And again:

'You must saw the bone down to the meninges with a serrated trephine (p????? ??? ?a?a?t? ?p??e??), and in doing so must take out the trephine (p????a), and examine with a probe and by other means along the track of the trephine' (p???? ?at? t?? ?d?? t?? p??????).

In injuries to the head in young people (iii. 371) he mentions a small trephine (s????? t??pa???), so that apparently several sizes were available. Hippocrates, we have seen, uses the words p???? and p????

?a?a?t?? to denote the trephine. Galen always uses ????????, but in his Lexicon he gives two other words, viz. ????p????? and pe??t????, ostensibly from the works of Hippocrates:

????p?????--t? ???????d?.

pe??t????--t??p??? t? e??e? ?a? ??e?, ?st? ??? ?a? ?te??? ? ????????.

These terms do not, however, occur in any extant Hippocratic writings, unless, as seems possible to me, the latter term pe??t???? be a _var.

lect._ for the obscure word t?????t???? applied to t??pa??? in ii. 470 in the description of trephining a hole through a rib to drain an empyema.

Galen held the trephine in little esteem. It must have been difficult to manufacture a satisfactory instrument of bronze. In x. 448 he says: 'Some people, shall I call them rather cautious or rather timid, have used trephines' (???????s??); and Paul, in a pa.s.sage I have already quoted, says: 'The mode of operating with saws and trephines is condemned by moderns as a bad one.'

The term ???????? is derived from ??????? and ????, the nave of a wheel.

The Latin term for the trephine, _modiolus_, has the same meaning. Celsus graphically describes the trephine and the method of its application. From him we learn how the ancients solved the problem of the centre-pin, which is necessary until the toothed portion has begun to bite. In modern trephines this difficulty is got over by withdrawing the pin up the centre of the shaft. In mediaeval trephines it was solved by providing two instruments, a male and a female, the male with centre-pin being used till a circular track had been cut by the toothed ring, the female without pin being then used. In the time of Celsus the centre-pin was removable, being taken out after the instrument had begun to bite. From Celsus too we learn that the trephine was driven by a thong.

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. Celsus says:

Exciditur vero os duobus modis: si parvulum est quod laesum est, modiolo, quem ???????da Graeci vocant: si spatiosius, terebris.

Utriusque rationem proponam. Modiolus ferramentum concavum teres est, imis oris serratum; per quod medium clavus, ipse quoque interiore orbe cinctus, demitt.i.tur. Terebrarum autem duo genera sunt: alterum simile ei quo fabri utuntur: alterum capituli longioris, quod ab acuto mucrone incipit, deinde subito latius fit; atque iterum ab alio principio paulo minus quam aequaliter sursum procedit. Si vitium in angusto est quod comprehendere modiolus possit, ille potius aptatur: et si caries subest, medius clavus in foramen demitt.i.tur; si nigrities, angulo scalpri sinus exiguus fit qui clavum recipiat ut, eo insistente, circ.u.mactus modiolus delabi non possit: deinde is habena, quasi terebra convert.i.tur. Estque quidam premendi modus, ut et foret et circ.u.magatur; quia si leviter imprimitur parum proficit, si graviter non movetur. Neque alienum est instillare paulum rosae vel lactis, quo magis lubrico circ.u.magatur; quod ipsum tamen, si copiosius est, aciem ferramenti hebetat. Ubi iam iter modiolo impressum est, medius clavus educitur, et ille per se agitur: deinde, quum sanitas inferioris partis scobe cognita est, modiolus removetur.

_Perforator for Fistula Lachrymalis._

Greek, ?ept?? t??pa???.

Galen (xii. 821) says that Archigenes in cases of fistula lachrymalis perforated the nasal bone with a small drill (?ept?? t??pa???), and Paul (VI. xxii) says:

Some, after excision of the flesh, use a perforator (t??pa???) and make a pa.s.sage for the fluid or matter to the nose.

Albucasis figures a drill for this purpose which he says had a triangular iron point and a conical wooden handle.

In the find of instruments of the third-century oculist Severus is a drill which Deneffe regards as intended for this purpose. It is 6 cm. in length and 7 mm. on each of its four sides. One end is pointed, the other has a slit for a knife-blade. It is beautifully damascened with silver (Pl. II, fig. 7).

_Bone Lever._

Greek, ????s???, ??a??e??.

Instruments for levering fractured bones into position are described in several places. Hippocrates (iii. 117) says:

'In those cases of fracture in which the bones protrude and cannot be restored to their place, the following mode of reduction may be practised: pieces of steel (s?d???a) are to be prepared like the levers (?? ?????) which the cutters of stone make use of, one being rather broader and the other narrower, and there should be at least three, or even more, so that you may use those that suit best, and then along with extension we must use these as levers, applying the under surface of the piece of iron to the under fragment of bone, and the upper surface to the upper bone, and in a word we must operate powerfully with the lever as we would do upon a stone or a log. The pieces of steel should be as strong as possible so that they may not bend.'

In a note to this pa.s.sage Galen (xviii. 593) says:

'It is evident that the instruments described resemble those of stone cutters, not in size but in principle. For the instruments prepared by us for levering bone are similar in size to those used for levering out teeth. But for levering bones several ought to be prepared, differing from each other in length as well as breadth and thickness at the point, by which means they may afford their greatest effect.'

Paul (VI. cvi) gives us some additional information:

'Of whatever bones therefore we endeavour to replace the protruded ends, we must not meddle with them when in a state of inflammation.

But on the first day before inflammation has come on, or about the ninth day after inflammation has gone off, we may set them with an instrument called the lever (t? ?e????? ????s??). It is an instrument of steel about seven or eight fingers' breadth in length, of moderate thickness that it may not bend during the operation, with its extremity sharp, broad, and somewhat curved.'

There are two bone levers in the Naples Museum, both of bronze. Pl. XLI, fig. 1 shows one of them (No. 78,012). It is 155 cm. in length, and with its ends flattened, and curved, and pointed, as described by Paul. The other instrument is of similar shape, but is somewhat less in size. The concave surface at one end is smooth, at the other ridged like a file.

It may be remarked, that though the similarity in form to the instruments figured by Pare as in use in his time for levering up depressed bones shows that these are undoubtedly bone levers, it is quite possible, from what Galen says, that they may also have been used for levering out teeth.

The smooth end also corresponds to the description of the meningophylax, so that it is possible it may have been used in that capacity also.

_Bone Forceps._

Greek, ?st???a.

Galen (x. 450) says, in comminuted fracture of the skull we must make a way for the lenticular with the bone forceps (d?? t?? ?st???a?); and in depressed fracture Paul (VI. xc) says:

'If the bone is strong it is first to be perforated with the drills called abaptista and the fractured bone is to be removed in fragments, with the fingers if possible, if not, with a tooth forceps or a bone forceps' (?d??t???a ? ?st???a).

Sora.n.u.s (lxiv. p. 366) says that in impaction of the foetal cranium the head may be opened with a sharp instrument and the pieces of the skull removed with tooth or bone forceps (?d??t???a? ? ?st???a?). Aetius copies this (IV. iv. 24) and so does Paul (VI. lxxiv).

An excellent specimen of the sequestrum forceps was found in the house of the physician at Pompeii, and is now in the Museum at Naples (No. 78,029).

It is formed of two crossed branches moving on a pivot. The handles are square, the jaws are curved, and have across the inside of them parallel grooves which oppose each other accurately (Pl. XLIII). It is cla.s.sed in the catalogue as an instrument for crushing calculus of the bladder. This is, however, not a manipulation which is described by the ancients. The only case in which splitting of calculi is referred to is in Celsus, and then a chisel is used.

_Varix Extractor._

An instrument, apparently a forceps, for extracting varicose veins in segments is mentioned by Galen:

'And with regard to varices in the legs, first having mapped them out on the surface with scarifications, then setting about the operation, taking hold of the skin we divide it first. Then pulling up the varix with a hook we tie it, and, doing this at all the cuts in the skin, and cutting the ends, we either remove it with a varix extractor (???s?????) or, taking hold of it with a doubled thread, we draw it through the channel of the varix after the manner of flaying' (xiv.

790).

Celsus (VII. x.x.xi) directs us to expose the vein and raise it by a blunt hook at intervals of four finger breadths, and divide the vein at one hook and pull the vein out at the next place. Galen, however, indicates that there was a special instrument for the purpose, and this can scarcely have been anything else than a forceps of some kind. The operation must have been excessively painful. Pliny (xi. 104) remarks that C. Marius was the only man who had undergone it in the upright position.

_Blacksmith's Tongs._

Latin, _vulsella quali fabri utuntur_.

For replacing a protruding bone in a case of compound fracture Celsus (VIII. x) says that a forceps such as smiths use may be employed:

Tum ipsum recondendum est; ac, si id ma.n.u.s facere non potest, vulsella quali fabri utuntur iniicienda est, recte se habenti capiti ab ea parte qua sima est; ut ea parte qua gibba est eminens os in suam sedem compellat.

'Then it is to be replaced, and if that cannot be done by hand the forceps such as smiths use is to be inserted, the head being kept straight by the snub-nosed part so that the curved part forces the bone into position.'

The blacksmith's tongs is very frequently represented in ancient art. Pl.

XLII, fig. 2 shows a forceps from Roman London in the Guildhall Museum.

_Tooth and Stump Forceps._