the scope of this investigation. ”

“ 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. ”

“ 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. ”

“ And accordingly there is among the appliances of medical men an instrument by which the private parts are dilated with a priapiscus worked by a screw, and also a ring-knife whereby the limbs are cut off in the womb with judicious care, and a blunt hook by which the whole mass is extracted and a violent form of delivery in this way effected. There is also a bronze stylet with which a secret death is inflicted ”

“ 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:
[Pg 39] 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. ”

“ Although, as I have shown, iron and steel were largely used in the manufacture of instruments, fortunately for us bronze was the metal usually selected, for thus many instruments have withstood the lapse of time which would otherwise have been oxidized out of existence. Copper is much more easily got from ore than iron, and consequently it was the first to be used by man, and very early the advantage of combining it with tin to form bronze was found out. ”

“ These remarks show that with the probe the ancients had cultivated the tactus eruditus to a high degree, and the remarks of Aetius and Paul are equally to the point.
The tips of the probes which have survived vary considerably in size and shape. Some have a point which is almost sharp like a stylet; in others the natural thickness of the shaft is kept right to the tip, which is simply rounded off or there is an oval enlargement like that on our olivary probes and sounds. In rare cases the enlargement is globular. The oval enlargement was named by the Greeks πυρήν, which means ‘olive-kernel’. ”

“ In Aetius (II. iv. 12) we have an interesting description of the amputation of the uvula by first crushing it in a forceps so as to prevent haemorrhage and then cutting it off:
‘Then inserting a vulsellum and making traction on it, the uvula crusher (τὴν σταφυλάγραν) is fitted on about the middle of the uvula or a little below it, and then it is pulled and twisted (by the vulsellum) . By the torsion it becomes lifeless and, as it were, snared off; it curls up, becomes livid and comes off without much effusion of blood. ”

“ The exact significance of the term κοπάριον is sometimes difficult to determine. It is easy to prove that in general it is merely a sound. Thus Paul (VI. lxxviii) , in quoting a passage from Hippocrates, substitutes κοπάριον for the word μήλη, which Hippocrates uses to denote the sound used for exploring a fistula. Throughout this chapter, in which the word occurs ten times in all, Briau translates it by ‘manche du scalpel’, although the whole context shows that a probe is meant. ”

“ In the British Museum several types of instrument will be found classed among surgical instruments, and a series of exactly similar articles will be found repeated among the styli used for inscribing and erasing characters on wax tablets. As even the writing stylus was occasionally used for surgical manipulations we are justified in looking on all styloid instruments as potentially implements of minor surgery. The claims of any doubtful instrument to be considered as once having been one of a surgeon’s tools must be decided on such grounds as the circumstances of its discovery. ”

“ In Aetius (IV. iv. 23) cephalotripsy is thus described:
‘But if the foetus be doubled on itself and cannot be straightened, if the head is presenting, break up the bones of it without cutting the skin. Then to some part of it fix on a traction hook and make traction, and the legs becoming straightened out we get it away.’
Though there is an essential difference between the operations of cephalotripsy and cranioclasie there is no essential difference between the instruments necessary for carrying out the same, and it is possible that the instrument used may be the same as the last. ”

“ Latin, vulsella.
The removal of the hair from the face for cosmetic purposes is a custom which has come down to us from prehistoric times, and seems to have been very prevalent among all primitive races. In the bronze age the method by which this was accomplished seems to have been to fix the hairs with a broad jawed forceps and cut them off close to the skin by means of a knife or ‘razor’. ”

“ Pots for ointments of certain kinds were made of iron, and we have actually two of these which had been the property of a Roman oculist whose full name is known. I have entered into this discussion because there seems to be a general tendency to underestimate the extent to which iron was employed by the Greeks and Romans. The quantity of scoria left by the primitive founders should alone be sufficient to teach us to how great an extent iron was in use. Wherever there was good iron in any of the Roman provinces, veritable mountains of scoria are found. ”

“ Thus did primitive men ‘shave’, and very often in early bronze age graves in Scandinavia and in the Swiss lake-dwelling excavations these forceps and razors are found together. No doubt also epilation proper was practised occasionally, but the majority of the prehistoric forceps are not for epilation but for fixing the hairs to allow the knife to divide them close to the skin. At a later time, with the more common use of steel, the Greeks and Romans shaved as we do, and epilation proper was practised for removing superfluous hairs from the face and also to remove trichiasis. ”

“ Further, if there be bone adjacent, it is possible to learn whether the fistula has entered it or not and how deeply it has caused disease. For if the part is soft which is reached by the end of the probe the disease is still intermuscular; if the resistance be greater it has reached the bone: if there the probe slip there is as yet no caries. If it does not slip but meets with a uniform resistance there is indeed caries, but it is as yet slight. ”

“ Yet modern writers almost invariably speak of or describe even the cutting instruments of the ancients as made of iron. Greek and Latin have each only one word to indicate both steel and iron, but that is because, as I have shown, they prepared both in the same way. The ancient Hindoo Vedas say that cutting instruments were to be made of steel, well polished and sufficiently keen to divide a hair. For sharpening, a stone was to be used, and they were to be kept clean and wrapt in flannel and laid by in a box of sandalwood. Albucasis in mentioning steel always specifies Indian steel. ”

“ 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. ”

“ Wherever possible two instruments are combined into one. Thus very few of the probes are simple instruments but carry a spatula, a scoop or spoon, an eye, or a hook, at the opposite end. Vulsella are more difficult to combine with other instruments, but here again we meet with combinations such as vulsella at one end and scoop, raspatory, or probe, at the other. The typical scalpel handle carries at the end opposite the blade a spatula for blunt dissection. We have needles at one end and probes, scalpel blades, &c., at the other end of a handle. ”

“ The patient having been fixed in the lithotomy position in the manner described by Soranus:
‘The operator is to make the examination with a speculum (διόπτρα) proportioned to the age of the patient. The person using the speculum should measure with a probe the depth of the woman’s vagina, lest the priapiscus of the speculum (τοῦ τῆς διόπτρας λωτοῦ) being too long it should happen that the uterus be pressed on. If it be ascertained that the tube is longer than the woman’s vagina, folded compresses are to be laid on the labia in order that the speculum may be laid on them. ”

“ We have frequent references to eyed probes, and we also possess a considerable number of different types. In dealing with the dipyrene I quoted a passage to show that it sometimes carried an eye in one of its olives. Hippocrates refers to an eyed probe of tin. In treating of fistula he directs us to take a rod of tin having one end pierced with an eye (μήλην κασσιτερίνην ἐπ' ἄκρου τετρημένην) , and having put one end of a twisted piece of lint through the eye put the probe into the fistula, get the end of the specillum, bend it and hold the thread with the finger and withdraw the ends. ”

“ Apart from the destruction of the foetus in criminal abortion, which was so common at Rome in the time of the Empire, we have mention of an instrument for legitimately producing the death of the foetus from humane motives before forced delivery. ”

“ In fact we shall see that where the scalpel and handle were not forged in one piece they were united by something very like our aseptic joint. Hippocrates insists on the importance of keeping everything in the surgery absolutely clean.
A few instruments bear the image of deities connected with medicine, or attributes of these. The figures of Aesculapius and his daughter Hygeia are found on medicament boxes, the former with the serpent entwining his staff, the latter feeding a serpent from a bowl. The serpent is sometimes found on a probe. A uterine dilator from Pompeii also carries it. ”

“ 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. ”

“ The use of the sound as a staff in lithotomy, or as a dilator of a strictured urethra, was not known to the ancients, and thus we have no evidence from the literature that a solid bougie existed. Some instruments have come down to us, however, which seem undoubted solid bladder sounds. [Pg 146] There are three sounds of bronze in the Naples Museum, which have the identical appearance of our modern bladder sounds. ”

“ It is self-evident that no clear conception of a surgical operation, ancient or modern, can be formed from a written description without some previous knowledge of the instruments intended to be used. ”

“ 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. ”

“ Thus λιθουλκῷ is translated ‘forcipe ad id facta’ because in Cornarius’s time the instrument used for extracting stone from the bladder was a forceps, whereas it is doubtful whether there was in the Roman period anything more than a scoop, and, therefore, we are not entitled to translate λιθουλκός by anything more definite than ‘stone extractor’, its etymological equivalent. ”

“ When going to bleed at the ankle the ligature is to be applied at the knee. When the blood does not flow well he advises us to slacken the bandage if too tight. This is the famous ‘band of Antyllus’.
It is mentioned also in the pseudo-Hippocratic treatise on Ulcers (iii. 328) :
‘When you have opened the vein and after you have let blood and have loosened the fillet (ταινίαν) and yet the blood does not stop.’
Paul also mentions the band, including one round the neck when the veins of the forehead are to be opened for ophthalmia. ”

“ 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. ”