Surgical Instruments in Greek and Roman Times Part 4

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 pa.s.sage giving even the most meagre description of this instrument. It is a.s.sumed 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 morb.u.m 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 pa.s.sage from Hippocrates shows that there were various sizes of the phlebotome:

???? ?e a?a?????? ???s? de? ???s?a? ?a? p??tes?, ??? ?p? p??t??

????? pa?a??????e?, ?t?. (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 (p?at?t????? ???s?a? t??? a?a??????), 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. lx.x.xvii), slitting the prepuce in phimosis (VI. lv), incising the tunica v.a.g.i.n.alis 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 v.a.g.i.n.a. Celsus has no special word for phlebotome. He always refers to it by the general term scalpellus. Theodorus Priscia.n.u.s, 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 pa.s.sage on the surgical treatment of empyema (ii. 258) says:

'Incise the skin between the ribs with a bellied scalpel, then let a phlebotome (???e?e?) which has been wound round with a rag, leaving the breadth of the thumb nail at the point, be pushed in.'

???e??? 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 ident.i.ty 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 Luxemburgerstra.s.se 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, s.h.i.+ning, 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 ill.u.s.tration of it (Pl. VII, fig. 5). A similar object is cla.s.sified as a surgical instrument in the Louvre, but both these articles are I believe detached mirror handles. The pa.s.sage 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 cla.s.sed 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 pa.s.sage beginning--p?t? ?? ?atape????te?

p?t? d? ??ape????te? f?e?t??e? (Oribasius, _Collect._ VII. x).

This pa.s.sage 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 ?atape????te?--cutting inwards--in cases where the vessels are deep, and ??ape????te?--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.'_

?at??? -??d?? (?) (Sora.n.u.s, II. xviii); ?a???? (Paul, VI. lxxiv); ?at??d??? (t?) (Aetius, II. iii. 2); ?ate??d??? (t?) (Aretaeus, _Cur.

Morb. Diut._ i. 2).

In Sora.n.u.s (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:

?????? d? ? ??ast???e??? ?at??d? p??se???t?? d?a??e?? t? da?t???

p????????a?ta t? ????.

The Latin version of Moschion has:

Folliculum verum non ruptum ante digito impresso formantes loc.u.m 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 ?ate??d???, or the one called the scoop'

(t?????).

In a note to his edition of Celsus, Lee says Aretaeus 'invented an instrument having at the end a blade of gra.s.s, or made like a blade of gra.s.s, which was thrust into the nostrils to excite an haemorrhage in some affections of the head. This instrument is named ?ate??d???, from ?at? and e?a a blade of gra.s.s'.

I have shown, however, that Sora.n.u.s, 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 ?a????, 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' (s??a??? ? ?at??d?).

Paul says that abscess of the womb is to be exposed with a speculum and opened with a scalpel or katias (spa??? ? ?at??d?). Paul also refers to it in perforating the foetal cranium in delivery obstructed through hydrocephaly (p???p??? spa??? ? ?a???d? ? s????p?a?a????) (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, spa???? (diminutive of sp???), ??sp?????; Latin, _spatha_.

On several occasions a knife called spa???? 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' (spa??? ? ?at??d?).

Again, Paul (VI. lxxviii) says:

Find the orifice of the fistula, pa.s.s an ear probe through it and cut down upon it. Divide the whole fistula with a hemispathion or a fistula-knife (??spa??? ? spa??? s??????t??).

What the nature of the spa???? 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.