Contents
Preface

1. Introductory
2. Material, Execution, and
    Ornamentation

3. Knives
4. Probes
5. Forceps
6. Bleeding Cups, Clysters, etc.
7. Cauteries
8. Bone and Tooth Instruments
9. Bladder and Gynaecological
    Instruments

10. Sutures, etc.
11. Étui, etc.

Appendix
I. Inventory of chief instruments
    in various museums

II. Bibliography

Plates
Surgical Instruments in Greek and Roman Times
by John Stewart Milne, M.A., M.D. Aberd.
Oxford: Clarendon Press (1907).



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CHAPTER II

MATERIAL, EXECUTION, AND ORNAMENTATION

Steel and IronBronzeCopperBrassTinLeadGoldSilverHornWoodBoneIvoryStoneExecution and OrnamentationRinged OrnamentationInlayingPlatingPatinaFinds of InstrumentsHerculaneum and PompeiiFind of Surgeon of ParisOculist Severus of RheimsOculist Sollemnis of FonvielMilitary Hospital at BadenSurgeon of Cologne.


Steel and Iron.

   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. In the Iliad we even read of implements of agriculture made of iron, but it is ‘hard to work’ (πολύκμητος, Iliad vi. 48, Od. xxi. 10). However, by the time that Hippocrates wrote, it was in common use, and, if we had only the evidence of the Hippocratic writings to go by, we could see that it was in common use in the time of Hippocrates. Certain instruments, such as the cautery, are always spoken of as made of iron, in fact, the term for cautery is, as a rule, ‘the iron,’ and σίδηρος ὁ ὀξύς is a general term for ‘the knife’. The smelting of iron is even used as a simile by Hippocrates:

   ‘In the same way iron comes from stones and earth burnt together. In the first exposure to the fire stones and earth mix together with scoria, but at the second and third burning the scoria separate themselves from the iron, and this phenomenon meets the eye, that the iron remains in the fire fallen apart from the scoria, and becomes solid and compact’ (ii. 371).

   Again, he uses as a simile a speculative theory as to the way in which heating iron softens it and dipping it in water hardens it. He believes that this comes about by the fire depriving the iron of its nourishing substance, while the addition of water restores it.

   Σιδήρου ὄργανα τέχνης· τὸν σίδηρον περιτήκουσι, πνεύματι ἀναγκάζοντες τὸ πῦρ, τὴν ὑπάρχουσαν τροφὴν ἀφαιρέοντες, ἀραιὸν δὲ ποιήσαντες, παίουσι καὶ συνελαύνουσιν. ὕδατος δὲ ἄλλου τροφῇ ἰσχυρὸν γίνεται. (ii. 641).

   ‘The instruments of ironworking soften iron by driving the fire with wind and taking away the supporting substance, and when they have rarefied it they strike and beat it. By the nourishment of water it is again strengthened.’

   This is the earliest reference to tempering steel by the Greeks with which I am acquainted. It is a curious commentary on the relative destruction of iron instruments compared with those of bronze, that cauteries, which are always described as made of iron and which must have existed in enormous numbers, are among the rarest surgical instruments found. We have a few cauteries of iron, however, and some knives and knife-blades and other instruments remain. 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. The heaps of scoria left in the Forest of Dean by the Roman founders contained such a large percentage of iron still remaining that they were smelted over again in later times, and to do this occupied over twenty furnaces for a couple of centuries. Tolouse calculated that similar heaps in Gaul contained over 120,000 tons of scoria. If, however, we tend to underestimate the extent to which iron was in use among the Greeks and Romans, still more, I believe, do we tend to underrate the quantity and the quality of the steel available in those times. This comes about from the fact that in our day we require such enormous quantities of iron and steel that we have to employ iron ores of a very low quality. The greater part of the so-called steel of which battleships are made is got from a ferruginous mud with only 30 per cent. of iron, less than there was left in the scoria after the Roman founder had done with it. To the impurities already existing in this we add others, because the coal we use contains sulphur. It is getting rid of these impurities that makes the production of steel such a roundabout process with us. We forget that, with primitive methods but fine ores and a fuel devoid of sulphur, the production of steel of fine quality is as easy a process as the manufacture of iron, in fact the only difference between the method of procuring iron and steel under these circumstances is the length of time the process is allowed to go on. The ancient founders used the finest ores, often containing 75 per cent. of iron, and, working with charcoal fuel, which was nearly pure carbon, they could produce steel as easily as iron. The difference between steel and iron is that steel contains carbon, and, by allowing the ore to remain longer in contact with the charcoal, steel is formed, so that a founder setting out to make iron with a pure ore and a pure fuel like charcoal, may, if he is not careful, turn out steel of fine quality. This primitive method of making steel is still in vogue in India, Burma, Borneo, China, &c., and very fine qualities of steel are produced. The majority of the tools found in the earliest Greek colonies on the Nile—Naukratis and Daphnae—are of steel or iron, although those of the Egyptians among whom they were living (circa 600 B.C.) were of bronze. The classical medical writings themselves are sufficient evidence of the quality of the steel available in those times. Galen (ii. 683) says that the best quality of steel (which came from Norica) yielded a knife which neither blunted easily nor bent or chipped.

   ’Εκ σιδήρου δὲ ἔστω τοῦτο τοῦ καλλίστου, οἷόν περ τὸ Νωρικόν ἐστιν, ἵνα μήτ’ ἀμβλύνηται ταχέως, μήτ’ ἀνακάμπτηται ἢ θραύηται.

   This shows that the Greek surgeon appreciated good steel, and what I have said will show that there was plenty of it to be had. 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. Many of the Roman shears of steel retain their spring perfectly. As an illustration of the keenness of edge which can be put by simple methods upon steel of primitive manufacture, take the following account of the operations of an African barber of the Hausa tribe, as reported in an account by Professor R. W. Reid, Aberdeen, of a Hausa barber-doctor’s outfit presented to the Anthropological Museum of the University by Sir William MacGregor, Governor of Lagos. The description of the outfit is quoted from Sir William MacGregor, who says:

   ‘The knife, made by an African bush blacksmith, he uses for shaving. He employs no soap to soften the skin or roughen the hair, only a little water. He sharpens his razor on a black leather strap, turning the knife on the back so deftly that the eye cannot follow the movement; the few last touches he gives to it by turning it with splendid dexterity on the front of the left arm, where the skin is worn and bare by this manipulation. He shaves the whole face, except the nose. He leaves a fine line of eyebrow. The hair is cut short. The outline of the hairy part of the scalp in front is very clearly demarcated by shaving back about a half to an inch and a half. Then he turns the front edge by a marvellous stroke. He holds the knife horizontally, and, with a downward stroke cuts off all the projecting ends of the hair round the forehead. No European barber could do it without burying his razor in the skin. He never draws blood’ (Proc. Anat. and Anthrop. Soc. Univ. Abdn., 1900-2).

Bronze.

   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 or combining it with tin to form bronze was found out. Bronze was used by the Egyptians 6,000 years ago, and the Phoenicians, who got it from them, passed it on to the whole of Europe. The quantity of tin in the bronze is very constantly about 7 1/2 per cent.

   The majority of the instruments which have been preserved to us are of bronze. Hippocrates (i. 58) says:

   Χαλκώματι δὲ πλὴν τῶν ὀργάνων, μηδενὶ χρήσθω. καλλωπισμὸς γάρ τις εἶναί μοι δοκεῖ φορτικὸς σκεύεσι τοιουτέοισι χρῆσθαι.

   ‘Use bronze only for instruments, for it seems laboured ornamentation to use vessels of it.’

   We have, however, a good many specimens of vessels which prove that physicians did not adhere to this advice. We know too that certain medicaments were intentionally stored in copper vessels. Scribonius says:

   Deinde in patella aeris Cyprii super carbones posita infervescit, donec mellis habeat non nimium liquidi spissitudinem, atque ita reponitur puxide aeris Cyprii (Compositiones, xxxvii).

   Pure copper was occasionally used for instruments, and of these we have a few remaining, and vessels and instruments of it are frequently mentioned: ‘Oportet autem moveri aquam ipsam rudicula vel spathomela aeris rubri’ (Marcellus, De Medicamentis, xiv. 44). Coins were frequently made of brass (ὀρείχαλκος, orichalcum, aurichalcum), a mixture of copper, tin, and zinc, and in Pompeii there have been found two scalpel handles of brass composed of 25 per cent. of zinc and 75 per cent. of copper. The copper was got mainly from Cyprus and Spain. A small amount, however, came from Africa and Asia.

Tin.

   Tin came mainly from Britain. We have no instruments of tin preserved to us, but they are frequently referred to. Hippocrates mentions, over and over again, uterine sounds of tin, and he also speaks of sounds and eyed probes for rectal work, which were made of tin so that they might be flexible. Vessels of tin for storing medicaments in are spoken of by Largus: ‘Reponitur medicamentum fictili vel stagneo vase’ (cclxviii). In the Museum at Chesters (Chollerford) there is a tin weight for medicines.

Lead.

   Leaden sounds and tubes for intra-uterine medication are frequently mentioned in the Hippocratic writings, and Celsus and Paul refer to leaden tubes for insertion in the rectum and vagina to prevent cicatricial contractions and adhesions after operations on these parts. The therapists also mention medicament jars of lead. There is one in the Capitoline Museum from the temple of Aesculapius in the forum.

Gold.

   There is in the Museum at Stockholm a forceps of gold, but it is more than probable that this is a toilet article. I have a spatula-probe which had been overlaid with gold, and I have met with several others similarly treated. Theodorus Priscianus recommends a cautery of gold for stopping haemorrhage from the throat (Logicus, xxii). Avenzoar speaks of a golden probe for applying salve to the eye and for separating adhesion of the eye to the lid. Avicenna lets out the pustules of small-pox with a golden probe. Albucasis recommends burning the roots of hairs in trichiasis with a probe of gold. Mesue recommends a heated scalpel of gold to excise the tonsil. Hippocrates binds the teeth together in fracture of the jaw with a gold wire (iii. 174); cf. Paul, VI. xcii. In one of his dialogues Lucian satirizes a medical man who sought to conceal his ignorance by a display of a fine library, bleeding-cups of silver, and scalpel handles inlaid with gold—the devices of quacks, Lucian says, who did not know how to use the instruments when necessity arose.

Silver.

   There is a forceps of silver in the Athens Museum, and another in the Museum at Kiel. Both are, however, possibly toilet articles. Paul condemns bleeding-cups of silver, as he says they burn, so it is evident that Lucian had grounds for his statement. In the Musée de Cinquantenaire, Brussels, there is in the section of ancient surgery a bronze instrument case from Pompeii which contained a silver spoon and probe combined, a plain probe, and a grooved director, all in silver. I have frequently met with ligulae of silver and also of copper overlaid with silver, and styli, which we shall see were used as implements of minor surgery, were frequently made of silver. Medicament boxes of silver are mentioned by Marcellus. Hippocrates describes a uterine syringe with a tube of silver. Albucasis mentions silver catheters.

   A mixture of gold and silver, which was called electrum, was much used for coinage, and I have met with one or two ligulae of this metal. It was found mixed naturally in the mountain districts of Tmolus and Sipylus in Lydia, and it was also artificially produced by alloying the two metals.

Horn.

   Hippocrates (iii. 331) speaks of a pessary of horn inserted into the rectum. It would seem that the tube of various syringes was often made of horn, as both Greek and Latin writers speak of the ‘horn’ of the syringe.

   Scribonius Largus (Compositiones, vii) says:


   Per nares ergo purgatur caput his rebus infusis per cornu, quod rhinenchytes vocatur (cf. Galen, xi. 125).

Wood.

   Galen speaks of sounds or directors of wood, and ointment spatulae of wood are very frequently mentioned in the therapeutic works, as are also boxes for storing ointments in.

Bone and Ivory.

   Numbers of bone ligulae were found in a Roman hospital lately excavated at Baden.

   In the Naples Museum there are two ointment spoons with carved bone handles. Needles such as Hippocrates and
Celsus speak of for stitching bandages to fix them were very frequently made of bone and ivory. Knife handles of bone and ivory are common. A carved ivory medicament box with sliding lid will be fully described later. Scribonius Largus describes knives of bone and ivory for preparing plants for pharmaceutical purposes (Compositiones, lxxxiii). An ivory pestle was found with surgeon’s outfit in Cologne.

Stone.

   Medicaments were prepared on stone slabs, and the great majority of oculists’ seals were of stone.

Execution and Ornamentation.

   The execution of the instruments is, as a rule, all that could be desired, and the weight and thickness are no more than is consistent with the requisite strength.

   Hippocrates points out the necessity for this:—

   Τὰδ’ ὄργανα πάντα εὐήρη πρὸς τὴν χρείαν ὑπάρχειν δεῖ τῷδε μεγέθει, καὶ βάρει, καὶ λεπτότητι.

   ‘All instruments ought to be well suited for the purpose in hand as regards their size, weight, and delicacy’ (i. 58).

   The ornamentation is simple and effective. In the round instruments like the probes it consists usually of raised circular ornamentation, with or without a secondary ornamentation on the raised ringing. In others there are longitudinal or spiral grooves running along the instrument. In some cases the bronze is decorated with an inlay of silver damascening. This is rare in the instruments from Pompeii, though there are two probes with a spiral inlay in the Naples Museum. The majority of the instruments treated in this way have been found in the western provinces, and they are of later date than the Pompeian. The handles of some scalpels belonging to the third century are beautifully inlaid with silver. Lucian, as I have mentioned, speaks of scalpels inlaid with gold. In the Mainz Museum there is a medicament box on the lid of which is inlaid a snake coiled round a tree, the tree and the snake’s body being outlined in copper and the snake’s head in silver. So far no damascened instruments are reported from Greece. Damascening began in Europe apparently in the first century, and reached its height in the time of the Merovingian kings.

   Examples of plated instruments are not uncommon. I have a spatula dissector thinly plated with gold, and I have met with several ligulae plated with silver. One of these was so thickly plated that on cutting into it the silver, which was deeply oxidized on the outside and was, therefore, quite black, showed also a layer of metallic silver still bright on section.

   All the surgical instruments found in the provinces have an air de famille which would lead one to suppose that they had been manufactured in Italy, but this is not certain. The ointment slabs, however, are rarely of the stone of the country in which they are found. On the other hand, the orthographical faults on the oculists’ seals would indicate that they were cut in the provinces. 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. This combination of two instruments in one is still in use in our day. We must notice the fact that the majority of instruments we know were all of metal, not folding into hollow handles of wood, bone, &c., as the instruments of a decade ago did, so that they were easily cleaned. 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. A probe surmounted by a double serpent (caduceus form) was found in the Roman Hospital at Baden. Two scalpels in the Naples Museum carry on their ends the head of Minerva Medica. The quadrivalve speculum in the Naples Museum has each end of the crossbar tipped with fine image of a ram’s head. There is also a medicine shovel with the same symbol. Illustrations of these instruments will be found later.

Preservation.

   Some of the instruments of silver retain their brightness as when they were made, but under certain circumstances a considerable amount of oxidation takes place, and then they have a thick black coating. Very few bronze articles are found to have retained their colour. In volcanic districts the various sulphur compounds formed give rise to a beautiful patina of varying shades of green and blue, sometimes so evenly distributed as to resemble enamel. This, when fine, much enhances the value of the article.

   Articles of iron are sometimes but little destroyed. It is surprising in how good condition the iron or steel may be. The bow of a shears is sometimes quite springy. In some cases a steel or iron article is often represented by a mass of oxide bearing some resemblance to the original. In others only a shapeless mass of oxide remains.

Finds of Instruments.

Finds of ancient surgical instruments, though not by any means common, are still sufficiently numerous for specimens to have found their way into most of our larger museums; and private collectors have here and there acquired considerable numbers. The most prolific source has been the excavations at Herculaneum and Pompeii, which have now been systematically pursued for nearly three hundred years, while the objects found have been deposited in the National Museum at Naples. In 1818 a physician’s house with a large number of surgical instruments was discovered in the Strada del Consulare of Pompeii, and two chemists’ shops have also been found with instruments in them. Besides these there is a large number of instruments from other finds in the two buried cities.

   The custom of burying personal effects along with the ashes of a deceased person, which prevailed among the Romans from the second to the fourth century, has preserved to us a number of interesting finds. In 1880 M. Tolouse, a civil engineer in Paris, in executing some alterations in the neighbourhood of the Avenue Choisy, discovered the grave of a surgeon, containing a bronze pot full of surgical instruments. Among these were numerous forceps and vulsella, ointment tubes, bleeding cup, scalpel handles for blades of steel, probes, and spatulae. Sixty-six coins of the reigns of Tetricus I and II showed that the grave belonged to the end of the second or the beginning of the third century. The find was reported by M. Tolouse in a volume entitled Mes fouilles dans le sol du vieux Paris (Paris, 1888). In 1892 the find was fully described by Professor Deneffe of Ghent, in the Revue Archéologique, under the title ‘Notice descriptive sur une trousse de médecin au IIIme siècle’, and reprinted, with photogravures, in 1893 in a monograph Étude sur la trousse d’un chirurgien Gallo-Romain du IIIme siècle (Antwerp, 1893). It is convenient to refer to this find as that of the ‘Surgeon of Paris’. Another grave containing surgical instruments was found at Wancennes in the canton of Beauraing, Namur, in a cemetery of the first or second century. The instruments are now in the Archaeological Museum at Namur (Deneffe, op. cit., p. 35).

   In 1854 there were discovered at Rheims the remnants of a wooden chest containing two little iron jars for ointments, several scalpel handles, a small drill, eight handles for needles, five hooks (two blunt and three sharp), two balances, various probes and spatulae, seven forceps, medicament box, a mortar, and a seal showing that the instruments had belonged to an oculist named Gaius Firmius Severus. The instruments are all of the most beautiful pattern and finish, several being finely inlaid with silver. Some coins of the reigns of Antoninus Pius and Marcus Aurelius showed that the interment belonged to the end of the third century.

   These instruments, &c., are now in the Museum of St-Germain-en-Laye. The majority of these will be found described and figured later.

   Find of Sextus Polleius Sollemnis, oculist of Fonviel, Saint-Privat-d’Allier. In levelling a heap of earth which had fallen from a cliff above as the result of a landslide, there were found at Fonviel in 1864 a number of bronze surgical instruments. The place where they were found is at the intersection of two old Roman roads, and the instruments had been buried in the grave of a Roman surgeon high up above the valley on the edge of a cliff. Eighteen coins of the reigns of Julia Augusta, Trajan, Hadrian, Commodus, Gordian, Philip, Valerian, and Gallus, showed that the interment had been made at the end of the third century. The instruments found included three scalpel handles, fragments of two forceps, and an oculist’s seal in stone showing that the grave was that of Sextus Polleius Sollemnis. Many more instruments had probably been buried originally. Those enumerated are now in the Museum of Le Puy-en-Velay. An account of this find, with illustrations, is to be found in the Annales de la Société d’Agriculture, Sciences, Arts et Commerce du Puy (tome xxvi. 1864-5). It is also described, along with the find of Gaius Firmius Severus, in a monograph by Deneffe, under the title of Les Oculistes Gallo-Romains au IIIme siècle (Antwerp, 1896).

   One of the most prolific finds of late years has been the discovery of a Roman military hospital at Baden, the ancient Roman station of Aquae, or Vicus Aquensis. From time to time isolated discoveries of instruments had been made, including a catheter, a scalpel, and several varieties of probes, and in March, 1893, MM. Kellersberger and Meyer proceeded to excavate systematically the remains of some Roman buildings on their property. A large chamber 10.35 metres by 12.5, with walls 60 cm. thick, was discovered, and later others were discovered varying from 3 to 27 metres in length. There were in all fourteen rooms. Along the side of the building on which a Roman road ran, there were the remains of an imposing façade, running the whole length of the building. It had consisted of a portico with colonnades, the foundations of which were found at regular intervals. It is possible that some of the larger rooms had been subdivided into others by thin walls or partitions, for fragments of partitions of plaster with wood lathing were found.

   A large number of objects—tiles, lamps, vases, pots, knives, spearheads, nails, glass, fibulae, beads, weavers’ weights, three amphorae a metre high—were found near the surface. Then, at a depth of two metres, surgical instruments began to be found. These included probes to the number of 120, unguent spoons in bone and bronze, a fragment of a catheter 13 cm. long, bronze boxes for powder, needles, earscoops, unguentaria, spatulae, a fragment of an étui for instruments, and cauteries. Many coins of the reigns of Claudius, Nero, Domitian, Vespasian, and Hadrian were found, showing that the hospital had been in use between 100 and 200 A.D. The objects mentioned are still the private property of MM. Kellersberger and Meyer. In 1905, by the kindness of these gentlemen, I was allowed to make a complete examination of the collection.

   A case containing a surgeon’s outfit was found in the Luxemburgerstrasse, Cologne. It contained a phlebotome, a chisel, and some fragments of other instruments of steel, two forceps and two sharp hooks in bronze, and a small ivory pestle-like instrument. These are now in the Cologne Museum. This is a most interesting and important little find. The phlebotome is by far the best preserved and best authenticated example which we possess of this instrument. Probably the same may be said of the chisel as a purely surgical instrument.


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FORUM ROMANUM