CHAPTER VIII

BONE AND TOOTH INSTRUMENTS

_Raspatory._

Greek, ??st??; 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, sc.r.a.pe the bone with the raspatory (?p???sa?). And if the bone is not sound but fractured and contused, the rest of the bone will be white when sc.r.a.ped, but the fracture and contusion, having imbibed the preparation, will appear black, while the rest of the bone is white.

And you must again sc.r.a.pe 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' (?p? t?? ??st????) (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 (??st?????) 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, ????pe??; 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' (????pe?s?) (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 (t? ????pe?), 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 ????p??? ??t???t??.

The following pa.s.sage 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_' (??t?a??????? d????

???????? ????p??? ?? ????).

The following pa.s.sage 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 (d?'

????p???), taking care that the instrument called 'meningophylax' (q.

v.), or another chisel, be put under the clavicle (??????f??a??? ?

?t???? ????p???) to steady it' (VI. xciii).

The phrase d?' ????p??? ??t???t??, which Paul uses in describing the treatment of a fistula leading to carious bone, is translated by Briau--'a l'aide de tenailles tranchantes'. It does seem here, and occasionally in other pa.s.sages, as if the phrase might suggest 'cutting forceps', but we have no knowledge of such an instrument being used by surgeons in cla.s.sical times, and the pa.s.sages from Paul and Galen show that only two chisels are meant. We may compare the pa.s.sage on extraction of the foetus in Paul (VI. lxxiv), where he directs a second hook to be fixed on opposite the first (?a? ??t??et?? t??t? de?te???).

_Gouge._

Greek, ?????s???, ?????s??t?? ????pe??, ?????s??t?? ????pe??, s????s??t??

????pe??; 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'

(t?? ?????? ????p??? ??? ?a? ?????s???? ???????s??, x. 445).

Paul (VI. xc) says:

'And if the bone be weak, naturally, or from the fracture, we cut it out with gouges (s????s??t???), 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, fa??t??.

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 b.u.t.ton, which being smooth did not injure the brain (Pl. XL, fig. 4). It takes its name from the lentil-like (fa??t??) shape of the b.u.t.ton. 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 k.n.o.b, 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 ill.u.s.tration 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, sf??a; Latin, _malleolus_.

I have already quoted pa.s.sages 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 (sf??a) 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. Pare 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._