Chapter IV: Probes (1)

Greek, μήλη, κοπάριον, ὑπάλειπτρον, ὑπαλειπτρίς; Latin, _specillum_.

This is a very comprehensive class. The original specillum was no doubt a simple sound. Varro thus defines the specillum: 'Quo oculos inunguimus quibus specimus specillum est. Graecis μήλη dicitur.' Thus it meant a probe or sound.

μήλη is probably derived from μῆλον, an apple or fruit, from the olivary enlargement at the end of a sound.

The term ὑπάλειπτρον, which is frequently used by Hippocrates, originally meant an ointment spatula, being derived from ὑπαλείφω, to spread ointment. But the custom of combining two instruments on one shaft gradually led to the application of these terms, especially the term specillum, to denote a large variety of instruments.

The name κοπάριον is evidently derived from the resemblance of the probe to the pestle, which was such a frequent utensil in Greek homes. It is connected with κόπανον, 'pestle,' κοπανιστήριον, 'mortar,' and κοπανίζω, 'bray,' and κοπτάριον, a medicament pounded in a mortar (Dioscorides, iv. 190). The exact significance of the term κοπάριον is sometimes difficult to determine. It is easy to prove that in general it is merely a sound. Thus Paul (VI. lxxviii), in quoting a passage from Hippocrates, substitutes κοπάριον for the word μήλη, which Hippocrates uses to denote the sound used for exploring a fistula. Throughout this chapter, in which the word occurs ten times in all, Briau translates it by 'manche du scalpel', although the whole context shows that a probe is meant. Even where it is spoken of as an eyed probe (διὰ τετρημένου κοπαρίου) Briau translates it by 'au moyen du manche percé d'un scalpel', an expression which is meaningless to a surgeon. Briau evidently thinks it is derived from κόπτω, and at times it seems as if it might denote a cutting instrument. Thus Adams, in a note to Paul, VI. lxxvii, says, 'if the κοπάριον, however, was the same as the μήλη or specillum it was evidently used for cutting with, as well as for cutting upon', and on one occasion (Paul, VI. lxxx) he translates κοπάριον by 'knife'. Liddell and Scott translate it as 'a small knife'. A careful examination of those passages where it seems to indicate a cutting instrument will show, however, that only blunt dissection, which was frequently performed with the spatula end of a probe, is meant. I am quite convinced that the word κοπάριον is only a late Greek term for the earlier μήλη, and means essentially a sound, and not a knife. While on this subject we may note that throughout the codices and texts there is great confusion between words meaning probe and words meaning scalpel. The proper forms σμίλη, 'scalpel,' and μήλη, 'probe,' are distinct, but the inferior reading σμήλη is frequent in both codices and texts as a bastard, for σμίλη is often written σμήλη incorrectly, and μήλη often becomes σμήλη, just as μικρός is written σμικρός. Thus in Paul (VI. viii), where the author is describing the eversion of the eyelid by means of the olivary point of a probe (τῷ πυρῆνι τῆς μήλης), four codices and the Aldine and Basle texts read σμήλης, two codices read σμύλης, one reads μήλης, four μίλης, and Briau reads σμίλης. In a case like this only a knowledge of surgery can tell us whether a probe or scalpel is meant.

_The Specillum as a Sound._

The ancients were fully aware of the value of the information to be gained by searching the recesses of a lesion with a rod of metal. Celsus (v. 28) says regarding fistulae:

Ante omnia autem demitti specillum in fistulam convenit, ut quo tendat
et quam alte perveniat scire possimus; simul etiam protinus humida an
siccior sit: quod extracto specillo patet. Si vero os in vicino est
id quoque disci potest si iam necne eo fistula penetraverit et
quatenus nocuerit; nam si molle est quod ultimo specillo contingitur,
intra carnem adhuc vitium est, si magis id renititur, ad os ventum
est. Ibi deinde si labitur specillum, nondum caries est: si non
labitur sed aequali innititur, caries quidem, verum adhuc levis est:
si inaequale quoque et asperum subest, vehementius os exesum est. At
cartilago ubi subsit, ipsa sedes docet; perventumque esse ad eam ex
renisu patet.

'But first it is well to put a probe into the fistula to learn where
it goes and how deeply it reaches, also whether it is moist or rather
dry as is evident when the probe is withdrawn. Further, if there be
bone adjacent, it is possible to learn whether the fistula has entered
it or not and how deeply it has caused disease. For if the part is
soft which is reached by the end of the probe the disease is still
intermuscular; if the resistance be greater it has reached the bone:
if there the probe slip there is as yet no caries. If it does not slip
but meets with a uniform resistance there is indeed caries, but it is
as yet slight. If what is below is uneven and rough the bone is
seriously eroded, and whether there is cartilage below will be known
by the situation, and if the disease has reached it will be evident
from the resistance.'

These remarks show that with the probe the ancients had cultivated the tactus eruditus to a high degree, and the remarks of Aetius and Paul are equally to the point.

The tips of the probes which have survived vary considerably in size and shape. Some have a point which is almost sharp like a stylet; in others the natural thickness of the shaft is kept right to the tip, which is simply rounded off or there is an oval enlargement like that on our olivary probes and sounds. In rare cases the enlargement is globular. The oval enlargement was named by the Greeks πυρήν, which means 'olive-kernel'. The sixteenth-century translators uniformly render this by 'nucleus', which is a convenient term to use, but it has no classical Latin authority. Indeed, there is no classical Latin equivalent used by medical authors. Theodorus Priscianus uses _baca_ (_sic_), a berry, and _bacula_, little berry, and in the _Additamenta_ (I. viii. 21, ed. Rose) he uses the transliteration _pyrena meles_. But this is African Latin.

A probe without enlargement at the tip was called ἀπυρηνομήλη or ἀπυρομήλη. The ear probe is frequently referred to as belonging to this class. These probes without nuclei were specially adapted for wrapping round with wool to apply medicaments, or wipe away discharge.

The size of the nucleus varied in different varieties of probe, but was pretty constant in each particular. It was largest in the probe known as the spathomele--a combination of spatula and probe which was in extremely common use for pharmaceutical purposes. The nucleus of this probe was such a well-known object that it is frequently referred to as a standard of size and shape. Galen (ii. 898) says:

'In the cervix uteri is the foramen by which the woman both passes the
monthly flux and receives the semen of the husband. By it also the
foetus leaves the womb. It is marvellous how it varies in size
according to circumstances. When the woman is not pregnant it admits
the nucleus of a probe or something slightly larger' (πυρῆνα μὲν μήλης
ἐπιδέχεται ἢ βραχύ τι τούτου παχύτερον).

Here Kühn translates πυρῆνα by 'acuminatum capitulum specilli', which is incorrect. It is an olivary enlargement, not sharp point. In Paul (VI. xc), we have the nucleus given at the measure of distance between the perforations by which a bone was surrounded preparatory to its excision by means of chisels: 'the space between the perforations made by the drills should be the breadth of the nucleus of a probe' (τὸ μῆκος πυρῆνος).

Aetius (III. i. 16) says in volvulus the sphincter ani is so contracted that the nucleus of a probe cannot be got in.

Paul (VI. xxi) says that in couching a cataract we must enter the couching needle a nucleus breadth from the iris.

Besides its use as a sound the nucleus was frequently used as a means of applying medicaments, either in the form of ointments or dry powder, to affected parts.

Paul (VI. ix) says that in the cases of entropion, where the ordinary plastic operation is objected to, an elliptical piece may be burnt out of the eyelid with caustic applied on the nucleus of a probe (πυρηνοσμήλης), and similarly after removal of sebaceous cysts from the lid, levigated salts may be applied on the nucleus (τὸν πυρῆνα τῆς μήλης).

Aetius (II. iv. 23), quoting from Galen, says that in caries of the teeth some wax may be warmed on the nucleus of a probe (πυρῆνος μήλης), and again (II. iv. 14) he directs us to use it for application of pomade to the face (πυρῆνι μήλης). It would seem that this, and not the exploration of wounds, was the original use to which the olivary-pointed probe was put, for in early Egyptian tombs small pestle-like probes are, as a rule, found accompanying the toilet pigment boxes which are so common. They are mostly made of wood (Pl. X, fig. 2). The kohl-stick was not unknown to Greek ladies. (See Eustathius, _Comment. in Iliad_.)

Hitherto I have spoken of the probe as if it were a single instrument; but, as a matter of fact, the ends of the shaft are usually fashioned to serve different purposes. Thus at one end there will be a probe, at the other a spatula, a spoon, or a hook. Some of these combinations have names of their own, and others are so frequently met with that they too seem to have been constant types.

It may simplify matters if we anticipate a little and remark that while the uses of the probes in actual surgery were the same as at the present day, in the minor surgery, consisting of the application of medicaments and toilet preparations, they were used in a slightly different manner. Semi-solids, like eyebrow pigment and eye ointments, were applied on olivary-pointed probes. Liquids, like ear and eye drops, were usually instilled by squeezing a ball of wool dipped in the liquid and placed round the middle of a probe, and letting it run off the point. Thus a common form of toilet instruments consists of a probe-like instrument with an olive at one end and a sharp stylet at the other. Ligulae with scoops were used to withdraw drops of fluid essences, &c. from unguentaria. Some of these ligulae run up to a foot and a half in length.

The specilla which remain to us are mostly made of bronze. A few are overlaid with gold and silver, and a few are solid gold or solid silver. We read, however, of specilla of lead, tin, copper, and wood, and of the use of a boar's bristle or a stalk of garlic for searching fistulae.

I shall now proceed to classify and discuss these different varieties, premising, however, that no hard and fast line can be drawn between different types. They shade off into each other by imperceptible gradations, so that whatever system of classification we adopt bastard forms are sure to occur.

_Double Simple Probe._

Greek, ἀπυρηνομήλη, ἀπυρομήλη; Latin, _specillum_.

The simplest form of specillum is a plain rod of metal rounded off at either end. These are not infrequently met with. I figure one from my collection. Its length is 14.5 cm., its diameter 2 mm. At either end it tapers rapidly off to a blunt point. At a distance of 3 cm. from one end is a raised ring (Pl. X, fig. 4). A similar probe in silver may be seen in the Musée de Cinquantenaire, Brussels. It was found with other probes in an étui. Pl. X, Fig. 3 shows a rather longer specimen from the Naples Museum. A variety with non-tapered ends is seen in Pl. X, fig. 1. It is also from the Naples Museum. Pl. XI, fig. 4 shows a probe, from my own collection, which carries the snake of Aesculapius at one end. One with a double snake (caduceus form) was found in the Roman Hospital at Baden (Pl. XI, fig. 2).

_Specilla with two olivary ends._

Greek, διπύρηνος μήλη, ἀμφίσμιλος.

A slender sound with slight olivary enlargement at either end is very frequently mentioned under the name διπύρηνος μήλη by Galen. He also calls it ἀμφίσμιλος. Thus he says:

Καί σοι διχόθεν ἔστι διεμβάλλειν αὐτοῦ τι τῶν παρασκευασμένων λεπτὸν
εἴτε ἀμφίσμιλον, εἴτε διπύρηνον ὀνομάζειν ἐθέλεις, εἰ δέ τι λεπτότερον
δέῃ καὶ μηλωτίδα (ii. 581).

'And in the double passage you must insert some one of the slender
instruments you have at hand, either a double-ended probe (a 'double
olive' if you prefer to call it so), or if something finer be
necessary, even an ear probe.'

In dealing with fistulae Paul (VI. lxxvii) says:

'We must first examine them with a sound if they be straight, or with
a very flexible 'double olive' (διπυρήνῳ εὐκαμπεῖ), such as those made
of tin or the smallest of those made of bronze, if they be crooked.'

Paul refers to its use as a cautery to destroy the roots of hairs after epilation (VI. xiv):

'Some, preferring cauterizing to the operation of transplantation,
evert the eyelid, and with a cilia forceps dragging out the offending
hair, or two or even three hairs, apply a heated double-olive probe or
an ear probe, or some such slender instrument, to the place from which
the hair or hairs were removed' (Διαπυρίνον ἢ μηλωτίδα ἤ τι τοιοῦτον
λεπτὸν ὄργανον πεπυρωμένον εἴρουσι τῷ τόπῳ ὅθεν ἡ θρὶξ ἢ αἱ τρίχες
ἐκομίσθησαν).

Here Briau reads πυρῆνα (an olivary point), but the balance of the evidence of the codices is in favour of διαπυρίνον, and the parallel to the passage quoted from Galen is so complete that I have no hesitation in adopting the reading given above.

I give an example of the dipyrene from my own collection. It is 11·2 cm. long. The shaft is unequally divided by a ringed fluting into two portions; 4·5 cm. and 6·7 cm. long respectively. The shorter portion of the shaft is plain, the longer is grooved longitudinally by eight grooves (Pl. XI, fig. 1). In many instances the dipyrene carried an eye in one of its olives. This variety is frequently mentioned. Thus Paul (VI. xxv) says, under treatment of nasal polypus:

'Taking then a thread moderately thick like a cord, and having tied
knots on it at the distance of two or three finger-breadths, we
introduce it into the eye of a dipyrene (διπυρήνου τρήματι), and we
push the other end of the probe (τὸ ἕτερον πέρας τοῦ διπυρήνου)
upwards to the ethmoid openings, withdrawing it by the palate and the
mouth, and then pulling with both hands we, as it were, saw the fleshy
bodies away by means of the knots.'

Pl. XI, figs. 5 and 3 show single olive probes for the application of semi-solid medicaments. The former is from the outfit of the oculist of Rheims, in the Museum at St-Germain-en-Laye; the latter, more highly ornamented by spirally twisting the stem, is from my own collection.

_Spathomele or Spatula probe._

Greek, ὑπάλειπτρον, σπαθομήλη; Latin, _spathomele_ (Theodorus Priscianus), _spathomela_ (Marcellus); German, _Spatelsonde_.

Almost every medical writer mentions the spathomele. It consists of a long shaft with an olivary point at one end and a spatula at the other. Galen (_Lex._) calls the one στρόγγυλον μήλην, the other μήλη πλατεῖα. It was a pharmaceutical rather than a strictly surgical instrument. The olive end was used for stirring medicaments, the spatula for spreading them on the affected part or on lint. Galen (xiii. 466) says that certain applications are to be softened in the hand with rosaceum by means of the spathomele (μαλάξας ἐπὶ τῆς χειρὸς διὰ σπαθομήλης).

Marcellus frequently refers to it as used for stirring liquids in a vessel:

Immo manu vel digitis moderantibus paulatim insperges et adsidue
spathomela commovebis et permiscebis, post haec omnia mittes oleum
chamaemelinum, et iterum igni non nimio adposita olla lente et
paulatim decoques medicamen, ita ut illud manu non contingas, sed
spathomela agites (vii. 19).

In xiv. 44 he mentions a spathomele of copper:

Oportet autem moveri aquam ipsam rudicula vel spathomela aeris rubri.

The following passage from Theodorus Priscianus refers to its use for applying ointment to an affected part:

Si veluti carbunculus innatus fuerit, lycium cum melle contritum
suppono frequenter per diem et spathomela temptante (_Euporiston_,
xxvii).

Aetius (II. iv. 16) directs a particular medicament to be rubbed in and to be scraped off after a moderate space of time with a spathomele (τῇ σπαθομήλῃ).

The spathomele was used by painters for preparing and mixing their colours. The very large numbers in which they are found would indicate that their use was not confined to medical men.

Although the nucleus of the spathomele was too large to admit of its use as a probe for small lesions, it is evident that in exploring large cavities it must have been a valuable instrument. Galen (ii. 712) says:

'In small bodies the opening into the torcular Herophili may not be
large enough to admit a spathomele nucleus, and therefore we must try
some of the other olivary probes or even an ear probe, and cut
alongside it.'

Priscianus alludes to plugging the nares with it:

Prius spathomeles extremo in baca molli lana obvoluto glebas sanguinis
e naribus frequentius purgare nos convenit, post lana identidem
obturando perclaudere (xiv).

'First of all we must frequently wipe away the clots of blood from the
nose with the end of a spathomele wrapped on the 'berry' with soft
wool, and then occlude it by plugging with wool in the same way.'

From Leonidas (Aetius, VI) we learn that it was used as a tongue depressor. He says:

'In inflammation of the throat in adults seat the patient, open his
mouth and depress the tongue with a tongue depressor or a spathomele,
and open the abscess with a scalpel or a needle-knife.'

The following passage from Galen shows that it was used as a substitute for the meningophylax (_q. v._):

'Having separated the pleura from the rib and placed a thin
meningophylax or a flat spathomele (σπαθομήλην πλατεῖαν) between the
ribs, and taking care that you neither tear nor perforate the
membrane, which being properly accomplished, cut the bone of the rib
with two chisels placed opposed to each other' (ii. 686).

Soranus (xxvii) refers to its use as a cautery:

'After cutting off the umbilical cord, cauterize the umbilicus with a
heated reed, or the flat of a probe' (τοῦ πλάτεος τῆς μήλης).

An interesting passage in Aetius shows that it was used as a dissector in opening up an occluded vagina:

'Pass a sound into the cervix, and dissect with the spathomele below
the spot marked out by the sound' (Aet. IV. iv. 96).

This probably means blunt dissection only, as none of the spathomeles found have edges sharp enough to be actually cutting. Large numbers of this instrument have been found. It is the commonest surgical instrument in museums. It must be remembered, however, that not every spathomele is a surgical instrument strictly speaking, as pharmacopolists and even artists used exactly similar instruments.

The average length of twenty specimens measured by me was 16 cm. Of this the nucleus occupies 1·5 cm., the spatula 6 cm. The average diameter of the nucleus is 7·5 mm. The width of the spatula averages 15 mm., but the size and shape of the spatula both vary considerably.

The different varieties of shape will be better understood by a reference to the accompanying figures of actual specimens than from a written description. Pl. XII shows neatly formed specimens from various sources; the specimen shown in fig. 3 having ornamental grooves along the length of the shaft. Figs. 3 and 4, Pl. XIII show coarse, thick specimens, which are most likely to have been used for non-medical purposes. All have the characteristic oar-blade shape, though the outline varies greatly. In some the blade widens out at the end, so that the tip is broad and rounded. In others the blade slopes to a rounded point, or the point is quite acute. The edges of the blade are usually thick and blunt. In some specimens, however, the edges are thin, sharp, and almost suitable for use for cutting with. These are well adapted for use as blunt dissectors.

The shaft, as a rule, is plain, occasionally it is ornamented with longitudinal or spiral fluting. More rare is a silver band, inlaid in a spiral round the shaft. I have seen a few specimens which have been entirely plated with gold.

Hitherto I have taken no notice of spathomeles in which the spatulae are not flat. In many specimens, however, the blades are hollowed. For these it seems advisable to constitute a special class, which may be called the cyathiscomele class.

_Cyathiscomele._

German, _Löffelsonde_.

Although this variety of the spathomele is not one which is specially mentioned by any classical writer, it is convenient to have a name by which we can denote that variety of the spathomele in which the blade is not flat.

It has the same large oval nucleus as the flat spathomele, and the same shaft, plain, or fluted, or overlaid with silver, but the spatula is replaced by a spoon, the outline of which shows the same variety of form as we met with in the spatula. The depth of the spoon varies greatly. Pl. XIV, fig. 3 shows an instrument in which the two lateral halves of the blade, instead of lying exactly in the same plane, meet in the midline at a slight angle so as to form a cavity obtusely angular on cross section, and gently rounded on longitudinal section:

Cross sec.

Long. sec.

Pl. XV, fig. 1 shows a similar arrangement, except that the cavity is more marked, and the tip instead of being sharp is rounded. In Pl. XIV, fig. 1 the cavity is so marked that a typical spoon is formed. This specimen is interesting as showing the ornamentation of the shaft by overlaying a spiral silver wire. It is from the Naples Museum, and it is figured by Vulpes. Other varieties are seen in Plates XIV, XV. Pl. XV, fig. 4 shows a very coarse, thick specimen. The scope of the cyathiscomele in medical art is evidently like the flat spathomele to act occasionally as a sound, but mainly to mix, measure, and apply medicaments. Some are adapted for use as curettes. But the large number in which this instrument occurs would of itself indicate that it was used for lay as well as medical purposes. Many are toilet articles. An interesting discovery of two typical specimens in the grave of a lady artist was made in Vendée in 1847. Among a number of colour pots and alabaster mortars for rubbing down and mixing colours was an étui similar to the typical cylindrical instrument case of the ancient surgeon, and in this were two spoon probes like the one shown in Pl. XIV, fig. 1. Evidently they were favourite instruments of the painter, and had been used by her for mixing and preparing her colours.[2]

[2] Blümner, _Technologie und Terminologie der Gewerbe und Künste bei
Griechen und Römern_, vol. iii. p. 458.

The form of cyathiscomele, in which the two lateral halves of the scoop meet at an angle (Pl. XIV, fig. 1), has a tendency to split along the ridge in the middle of the scoop if roughly handled. One of these, to which this accident has happened, is in the Naples Museum (Pl. XV, fig. 3) and has an interesting history. In 1847 Vulpes described it as a guard for dividing the fraenum linguae, and successive writers have copied this ever since, and it is so described in the catalogue. As the photograph shows, it is only a spoon probe which had been trod on or otherwise damaged, and which had split down the centre, or rather near the centre, for the crack has deviated at its termination from the midline. The termination of the notch thus formed has quite a different appearance from the figure by Vulpes. The accident is not an uncommon one. There is in the Capitoline Museum an instrument to which precisely the same has happened, and I have a probe in my own possession which has split, and which with a little manipulation would make a beautiful duplicate of the one in the Naples Museum (Pl. XV, fig. 1). It is almost certain that the guard is quite a modern invention.

Many ancient writers point out the danger of wounding the vein, but none mention the guard. Thus Celsus says:

Horum extrema lingua vulsella prehendenda est, sub eaque membrana
incidenda: magna cura habita ne venae quae iuxta sunt violentur et
profusione sanguinis noceant (VII. xii).

Paul says:

'The patient is to be placed in a proper seat, the tongue is to be
raised to the roof of the mouth and the membranous fraenum cut
transversely. But if the curvature is occasioned by a cicatrix we
transfix the callus by a hook and draw it upwards, and making a cross
incision free the bent parts, taking care not to make deep incisions
of the parts, for haemorrhages, which have been found difficult to
stop, have thereby been occasioned' (VI. xxix).

Aetius gives a similar account.

These writers, then, all take note of the possibility of wounding the vein, but give no clue that they knew of the utility of a cloven plate in preventing the accident. Further, the Arabs, timid operators all and fond of describing safeguards such as this, give no mention of it, although Albucasis, Rhases, Avicenna, and Haly Abbas all describe the operation. I can find no reference to the use of a guard for this purpose until quite recent times.

_Ear specillum._

Greek, μηλωτίς, -ίδος, μηλωτρίς, ἀπυρομήλη, τῇ πυρῆνα μὴ ἐχούσῃ τούτεστι τῇ μηλωτρίδι (Galen, Lexicon); ὠτογλυφίς, μήλην ἐξωτίδα (Galen, Lexicon); Latin, _oricularium specillum_ (Celsus); _auriscalpium_ (Scrib. Largus); German, _Ohrlöffel_.

Of all the specilla this is one of the most frequently mentioned by name. It consists of a small narrow scoop at one end and a simple probe without olivary enlargement at the other. We shall discuss the scoop first. The following passage from Archigenes describes it (Galen, xii. 652):

'If a bean, stone, &c., fall into the ear remove it with the small
narrow scoop of the ear specillum' (κυαθίσκῳ στενῷ μικρῷ μηλωτρίδος).

Again Galen (loc. cit.) and Paul (VI. xxiv) say that in cases where foreign bodies cannot be got out of the ear by more simple methods, we must incise behind the ear and remove them by means of the ear scoop. The removal of foreign bodies from the ear by means of this instrument is very frequently referred to and shows that the scoop was small. Celsus says (VI. vii):

'When a person begins to experience a dullness of hearing, which very
often happens after long continued headaches, first of all we must
examine the ear itself, for there will appear either a scab such as
occurs upon ulcers, or a collection of sordes. If there is a scab it
ought to be fomented with warm oil or with verdigris in honey, or leek
juice or a little nitre in hydromel, and when the scabs have been
detached from the part, the ear is to be washed out with tepid water,
in order that being spontaneously separated it may be the more easily
extracted with the ear specillum (_oriculario specillo_). If there is
cerumen and it is soft, it is to be extracted with the same specillum,
or if it is hard vinegar with a little water is to be put in, and when
it is softened the ear is to be washed out and evacuated in the same
way.'

In VI. vii he says:

Ubi vero vermes orti sunt, protrahendi oriculario specillo sunt.

'Where worms have arisen they are to be extracted with an ear
specillum.'

Celsus also recommends it for extracting a calculus from the meatus urinarius (VII. xxvi):

Eum, si fieri potest, oportet evellere vel oriculario specillo, vel eo
ferramento quo in sectione calculus protrahitur.

'It, if possible, is to be extracted with the specillum or the
instrument for extracting the calculus in lithotomy.'

Aetius (III. v) also describes removal of urethral calculus in this way.

The following passage from Paul (VI. xl) on venesection shows that in cases where the band of Antyllus could not be applied, the back of the ear scoop was pressed on the proximal end of the vein, in order to obstruct the flow of blood and cause it to discharge by the opening made with the phlebotome:

'Tie a ligature round the neck, and when the frontal vein is properly
filled divide it with the point of a phlebotome or a scalpel. In the
same way we open the external jugulars for chronic ophthalmia,
producing a discharge of blood with the scoop of a probe' (κυαθίσκου
μήλης).

Adams evidently misunderstood this passage. He translates it 'with the concave part of a scalpel', which is meaningless. This use of the scoop will also explain an otherwise obscure passage in Hippocrates (iii. 678). He says:

'In letting blood avoid pressing hard with the specillum (καὶ ὅταν
ἀφαιρῇς τὸ αἷμα τῇ μήλῃ μὴ κάρτα πιέζειν ὡς μὴ φλάσις προσγίνηται)
lest injury be caused.'

Of the use of the ear scoop as a curette we have several instances. Thus Aetius (II. iii. 81) recommends it for curetting the interior of a chalazion, and again (II. iii. 84), cf. Galen, _Comp. Med._ vii. 2. The scoop was also used for applying medicaments, especially to the eye. Liquid applications were poured from it, semi-solid were applied with the back of it (_averso specillo_). This use of the back of the scoop has often been misunderstood. The natural translation of the phrase _averso specillo_ is 'with the probe turned away', i. e. the back of the probe. Scultetus, however (_Tab._ VIII. vii), considers that it refers to a spatula probe, and says it means the probe turned end for end. Other translators adopt this meaning. Deneffe (_Les Oculistes Gallo Romains_, p. 108), e. g., says:

Il faut entendre par _averso specillo_ la partie de la spatule
opposée à celle qui sert comme sonde, c'est-à-dire son extrémité
large, l'autre bout étant le plus souvent olivaire.

Scribonius Largus puts the true meaning of the phrase beyond doubt. He directs us, after the application of caustic to haemorrhoids, to endeavour to get them to fall off by the back of an ear scoop, which part the Greeks called the spoon ('auriscalpio averso quam partem κυαθίσκον Graeci vocant').

Marcellus copies this passage from Scribonius, but alters it. He says: 'de specilli latitudine illinendae sunt' (xxxi. 6, p. 329).

I shall now proceed to give a few instances of this use of the back of the scoop in minor surgical manipulations.

In ancyloblepharon Celsus says the eyelids are to be separated with the back of the scoop.

Igitur aversum specillum inserendum, diducendaeque eo palpebrae sunt (VII. vii. 6).

The back of the scoop was used as a retractor for delicate structures. In radical cure of hernia Celsus directs us to keep the bowel from prolapsing by means of it:

'For if the piece be small it is to be pushed back over the groin into
the abdomen, either with the finger or the back of the specillum.'

Nam quod parvulum est super inguen in uterum vel digito vel averso
specillo repellendum est (VII. xxi).

In the cure of varicocele it is used to replace the veins in position:

Tum venae, quaecunque protractae sunt, in ipsum inguen averso specillo
compelli debent (VII. xxii).

'Then the veins which have been drawn upon ought to be replaced with
the back of a specillum.'

In sloughing ulcer of the bladder it is used to separate the lips of the perineal wound:

Quod si antequam vesica purgata est orae se glutinarunt, dolorque et
inflammatio redierunt, vulnus digitis vel averso specillo diducendum
est (VII. xxvii).

'But, if before the bladder has become cleansed the lips unite and
pain and inflammation have returned, the wound is to be separated with
the fingers or the back of a specillum.'

We shall next proceed to discuss the other end of the ear specillum. This was a simple probe. It had no nucleus. In his Lexicon Galen defines it thus:

Ἀπυρομήλῃ· τῇ πυρῆνα μὴ ἐχούσῃ τούτεστι τῇ μηλωτρίδι.

'Probe without olivary enlargement--that is to say "the ear
specillum".'

Not only was its tip not expanded into a nucleus, it was actually sharp. Galen (xiv. 787) treating of fistula in ano, says in non-perforating fistulae we perforate all the sound flesh with the sharp end of an ear probe (τῷ ὀξεῖ τῆς μηλωτίδος). The chief use of an ear probe in aural work was to instil liquids into the ear. A large ball of wool saturated with the liquid was wrapped round the middle of the probe, and on squeezing this the liquid ran down and dropped into the meatus. There are many mediaeval illustrations showing the ear probe used in this fashion. Sometimes, however, we read of the tip of the probe being wrapped in a small ball of wool, which was dipped in some sticky substance to extract foreign bodies from the ear. Galen (xii. 689) says foreign bodies may be removed thus by a probe dipped in resin.

The ear probe seems to have been much used for probing wounds and fistulae when a very slender instrument was required. Galen (ii. 581), in describing the torcular Herophili, says:

'And in the double passage you may be able to insert some of the
slender instruments you have at hand, a double ended probe--a
'double-olivary' if you prefer to call it so--or if something smaller
be necessary even an ear specillum' (καὶ μηλωτρίδα).

In his chapter on the extraction of weapons (VI. lxxxviii) Paul says:

'If the weapon has a tang, which is ascertained by examination with an
ear probe' (ἐκ τῆς μηλωτῆς).

As a cautery it was used to destroy the roots of hairs, which had been removed for trichiasis. Paul says:

'We may apply a double olive or an ear probe (μηλωτίδα) or some such
fine instrument heated' (VI. xiii).

In fistula in ano Paul says it may be used as a director to cut upon.

'Having introduced a sound or an ear probe (ὑποβάλλοντες κοπάριον ἢ
μηλωτίδα) through its orifice, we cut the skin over it at one
incision' (VII. lxxviii).

Illustrations of two ear probes are given. What I regard as the type is seen in Pl. XV, fig. 5, which shows an instrument from the Roman Hospital at Baden. Typical specimens are not by any means common. Pl. XV, fig. 2 shows another variety from my own collection.

_Screw Probes._

On probes for wrapping round with wool we frequently raise a screw thread to enable the wool to adhere better. This useful contrivance was also known to the ancients. I give a figure of one in my possession. It was found in the Roman Camp at Sandy (Pl. XXI, fig. 5). It measures 9·7 cm. in length and is 1·5 mm. thick. The screwed portion occupies 7 mm. of one end. The other end is plain. The little instrument is well adapted for treating small cavities, such as an ear or a carious tooth by wrapping round the screw portion with wool and dipping in medicaments.

_Ear specillum for wounds._

Greek, τραυματικὴ μήλη; Latin, _specillum vulnerarium_.

There was a special variety of ear specillum which was adapted for wounds. Paul (VI. lxxxviii) says:

'Stones and other missiles from slings may be removed by levers or the
scoop of an ear probe adapted for wounds' (κυαθίσκου τραυματικῆς
μηλωτίδος).

This was probably an instrument on the same principle as the ear probe, i. e. a combined probe and scoop, but on a larger scale. Possibly it may have had a slight olivary enlargement. That it was large we learn from Galen's Lexicon, where μήλην ἰσχυράν is stated to mean τὴν τραυματικὴν μήλην. It will easily be seen that the _specillum vulnerarium_ has considerable affinity with the other class of spoon probes which I constituted, viz. the class of cyathiscomeles--for these had a scoop at one end--and this being specially intended for wounds most likely had a certain amount of olivary enlargement at its tip, but smaller than the olive of a cyathiscomele, which was too large for ordinary wounds. The typical ear specilla and the typical cyathiscomeles both form well defined groups, but between these innumerable gradations occur among the specimens extant. For practical purposes it is convenient to class all these intermediate forms as _specilla vulneraria_.

_Handled Needles._

In the find of the oculist Severus were no less than nine handles for needles. Of these, six were merely cylinders of bronze, expanded slightly at one end and perforated at the other with a small hole for a needle. They were from 72 to 40 mm. long and 7 to 5 mm. in diameter. Two were hexagonal, four were round (Pl. XXI, figs. 2, 4, Pl. XVI, figs. 3, 4, 5, 6). Two others had the same holes for needles at one end, but at the other they were pierced with a slot, 10 mm. deep, for the insertion of a knife blade. One was 60 x 7 mm., the other 53 x 5 mm. (Pl. II, figs. 1, 2). Another, perforated at one end as before, carried at the other an olive-pointed probe. It was 8 cm. in length, and of this 3·5 cm. consisted of a hexagonal handle 3·5 cm. in diameter. The remainder was cylindrical, and it terminated in a probe point with a slight olivary enlargement (Pl. XVI, fig. 2). In all cases the needles had evidently been made of steel and had entirely disappeared.

We have many allusions to the use of handled needles in ophthalmic work. In describing the couching of cataract Celsus says:

Tum acus admovenda est, acuta ut foret sed non nimium tenuis (VII.
vii).

'Then a needle is to be applied, sharp so as to penetrate, but not too
fine.'

Sextus Platonicus (_Med. ex Animalibus_) says that cataract is depressed with a specillum.

A full description of the operation is given by Paul:

'We measure off a nucleus' breadth (ὅσον πυρηνομήλης) from the part
called the iris and in the direction of the outer canthus, then mark
with the olivary end of the couching needle (πυρῆνι παρακεντηρίου) the
place to be perforated. If it is in the left eye, we work with the
right hand, and vice versa. Bringing round the pointed end of the
perforator, which is round at the tip (καὶ ἀναστρέψαντες τὴν ἀκμὴν
στρογγύλην κατὰ τὸ πέρας ὑπάρχουσαν τοῦ κεντηρίου), we push it firmly
through at the part which was marked out until we come to an empty
space. The depth of the perforation should be as great as the distance
of the cornea from the iris. Then raising the needle to the apex of
the cataract (the bronze of it is plainly visible through the
transparent part of the cornea) we depress the cataract to the
underlying parts. After the couching of the cataract we gently extract
the needle with a rotatory movement' (VI. xxi).

It will be seen from Paul's vivid description that the couching instrument consisted of a handle with a nucleus at one end, to measure off the spot at which to perforate, and a needle at the other. We saw that the outfit of the oculist Severus contained one such instrument (Pl. XVI, fig. 2). The same combination is not infrequently met with. In the Museum at Aarau there are four from the station at Vindonissa. I have one in my collection which is interesting as showing a screw thread for fitting on a cover to protect the needle (Pl. XVI, fig. 7). It was found in Bedfordshire. It reminds one very strongly of the couching needle figured by Paré. Other handled needles were used in eye work as cauteries. Of trichiasis Celsus says (VII. vii):

Si pili nati sunt qui non debuerunt, tenuis acus ferrea ad
similitudinem spathae lata in ignem coniicienda est: deinde candens,
sublata palpebra sic ut eius perniciosi pili in conspectum curantis
veniant, sub ipsis pilorum radicibus ab angulo immittenda est ut ea
tertiam partem palpebrae transsuat; deinde iterum, tertioque usque ad
alterum angulum; quo fit ut omnes pilorum radices adustae emoriantur.

_Ophthalmic Probe._

Greek, ὀφθαλμικὴ μήλη.

In Hippocrates (ii. 100) we find an ophthalmic probe mentioned.

Λεπίδος μῆλαι τρεῖς τῷ πλατεῖ καὶ ἀλήτου σητανίου κόλλης, πάντα ταῦτα
λεῖα τρίψας, καταπότια ποιήσας δίδου.

'Of squama aeris three times the full of a specillum and [as much] of
the gluten of wheat. Levigate all up fine, form into pills and
administer.'

Galen in his Lexicon explains that μῆλαι τρεῖς τῷ πλατεῖ means τῷ κυαθίσκῳ ὀφθαλμικῆς μήλης. This is the only mention which we have of a special ophthalmic probe with scoop. In applying medicaments to the eye with a probe whenever any variety of probe is mentioned it is always the ear specillum which is named. It seems most likely that either the ear specillum or some variety of it is referred to here. It may have had a nucleus for applying medicaments at one end and a scoop at the other.

_Rasping Specillum._

Greek, βλεφαρόξυστον; Latin, _specillum asperatum_ (Celsus).

A special burred specillum, for curetting the granular lids so common as a result of the ophthalmia which is endemic in most Eastern countries, and which was rampant in ancient Greece and Rome, is described by Celsus and also by Paul. Celsus says:

In hoc genere valetudinis quidam crassas durasque palpebras et
ficulneo folio, et asperato specillo, et interdum scalpello eradunt,
versasque quotidie medicamentis suffricant (VI. vi).

Paul says:

'But if the granulation be hard and yield to none of these things we
must evert the eyelid, and rub it down with pumice stone, or the
shell of the cuttlefish, or fig-leaves, or the surgical instrument
called blepharoxyston' (διὰ τοῦ βλεφαροξύστου καλουμένου, III. xxii).

Heister (vol. i. tab. xvi. p. 591) figures the blepharoxyston as a spoon-shaped instrument burred on the convex side. There is in the Orfila Museum, Paris, an instrument of similar form. It consists of a handle with an olivary point at one end, and at the other a plate with transverse ridges. This agrees well enough with what we know of the classical instrument. It was found in Herculaneum. (Pl. XVI, fig. 1).

_Styli and Styloid Specilla._

Greek, γράφιον, γραφεῖον, γραφίς; Latin, _stylus_ or _stilus_.

The difficulty of deciding as to whether any particular instrument is a surgical or a domestic article is often well illustrated by styloid instruments. In the British Museum several types of instrument will be found classed among surgical instruments, and a series of exactly similar articles will be found repeated among the styli used for inscribing and erasing characters on wax tablets. As even the writing stylus was occasionally used for surgical manipulations we are justified in looking on all styloid instruments as potentially implements of minor surgery. The claims of any doubtful instrument to be considered as once having been one of a surgeon's tools must be decided on such grounds as the circumstances of its discovery.

Galen (xii. 865) says teeth may be extracted with the stylus (γραφείῳ ἀνάλαβε) or with the finger.

Hippocrates (i. 46) thus describes the method of extraction of the secundines:

'Place the patient on the obstetric chair and, leaving the cord uncut,
place the child on two bladders filled with water and puncture each of
the bladders with a stylus (γραφίῳ) so that the water may slowly flow
away.'

The writing stylus, then, from the fact of its being at hand and of suitable shape was occasionally, perhaps often, used as a surgical instrument.

I give a figure of a stylus in silver, beautifully oxidized, which was found at York while making excavations there in constructing the railway (Pl. XVII, fig. 3).

Pl. XVII, fig. 6 shows an instrument which is figured by Vulpes (op. cit.) as a specillum. Personally, I think its highly ornamented form shows that it is rather a domestic article, but, as no information is available as to the surroundings among which it was found, we can only say that its shape fits it equally well either for writing or minor surgical manipulations.

_Grooved Director._

Although we have no actual description of a grooved director, we have many manipulations described in which such an instrument would be used nowadays. For example, in describing the treatment of fistulae Celsus says:

In has demisso specillo ad ultimum eius caput incidi cutis debet (VII.
iv).

'A director being inserted into them down to their termination the
skin ought to be incised.'

It is interesting to find that we have at least one grooved director extant to prove that this instrument was known to the Romans. It is in the Section of Surgical Antiquities of the Musée de Cinquantenaire, Brussels, and it was discovered, along with several other surgical instruments, in a surgeon's case of the usual cylindrical form.

It is 15 cm. long, 2 mm. in diameter. A deep groove runs for 6 cm. from one end. The other end terminates in a small button. It is of silver, as also were the other contents of the case. It is possible that grooved specilla may have been in quite common use, but may have been made of wood or tin, and have therefore not survived; because we learn from Galen's Manual of Dissection that probes which were used as directors in dissecting work were generally of wood, such as boxwood, so that they might not chip the scalpel (ii. 711).

_Surgical Needle (three cornered)._

Before discussing the eyed probes it will be well to clear the way by disposing of the needles, and of these, as the most easily defined class, it will be best to take the surgical needles first. We have innumerable references to the surgical needle though we have no actual description of it. There must have been many different sizes of it, for the manipulations vary greatly in magnitude. I shall content myself with giving two quotations describing respectively one of the largest and one of the smallest of these. Both passages are from Celsus. He thus describes the operation of suturing the abdominal parietes:

Sutura autem neque summae cutis neque interioris membranae per se
satis proficit; sed utriusque: et quidem duobus linis iniicienda est,
spissior quam alibi; quia et rumpi facilius motu ventris potest, et
non aeque magnis inflammationibus pars ea exposita est. Igitur in duas
acus fila coniicienda, eaeque duabus manibus tenendae; et prius
interiori membranae sutura, iniicienda est sic ut sinistra manus in
dexteriore ora, dextra in sinisteriore a principio vulneris orsa, ab
interiore parte in exteriorem acum immittat: quo fit ut ab intestinis
ea pars semper acuum sit quae retusa est. Semel utraque parte
traiecta, permutandae acus inter manus sunt, ut ea sit in dextra quae
fuit in sinistra, ea veniat in sinistram quam dextra continuit:
iterumque eodem modo per oras immittendae sunt: atque ita tertio et
quarto, deincepsque permutatis inter manus acubus plaga includenda.
Post haec, eadem fila eaedemque acus ad cutem transferendae similique
ratione ei quoque parti sutura iniicienda; semper ab interiore parte
acubus venientibus, semper inter manus traiectis: dein glutinantia
iniicienda (VII. xvi).

In the next case, where Celsus describes the treatment of staphyloma of the cornea, a very small needle must have been used:

Haec fere circa oculum in angulis palpebrisque incidere consuerunt. In
ipso autem oculo nonnunquam summa attolitur tunica, sive ruptis intus
membranis aliquibus sive laxatis; et similis figura acino fit: unde id
σταφύλωμα Graeci vocant. Curatio duplex est: altera, ad ipsas radices
per mediam transsuere acu duo lina ducente; deinde alterius lini duo
capita ex superiore parte, alterius ex inferiore adstringere inter se;
quae paulatim secando id excidunt: altera in summa parte eius ad
lenticulae magnitudinem excidere (VII. vii).

Now for suturing tissues, and more especially tissues of such toughness and thickness as the abdominal parietes, a round needle is absolutely of no use. A surgical needle not only requires to have cutting edges, as our three-cornered needles have, but these edges need to be in good condition to work well. Three-cornered surgical needles were in use from very early times. They are fully described in the Vedas of the Hindoos (Wise, _Hindoo System of Medicine_, p. 171). A few three-cornered needles of Roman origin have been found, although they are rare. Those which exist are of bronze. Probably the majority were of steel, and of these none have survived. I give a photograph of a three-cornered needle from my collection (Pl. XVII, fig. 4). It is imperfect at the point. It measures 7·2 cm. in length, and the sides are each 2 mm. in breadth. It is important to emphasize the fact that only needles with cutting edges are to be looked on as surgical, because it is not unusual to find needles, which are round and of large calibre, described as surgical, although they are quite unfitted for surgical work. Such is the one figured by Vulpes (op. cit.).

Needles of this kind are sometimes found, as this one was, among surgical instruments. But they are not surgical needles in the sense that they are intended for suturing tissues. They are for fixing bandages. I shall describe them in the next section.

_Round Needles and Bodkins._

Hippocrates tells us that bandages for fixing dressings and splints on a fractured limb ought to be finished off by stitching with a thread (iii. 55), and Celsus repeats the advice:

Hieme saepius fascia circumire debet: aestate quoties necesse est.
Tum extrema pars eius inferioribus acu assuenda est; nam nodus vulnus
laedit, nisi tamen longe est (V. xxvi).

The round sewing needle was therefore part of the recognized outfit of the surgeon, and numbers have been found associated with surgical instruments. Apart from this association with other instruments it is quite impossible to distinguish them from domestic needles. The same may be said of bodkins, as these too occur in surgical finds, and are also quite indistinguishable from the domestic articles for embroidering. Pl. XVII, fig. 2 shows a bronze needle from Roman London. A similar one from Pompeii, now in the Naples Museum, is given by Vulpes as a surgical needle, owing to the fact that it was found along with surgical instruments; but it is evident that it is only a needle for sewing bandages, &c.

Other types of needles and bodkins are found in bronze, but many also are of bone and ivory. Even the latter are quite serviceable, and in spite of their being comparatively thick will stitch compact cloth easily. An ivory needle from Roman London is shown in Pl. XVII, fig. 5.

_Eyed Probes._

We have frequent references to eyed probes, and we also possess a considerable number of different types. In dealing with the dipyrene I quoted a passage to show that it sometimes carried an eye in one of its olives. Hippocrates refers to an eyed probe of tin. In treating of fistula he directs us to take a rod of tin having one end pierced with an eye (μήλην κασσιτερίνην ἐπ' ἄκρου τετρημένην), and having put one end of a twisted piece of lint through the eye put the probe into the fistula, get the end of the specillum, bend it and hold the thread with the finger and withdraw the ends. Paul quotes this passage (VI. lxxvii), but alters the wording slightly:

'Hippocrates directs us to pass a thread consisting of five pieces
through the fistula by means of an eyed probe or a dipyrene' (διὰ
τετρημένου κοπαρίου ἢ διπυρήνου).

Again in polypus naris (ii. 243) Hippocrates directs us to cut a sponge to the shape of a ball and tie the ball round with thread, and make it hard and of such a size as to fill the nose. To the sponge tie a thread of four pieces, each a cubit long, and make one thread of them. Put the end through a fine tin rod having an eye at the end. Push the rod bent at an acute angle into the mouth, and catch the end of the thread under the palate and pull it through, propping it with another hoof-like probe, and extract the polypus. Pl. XVII, fig. 1 shows an eyed probe from the Baden Hospital. Its shape is exactly the same as a lead probe figured by Paré for the insertion of the apolinose.

An example of a scoop at one end and an eyed probe at the other was found at Augst, and is now in the Museum at Basle (Brunner, loc. cit., Taf. I, fig. 14). It is 16 cm. long, of which the spoon, slightly defective at its tip, occupies 3 cm. About 2 cm. from its tip, which is fine, there is an elongated eye, 5 mm. in length.

Various other combinations are met with.

_Ligula type of Specillum._

Greek, κυαθίσκος; Latin, _ligula_.