Surgical Instruments in Greek and Roman Times Part 5

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, p???p???? spa????, p???p?d???? spa????; 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 (p???p??? spa??? t? ??s???e?de?

??a??), we cut round the polypus or fleshy tumour, applying the point of the steel blade (t?? ???? t?? s?d????) to the part where it adheres to the nose. Afterwards turning the instrument end for end (??t?st???a?te?) we bring out the separated fleshy body with the scoop' (t? ??a??s??).

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 pa.s.sages, 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 ca.n.a.l.

'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. Sora.n.u.s refers to it for opening the foetal head in cranioclasis:--

?? d? e?????? t?? ?efa???? ?p?????t?? ? sf???s?? ?p?te???t?, d?? t??

????t??? ? t?? p???p???? spa???? ???pt????? eta?? ???a??? ?a? t??

a???? da?t???? ?at? t?? ???es?? (xviii. 63).

Paul copies this (VI. lxxiv). Sora.n.u.s 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, ????t??? (t?); Latin, _scalpellus_.

In describing lithotomy Paul says:

'We take the instrument called the lithotomy knife (t? ?a???e???

????t???), and between the a.n.u.s and the t.e.s.t.i.c.l.es, not however in the middle of the perinaeum, but on one side, towards the left b.u.t.tock, 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 a.n.u.s, 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 pa.s.sage 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:

?a? e? ?? p???e???? e??, t? ?a? t?? a?a????? ?????e??, pep?es????

d? t? ?a? t?a?e?? te ?a? ?ap??? ?? ?????, ?? ?? ???sta s?f???? t?

'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 pa.s.sage 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 r.e.c.t.u.m, in summa parte labrosum, in ima semicirculatum acutumque. Id receptum inter duos digitos, indicem ac medium, super pollice imposito, sic deprimebat ut simul c.u.m 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. _r.e.c.t.u.m_ 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, ????t???.

A special instrument for perforating the foetal cranium is mentioned by Sora.n.u.s (II. viii. p. 366):

?? d? e?????? t?? ?efa???? ?p?????t?? ? sf???s?? ?p?te???t?, d?? t??

????t??? ? t?? p???p???? spa???? ???pt????? eta?? ???a??? ?a? t??

a???? da?t???? ?at? t?? ???es??.

'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, ??????a??? s?????.

In extirpating warts Paul (VI. lx.x.xvii) 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 (????????? s???? ? f?e?t?? ?? ?????

??e?e??). This undoubtedly refers to a curved scalpel, for the grappling hook was called ???a?.

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).