Chapter IV: Probes (2)

Ligulae are found in enormous numbers and in very great variety. They are toilet articles for extracting from tubes and boxes ointment, the various salves, balsams, and powders which entered into the mysteries of the Roman lady's toilet. The ligula is therefore not strictly speaking a surgical instrument, but as it was used by the laity, and no doubt also by physicians, for making applications to affected as well as to unaffected parts, and as it is often found associated with surgical instruments, it is advisable to bring it within the scope of this investigation. It is also convenient to do so, because some varieties approach so closely in form to the true surgical specilla that it is often difficult to decide which class to place a particular specimen in. In doubtful cases it is well to remember that the specillum is most usually a combination of two instruments on one shaft. Brunner (loc. cit.) figures a number of ligulae from the Swiss museums. These he names specilla oricularia, although admitting that they are only domestic articles. I have shown, however, that the specillum oricularium is a well-defined combination of scoop and probe.

Plate XVIII shows a variety of ligulae from various sources, some simple, some combined instruments. Figs. 4, 5, 8 are most typical forms. Some of this simple type are two feet in length. They are often overlaid with gold. Fig. 7 shows a ligula which has so been treated. It carries a small fork on which to poise a pellet of semi-solid medicament.

_Spoons for measuring, preparing, and pouring medicaments._

A type of spoon not uncommonly met with has a round bowl about 2 cm. in diameter, and a handle of about 10 cm. long. Usually they are of bronze; but occasionally they are of silver, and a considerable number in bone were found in the Roman Hospital at Baden. They are for measuring medicaments, heating them, and removing them from unguentaria, &c. They are often found alongside the glass unguentaria which contained the salves. They were also used for religious purposes.

Similar spoons with pointed handles are common in finds of domestic articles. The sharp end is for extracting shellfish, &c. A larger variety of the unguent spoon has a spout to assist in pouring the contents. This variety is rather rare.

Pl. XIX, fig. 4 is from the British Museum. The bowl is 2.5 cm. in diameter and the handle is 15 cm. long. The handle is round, and it has a small ringed ornamentation at its end and one close to the bowl. The bottom has been thinned out with heat, and there is a small perforation visible in it. A similar spoon was found in the grave of the Paris surgeon. Traces of medicament remain on it. This type is probably intended for warming salves and pouring them into the eye and other affected parts. Another variety is seen in Pl. XIX, fig. 1. This specimen is in the Naples Museum, and was found along with the spatula shown in Pl. XIX, fig. 2. The handles of each are of bronze, the scoop and spatula parts are of silver. Vulpes describes these as a lancet for drawing blood and a spoon for collecting and examining the same. It is impossible to regard an instrument of silver as a cutting instrument. These are for mixing and spreading medicaments. A large spoon of a peculiar shape from the Naples Museum is seen in Pl. XIX, fig. 3. It is of silver. The handle, which is of ivory, is ornamented with spiral carving, and the end bears a ram's head. Another interesting little shovel from the same museum is of bronze, and carries the head of Minerva Medica on the end of the handle (Pl. XX, fig. 5). We may here include the large double spatulae of the type shown in Pl. XX, fig. 1, which represents a specimen from Naples. A similar one was found in the outfit of the Paris surgeon, and Scultetus shows precisely similar instruments in use in his time for applying the stiffening to the bandages, &c. for setting fractures. The Romans probably used theirs for a similar purpose.

_Tongue Depressor._

Greek, γλωσσοκάτοχος.

To open a quinsy Aetius says (II. iv. 45):

'If the patient is adult, seat him and make him open his mouth, and
depress the tongue with a spathomele, or a tongue depressor, and open
the abscess with a probe or a needle knife.'

In excision of the tonsil Paul (VI. xxx) bids us seat the patient in the sun and depress the tongue with a tongue depressor (γλωσσοκατόχῳ).

Pl. XX, fig. 6 shows one of six bronze tongue depressors, burnished like small mirrors, from the Lépine collection (Védrènes, _Celse_).

_Uterine Sound._

The uterine sound is frequently mentioned by Hippocrates for correcting malpositions of the uterus, and dilating and applying medicaments to the interior of the cervix. After falling into disuse in the middle ages it was reintroduced by Sir J. Y. Simpson, only to disappear once more almost entirely from sight.

I have already referred to Galen's statement that the non-pregnant os is of such a size that it will just admit an olive-pointed probe (p. 54).

Hippocrates (ii. 836) directs us to treat hysteria by dilating the cervix, first with an ointment probe and then with the finger.

Καὶ ὑπάλειπτρον καθιέναι καὶ ἀναστομοῦν καὶ τῷ γε δακτύλῳ ὡσαύτως
λειοῦν.

Soranus (II. x) describes plugging for uterine haemorrhage by means of the sound:

Καὶ τρυφερὸν ἔριον ἑνί τινι τῶν εἰρημένων χυλῶν διάβροχον διὰ δακτύλου
ἢ μήλης παρεντιθέσθω τῷ στόματι τῆς ὑστέρας. καὶ πολὺ μᾶλλον ἐντεῦθεν
τῆς αἱμορραγίας ὑπαρχούσης.

Hippocrates (iii. 34) alludes to applying medicament to the internal os with the sound:

'Grind the pulp of colocynth, &c., and rub it up with honey and smear
it on the sound (περὶ μήλην) making the consistence such that it can
enter the os and always be pushed beyond until it has penetrated to
the interior of the uterus. When the medicament has liquefied extract
the sound, and again in the same way apply elaterium.'

If pus collect in the uterus post partum, or after abortion or from any other cause, it is good practice to pass a sound (μήλην ὑπαλειπτρίδα) into the cervix (i. 471). In another place we are directed to draw off gas in the uterus by fomenting the whole body and the uterus with vinegar and water, warmed specilla being afterwards inserted (μήλας διαπύρους ἐμβάλλοντα).

Again we find the sound applied to correct malposition of the uterus (iii. 140):

'When the semen is extruded on the third day and the woman
consequently fails to conceive, take small soft feathers and tie them
together, and foment the uterus as we do the eyes. Make the feathers
even at the tips and tie the ends with a very fine thread, and anoint
with much rosaceum. Also place the patient on her back on a couch, and
place a pillow under the loins, and, the woman's thighs being extended
and separated, insert a sound and turn it to this side and that till
it project.'

In all these cases there is no special instrument designated as being used for a uterine sound, only the spathomele (ὑπάλειπτρον) and the olivary probe named. With both of these we have met before. However, I have thought it of historical interest to cast these passages together. It will also clear the way for the discussion of other instruments, whose use is entirely reserved for the purpose of dilation of the cervix.

A more questionable use of the sound is referred to by many authors. During the Empire the death of the foetus was frequently procured both by abortifacients and instruments. Frequent references to the use of drugs for this purpose may be found in the lay writers such as Juvenal and Suetonius (_Domitian_), and the later medical authors do not hesitate to describe the composition of abortifacient pessaries. It will be remembered that the Hippocratic oath specially forbids this practice.

_Uterine Dilators--Solid, graduated wooden._

Greek, διαστομωτρίς, μήλην τὴν διαστέλλουσαν--τὸν διαστολέα (Galen, _Lexicon_).

Besides the ordinary probes, which we have just seen that Hippocrates used occasionally for dilating the os, we have frequent mention made of a special variety of dilators which, although they are called μήλη by Hippocrates, are not, strictly speaking, probes or sounds, but a graduated set of dilators of wood, tin, or lead. They correspond, in fact, to our Hegar's dilators.

Hippocrates describes these dilators (ii. 799). The patient is to have fumigations for five or six days till the cervix is softened. After these fumigations, dilators (προσθέτων) made of pieces of very smooth slipping pinewood are to be introduced into the cervix. There were six of these. Each was six finger breadths (4·2 in.) in length. They ended in a point, and each succeeding rod was larger than the preceding one; the largest being of the diameter and shape of the index finger, being smaller at one extremity than the other. They should be as round as possible and with no splinters. Before being introduced they were smeared with oil. First the point was gradually introduced by rotating the dilator and pushing it simultaneously till it entered for a distance of four finger breadths (2·8 in.). After the first rod was introduced it was withdrawn and replaced by a larger one. During the after treatment a leaden tube filled with mutton fat was left in the uterus at night, while through the day one of the pine dilators was used. Pl. XX, fig. 2 shows a specimen from Pompeii, which Védrènes regards as a uterine dilator. It is hollow, and is ornamented to resemble the head and body of a snake.

_Metal Dilators mounted on handles of wood._

Hippocrates (i. 473) mentions a variety of dilator made of tin or lead, and hollow behind for mounting on a wooden handle:

'After douching and fumigation, dilate, and, if necessary, straighten
the cervix with a dilator of tin or lead (τῇ μήλῃ τῇ κασσιτερίνῃ ἢ
μολυβδαίνῃ), beginning with a fine one, and then a thicker if it be
admitted, until it seems to be in proper position. Dip the dilators in
some emollient. The dilators are to be made hollow behind, and fitted
round rather long pieces of wood and thus used.'

This evidently refers to a portable set of dilators, each capable of fitting on a common handle, like Fritsch's, Peaslee's, or Lawson Tait's of modern times.

_Bifurcated Probe._

Greek, μήλη δικροῦς, χηλή.

In treating of polypus naris Hippocrates directs us to take a sponge and tie it into a hard ball, and attach a four ply thread to it. Next to pass the end of this thread by means of an eyed probe of tin till it is caught at the back of the mouth, and drawing it out of the mouth to place a bifurcated probe under the palate, and using this as a fulcrum pull until the polypus is extracted (_De Morbis_, ii. 243: ἔπειτα χηλὴν ὑποθεὶς ὑπὸ τὸν γαργαρεῶνα ἀντερείδων ἕλκειν ἔστ' ἂν ἐξειρύσῃς τὸν πώλυπον). In Galen's _Lexicon_ we find χηλή explained as meaning a notched probe, split like a hoof at the point (μήλην δικροῦν, κατὰ τὸ ἀκρὸν ἐκτετμημένην ἐμφερῶς χηλῇ). And again under the heading δικροῦν he gives τὸ οἷον δίκρανον, ὅπερ καὶ δισχιδὲς ὀνομάζουσι τὸ δὲ αὐτὸ καὶ δηλοῖ, 'what they call cloven and also cleft.' The same word also means the notch of an arrow. In _De Morbis_ (ii. 245), Hippocrates describes another method of extracting polypus with the same instrument. Taking a piece of stringy gut (χορδήν) and making a loop on it pass the end through the loop, thus making a second larger one, i. e. a noose. Pass the end of the gut through the nose into the mouth with a tin probe. Pull the loop into the nose and adjust it round the polypus with a notched probe (μήλῃ τῇ ἐντετμημένῃ), and when this is done pull on the gut, using the notched probe as a fulcrum.

There must have been one form of bifurcated probe with a rounded end bearing a notch like an arrow. This is the only form of cleft probe which it would be safe to use in the back of the throat in the manner described by Hippocrates. We know, however, of other forms of bifurcated probes. Celsus describes a bifurcated retractor used for the extraction of weapons buried in the flesh:

Saepius itaque ab altera parte quam ex qua venit recipienda est;
praecipueque quia fere spiculis cingitur; quae magis laniant si
retrorsus quam si contra eximatur. Sed inde aperta via caro diduci
debet ferramento facto ad similitudinem Graecae litterae Y; deinde,
ubi apparuit mucro, si arundo inhaeret propellenda est donec ab altera
parte apprehendi et extrahi possit (VII. v).

Variant readings are V and Λ. The Aldine edition has ψ. The reading I have adopted is Daremberg's; but whichever is correct matters little, as all indicate a bifurcated instrument, except the Aldine, which would indicate a three-pronged one. There are several bifurcated specilla in the British Museum (Pl. XXII). One in the Orfila Museum, Paris, of slender construction, carries a hook at the other end. It is from Herculaneum (Pl. XXI, fig. 1). A plain variety is shown in Pl. XXI, fig. 6. The specimen shown in Pl. XXI, fig. 3 is interesting as showing a possible fallacy. It has considerable affinity to the Roman netting-needle, and may not be a probe at all. The typical netting-needle has, however, blunt points, and the planes in which the forks lie are at right angles to each other.

_Blunt Dissectors._

In his chapter on Angiology (or Division of the Temporal Blood Vessels) for headache and ophthalmia (VI. v), Paul mentions the use of dissectors:

'Having therefore first shaven the hairs of the temples we make an
examination by palpation, applying warm fomentations or even a fillet
round the neck, and mapping out the vessels with ink as they become
apparent, we stretch the skin to either side with the fingers of our
own left hand and those of an assistant, and make a superficial
incision along the vessel. Then cutting down and retracting with hooks
and exposing the vessel with dissectors (δι' ἐξυμενιστήρων) we must
raise it up completely isolated. If it be small, having stretched it
and applied torsion we may divide it through in such a way as to
remove a piece of it at one stroke.'

The typical scalpel handle ends in a leaf-shaped dissector, and Celsus always describes blunt dissection as being performed with the manubriolus of the scalpel. We have, however, a few dissecting manubrioli as separate instruments not designed to carry scalpel blades. Three were found together in the grave of the surgeon of Paris. There are also two in the museum of St-Germain-en-Laye, and one in the Museum at Mainz. We may take as types two from the find of the oculist Severus in the St-Germain-en-Laye Museum (Pl. XX, figs. 3, 4). They consist of elongated leaf-shaped blades carried on hexagonal handles, and are exactly similar in appearance to a scalpel handle, except that they do not carry a slot for the insertion of a blade.

_Curved Dissectors._

Greek, ὑδροκηλικὸν κοπάριον.

On the cure of hydrocele Paul (VI. lxii) says:

'When the fluid is in the tunica vaginalis we make the incision where
the apex of the tunica makes its appearance, and, separating the lips
of the incision with a hook, and having dissected off the fascia with
the hydrocele specillum and the scalpel (ἐξυμενίσαντες τῷ τε
ὑδροκηλικῷ κοπάριω καὶ τῷ σμιλίῳ), we divide it through the middle
with a lancet.'

Treating of the excision of varices (VI. lxxxii) he says:

'Having separated the lips of the wound with hooks, and dissected away
the fascia with curved hydrocele specilla, and laid bare the vein and
freed it all round' (ὑδροκηλικοῖς ἐπικαμπέσι κοπαρίοις).

A curved dissector from the find of the oculist Severus, now in the Museum of St-Germain-en-Laye, has a neatly ornamented handle with a small hook at one end, and at the other it curves first backward and then forward to join a small leaf-shaped dissector 3 cm. long and 1 cm. in its greatest breadth (Pl. XXIII, fig. 2).

_Sharp Hooks._

Greek, ἄγκιστρον, ἀγκυρομήλη; Latin, _hamus_, _hamulus acutus_.

Hooks blunt and sharp are frequently mentioned in both Greek and Latin literature, and served the same purposes as we use them for; the blunt for dissecting and raising blood-vessels like the modern aneurism needle, the sharp for seizing and raising small pieces of tissue for excision, and for fixing and retracting the edges of wounds. We are fortunate also in possessing many fine specimens of both sharp and blunt hooks in museums, &c. In the Naples Museum alone there are upwards of forty examples of hooks. Of pterygium Celsus says:

Tum idem medicus hamulum acutum, paulum mucrone intus recurvato,
subiicere extremo ungui debet eumque infigere; atque eam quoque
palpebram tradere alteri; ipse, hamulo apprehenso, levare unguem
eumque acu traiicere linum trahente (VII. vii).

Aetius also mentions this use of the sharp hook:

'And, transfixing the pterygium with a hook (καὶ ἀγκίστρῳ
καταπείροντες περὶ τὰ μέσα τὸ πτερύγιον), we gently make traction on
it' (_Tet._ II. iii. 60).

Paul also says:

'Seizing the pterygium with a hook with a small curve, (ἀγκίστρῳ
μικροκαμπεῖ ἀναδειξάμενοι) we stretch it' (VI. xviii).

The method of excision of the tonsil described by Celsus, Aetius, and Paul is to bring the tonsil into view by dragging on it with a sharp hook and then amputating it. Thus Paul says:

'Wherefore seating the person in the light of the sun, and, directing
him to open his mouth, while one assistant holds his head and another
presses down the tongue to the lower jaw with a tongue depressor we
take a hook (ἄγκιστρον) and transfix the tonsil with it and draw it
outwards as much as we can without drawing the capsule along with it,
and then we cut it out by the root with the tonsil knife suited to
that hand' (VI. xxx).

In contraction of the vulva, Paul says:

'Having transfixed the connecting body, whether flesh or membrane,
with hooks, we stretch it and divide it with the fistula knife' (VI.
lxxii).

Similarly Celsus (VII. xxviii) says:

At si caro increvit, necessaria est recta linea patefacere; tum ab
ora, vel vulsella vel hamo apprehensa, tamquam habenulam excidere.

In dissection, many of the manipulations which we perform with the dissecting forceps were performed by the ancients with sharp hooks. Pl. XXIV, figs. 1-5 represent specimens from various sources; some simple, others combined with another implement.

_Blunt Hooks._

Greek, τυφλάγκιστρον; Latin, _hamus retusus_.

Aetius (_Tet._ III. i. 13) says:

'Whatever adhesions there are of the lower border of the lids to the
tunics of the eye, we must put them on the stretch with a blunt hook
(τυφλαγκίστρῳ) and with a pterygotome free the adhesion.'

In Aetius (_Tet._ II. iii) we see the blunt hook used in the same way as we use an aneurism needle, except that the ligature is not introduced with it, but with another needle. He says we transfix the lips of the incisions with two hooks and gradually dissecting with the scalpel we free the vessel from the underlying fascia. Then with a blunt hook (τυφλάγκιστρον) placed under the vessel we raise it up from the depth, and beneath it when raised we place a two ply thread by means of a needle, and doubly tie and cut between.

Paul says:

'Exposing the vessel with dissectors we must raise it up when it is
separated all round. If it be small, having stretched and twisted it
with a blunt hook, we may divide it through in such a way as to remove
part of it. But if it be large we must apply a double ligature under
it with a needle, either a piece of raw flax or some other strong
thing' (VI. v).

The 'eyed hook' is mentioned by Galen in describing the dissection of the spinal cord:

Ἐνδέχεται δὲ καὶ χωρὶς βελόνης ἀγκίστρῳ διατρήτῳ γενέσθαι τὴν
ἐγχείρησιν, ὡς ἐπὶ τῶν περὶ τὰς καρωτίδας ἀρτηρίας νεύρων εἴωθε
ποιεῖσθαι (ii. 669).

'It is advisable that the manipulation be performed not with a needle
but with an eyed hook, as is usually done in the case of the tendons
in the neighbourhood of the carotid arteries.'

A small variety of the blunt hook is mentioned by Celsus, Galen, and Paul.

Of the extraction of foreign bodies from the ear Celsus says:

Sin aliquid exanime est, specillo oriculario protrahendum est, aut
hamulo retuso paulum recurvato (VI. vii).

Paul says that if stones of fruits, &c. fall into the ear they must be extracted with an ear scoop, a hook, or a forceps.

Both types of blunt hook are represented by extant specimens; see Pl. XXIII, figs. 3, 4. These remind us of our aneurism needles, and it is interesting to note that Galen (_ut supra_) speaks of an 'eyed hook'. The instruments shown in Pl. XXIII, figs. 2, 4 we might look on either as curved retractors or dissectors as they are half sharp. Pl. XXV, fig. 2 shows a hook of crotchet-hook type combined with a scoop. It is from Herculaneum.

_The Strigil._

Greek, ξύστρα. Latin, _strigil_.

It seems to have been a common method of applying remedies to the auditory canal to warm them in a strigil and pour them in with it. Galen frequently mentions this. In _Med. Sec. Loc._ (xii. 622) he says:

Having warmed the fat of a squirrel in a strigil, instil it.

Celsus (VI. vii. l) says:

In aurem vero infundere aliquod alimentum oportet quod semper ante
tepefieri convenit; commodissimeque per strigilem instillatur.

Marcellus (IX. l) says:

Conteres et in strigili calefacies, et infundes, et lana occludes
aurem.

Scribonius Largus (xxxix) says:

Ad auriculae dolorem et tumorem sine ulcere prodest herbae urceolaris
aut cucurbitae ramentorum sucus tepens per strigilem in foramen auris
dolentis infusus.

The strigil varied much in size and shape. A common form was a sickle-shaped instrument, the circular part being hollow and semicircular on section, and admirably adapted for warming and pouring oil and other medicaments into the ear as above described. Pl. XXV, fig. 1 shows a small strigil from my collection.

_Spoon for applying astringent liquids to the uvula._

Greek, σταφυλεπάρτης.

In his description of the medical treatment of diseases of the mouth Paul (III. xxvi) says:

'When the uvula is inflamed we must use the gargles recommended for
inflammation of the tonsils, and those of a moderately astringent
nature, such as the juice of pomegranate, applied by means of a spoon
or the instrument called the "uvula medicator"' (σταφυλεπάρτου).

It is evident that it is quite a different instrument from the staphylocaustus (_q. v._), which we are specially told had more than one hollow and was a grasping instrument like a forceps. The present instrument is for applying liquids, and was apparently of the form of a spoon. Fabricius describes and figures such an instrument. It is a small round spoon with a long handle.