A powerful variety so strongly curved as to resemble a small billhook was found in the Roman hospital at Baden (Pl. IX, fig. 5). The handle is of ivory, the blade is of steel, and there is a mounting of bronze.

_Pterygium Knife._

Greek, pte????t???, ?; Latin, _scalpellus_.

Paul (VI. xviii), quoting Aetius, II. iii. 60, says that there were two methods of curing pterygium. In the first the pterygium was raised by a small sharp hook, and a needle carrying a horsehair and a strong flaxen thread was pa.s.sed under it. Tension being made on the thread by an a.s.sistant, the operator sawed off the pterygium towards the apex by means of the horsehair. The base of the pterygium was then severed with the scalpel for the plastic operation on entropion. The second method consisted in dissecting away the pterygium (stretched as aforesaid with a thread) with the instrument called the pterygotome (pte????t??) care being taken not to injure the lids.

Aetius (II. iii. 74) says that adhesion of the sclerotic to the lid may be separated by means of the pterygotome. Paul (VI. xxii) in empyema of the lachrymal sac dissects out the part between the sac and the canthus with the pterygotome, and again in excision of polypus aurium he says it may be employed. These uses of the pterygotome point to its having been a sharp-pointed knife of a small size. Albucasis, who conveys entire the pa.s.sage on pterygium from Paul, gives figures of both these instruments.

The pterygotome which Albucasis depicts is a small, narrow, sharp-pointed scalpel (Pl. IX, fig. 2).

_Knife for plastic operation on the eyelid._

Greek, ??a??af???? s?????.

I have in describing the pterygotome given one instance of the use of the 'scalpel for the plastic operation', viz. to dissect away the base of a pterygium the rest of which had been separated off by means of sawing with a horsehair. The plastic operation for entropion seems to have been one which was very frequently required. We know that granular ophthalmia with trichiasis as a sequela was very rife. Aetius (quoting from Leonidas) and Paul give very nearly the same account of the operation to remedy the trichiasis. Paul says:

'Having placed the patient on a seat either before us or on the left hand, we turn the upper eyelid outwards, and if it has long hairs we take hold of them between the index finger and thumb of the left hand; but if they are very short we push a needle having a thread through the middle of the tarsus from within outwards. Then stretching the eyelid with the left hand by means of this thread, with the point of the scalpel held in the right hand, having everted the eyelid, behind the thread we make the inferior incision inside the hairs which irritate the eye, extending from the larger canthus to the smaller along the tarsus. After the inferior incision, having extracted the thread and having put a small compress under the thumb of the left hand, we stretch the eyelid upwards. Then arranging other small compresses on the canthi at their extremities we direct the a.s.sistant, who stands behind, to stretch the eyelid by means of them. Then by means of the 'scalpel for the plastic operation' (??a??af???? s?????) we make the first incision called the 'arrow-shaped' a little above the hairs which are normal, extending from canthus to canthus and penetrating only the depth of the skin. Afterwards we make the incision called the crescent-shaped, beginning at the same place as the former and carrying it upwards to such a height as to enclose the whole superabundant skin and ending in like manner as it did. Thus the whole skin within the incision will have the shape of a myrtle leaf.

Having perforated the angle of this portion with a hook we dissect away the whole skin. Then washing away the clots with a sponge we unite the lips of the incision with three or four sutures' (VII.

viii).

The use of the scalpel for the plastic operation, therefore, was to make an incision in the eyelid in such a way as to enclose a leaf-shaped area and to dissect off the skin surrounded by the incision. Albucasis figures it as a small but fairly broad blade with a rounded cutting tip (Pl. IX, fig. 3).

It must have been a small scalpel to suit the operation described, and to make the dissection indicated it must have been sharp-pointed. It is contrasted to some extent with the pterygotome by Paul, and we saw that the pterygotome was narrow and sharp-pointed. These various references to its use are in agreement with the supposition that it was of the shape figured by Albucasis. I have considered it here because the question of its shape is rather hypothetical, and therefore it seemed best to consider it close by its confrere the pterygotome. We may recall the fact that in the grave of the third-century oculist Severus several tiny scalpel handles were found. These were probably handles for these two ophthalmic scalpels, but unfortunately only a trace of the steel remains. Vedrenes, in his edition of Celsus, figures an instrument from Pompeii of a shape which we are accustomed to a.s.sociate with eye work (Pl. IX, fig. 6).

_Uvula Knife._

Greek, staf???t???.

This is a special scalpel for throat work, of whose shape we know nothing. It is mentioned by Paul as a special scalpel for excision of the uvula:

'Wherefore, having seated the patient in the sunlight and directed him to gape wide, we seize with the uvula forceps or a common tenaculum upon the elongated part and drag it downwards and excise it with the instrument called the uvula knife (staf???t??), or the scalpel used for the plastic operation on the eyelid' (VI. x.x.xi).

The knife figured by Albucasis as used for the purpose is a small curved bistoury (Pl. IX, fig. 4). We have no other means of determining its shape. I have placed it here because it was mentioned along with the 'scalpel for the operation on the eyelid'.

_Blade curved on the flat.--Tonsil Knife._

Greek, ??????t??? (??????, 'bend of elbow,' _or_ ???????, 'crooked').

This instrument is described by Paul (VI. x.x.x) in the operation for removing the tonsils:

'Wherefore, having seated the patient in the sunlight, and directed him to open his mouth, one a.s.sistant holds his head and another presses down the tongue with a tongue depressor. We take a hook and perforate the tonsil with it and drag it outwards as much as we can without dragging the capsule out along with it, and then we cut it off by the root with the tonsillotome (??????t???) suited to that hand, for there are two such instruments having opposite curvatures. After the excision of one we may operate on the other in the same way.'

This pa.s.sage clearly proves that there were two scalpels of a set, each having opposite curvatures after the manner of our right and left vesicov.a.g.i.n.al fistula knives.

_Curved blade cutting on one side, blunt-pointed.--Fistula Knife._

Greek, s??????t???, from s?????, 'a fistula.'

This was a falciform blade whose end was blunt, but the handle end was prolonged into a slender, rounded sound-like portion with a sharp point (Pl. IX, fig. 1). The narrow point was pa.s.sed into a fistula, caught, and the whole instrument pulled outwards by means of it, thus dividing the overlying tissues with the falciform blade. This instrument remained in use till comparatively recent times. Heister figures a large number of varieties, and from him I have taken the figure shown, although it is also described and figured by Fabricius. The two following pa.s.sages, taken in conjunction with each other, show that the cla.s.sical instrument was of the form I have indicated. The first pa.s.sage, from Galen, shows that the end of the blade was blunt, and that there was only one cutting side. The second, from Paul, shows that the blade was falciform and was operated in the manner I have stated. Galen (x. 415) says that in enlarging an abdominal wound we use a fistula knife (s??????t??). 'But the scalpels which are two-edged or have a point are distinctly to be avoided' (t? d'

?f??? t?? a?a????? ? ?at? t? p??a? ???a pa?t? t??p? fe??t?a).

Secondly, Paul (VI. lxxviii) says:

'Having perforated the bottom of the fistula with the point of the falciform part of the syringotome (t?? d?ep???? t?? s??????t???) bring the instrument out of the a.n.u.s and so divide all the intervening s.p.a.ce with the edge of the falciform part' (t? ??? t?? d?ep????).

Another pa.s.sage in the same chapter indicates that some of the syringotomes had an eye in the instrument:

????? d? ?? t? t??at? t?? s??????a??? d?ep???? t? ????? ??e??a?te?.

There was also a straight variety of the instrument (t? ?a???e?a ????

s??????t?a, Paul, VI. lii).

_Curved blade cutting on two edges._

A curved blade of a somewhat unusual type is described by Galen in discussing the dissection of the thorax (ii. 673). However, the description is unmistakably clear. He says:

???s?a? d' a?t?? ???sta t? ???t? ??e? ?e?a??e????? ?????

??at????e?, ?ste ?f????t??? ??e?? ?f?te?a? t?? te???sa? ??a??

???? ?at? ?? t?? ?t??a? s???, ?at? d? t?? ??t??e????? ta?t? ???t??.

'It is best to have the curved part forged alike on both sides so that the cutting edges are curved in two ways, viz. one concave and the other convex.'

A smaller variety for fine dissection is referred to in the same book (e??

?pe? ?st?? ?p?t?de??t?t? ??s??? ???t?, ii. 674).

_Shears._

Greek, ?a???; Latin, _forfex_.

Oribasius treats of cutting the hair as a regular medical procedure, in a special chapter, pe?? ?????? ?a? ????se??. Celsus also frequently refers to cutting the hair as a therapeutic measure. Possibly the ancients found difficulty in putting an edge sufficiently smooth for surgical purposes on their shears. We have a few references to the use of the shears for cutting tissues. Celsus, in the treatment of abdominal injury with protusion of omentum, says:

Omentum quoque considerandum est: ex quo, si quid iam nigri et emortui est, forfice excidi debet: si integrum est, leniter super intestina deduci (VII. xvi).

Again in the operation for the radical cure of hernia he says:

Fuerunt etiam qui omentum forfice praeciderent: quod in parvulo non est necessarium; si maius est, potest profusionem sanguinis facere, siquidem omentum quoque venis quibusdam etiam maioribus illigatum est.

Neque vero, si discisso ventre id prolapsum forfice praeciditur, quum et emortuum sit et aliter tutius avelli non possit, inde huc exemplum transferendum est (VII. xxi):

'There have been others who cut away the omentum with scissors, which is unnecessary if the portion is small; and if very great it may occasion a profuse haemorrhage, since the omentum is connected with some of even the largest veins. But this objection cannot be applied in cases where, the belly being cut open, the prolapsed omentum is removed with shears, since it may be both gangrenous and unable to be removed in any other way with safety.'

We have also two references in Paulus Aegineta. He says some of the moderns effect a cure of warty excrescences on the p.e.n.i.s by a pair of shears (?a??d?, VI. lviii), and dealing with relaxation of the s.c.r.o.t.u.m he says that Antyllus, having first transfixed the superfluous skin with three or four ligatures, cut off what was external to them with a pair of sharp-pointed shears or a scalpel (?a??d? ?p??? ? s???), and having secured the parts with sutures he effected healing with the treatment for recent wounds.