Surgical Instruments in Greek and Roman Times Part 16

Aristotle in his _Poetics_ discusses various tricks and arts of authors and among these he mentions the riddle of which he gives as an example: ??d?' e?d?? p??? ?a???? ?p' ????? ?????sa?ta 'I saw a man who had glued on a man bronze by means of fire' the reference being to a bronze cupping-vessel (see also Mayor's note to Juvenal xiv. 58). The cups mentioned by Hippocrates are also of bronze. The earliest written references are thus to bronze cups worked by fire. Ethnological research would indicate, however, that horns worked by suction represent the more primitive form.

A good number of cups have come down to us. There are fourteen in the Naples Museum. There are two prevalent or usual types, one conical, and the other flatter and more rounded. The largest cup known is in the Athens Museum. Attached to it had been a chain 20 cm. long to hang it up by. It is 16 cm. in height, and was found in a tomb at Tanagra. This cup with its chain and attachment is shown in Pl. x.x.xIII.

In the British Museum there is one of bronze, 4 inches high and of the elongated conical shape. It was found in Corfu (Pl. x.x.xIV). One in Naples of similar shape has a ring attached to its summit as the Athens specimen had (Pl. x.x.xV).

There are four very small cups in the museum at Mainz. These are 25 to 3 cm. in height and 3 to 35 cm. in diameter. Two of these are shown in Pl.

x.x.xVI, figs. 1, 3.

There are ten cups of gla.s.s in the Athens museum. They are of the general shape of the Mainz cups, but vary in height from 4 cm. to 68 cm. and in the Scottish National Museum of Antiquities there are two cupping-horns which correspond to the description of Celsus. They were brought from Shetland, where they were in use until comparatively recent times. Prosper Alpinus, who visited Egypt in the sixteenth century and wrote a book on the state of medicine in that country, found these cupping-horns in use there, and he gives drawings of the instruments he saw (Pl. x.x.xVII, fig.

1). The horns used were those of young bulls, highly polished and with a small hole at the tip, by which the air was extracted by suction. To close this a small tab of parchment was taken into the mouth, and moistened and affixed by the tongue. The Egyptians also used cupping-vessels of gla.s.s, specially shaped and worked by suction. Pl. x.x.xVI, fig. 2 shows the shape ill.u.s.trated by Prosper Alpinus. The method of using fire with cups was not known to the Egyptians at the time when Alpinus wrote (_De Med.

Aegyptiorum_, ed. 1541, lib. ii. ch. xii. p. 139).

Horn cups worked by suction are spoken of in the Hindoo Vedas.

It is interesting to find that these horn cupping-vessels are still in use in some parts of Africa, and one, the property of a Hausa barber-surgeon, was presented to the Aberdeen Anatomical Museum by Sir William Macgregor (_Proc. Aberdeen Anat. Soc._ 1900-2).

An interesting form of cup is described by Hero of Alexandria (B. C.

285-222). Hero's description is quite intelligible, although it would be difficult to give an accurate translation that would be readily understood. I shall content myself with summarising his account. The figure (Pl. x.x.xVII, fig. 2) shows a cup of ordinary flattened form, divided into two by a diaphragm. Two tubes pa.s.s through the fundus, one pa.s.sing through the diaphragm, the other not. Each of these tubes is fitted with another which is open at its inner end, but closed at its outer end and provided with a small crossbar to rotate it. Each of these sets of tubes is perforated by small openings. In the case of the short tube these are outside the cup, in the case of the long tube they are inside the cup, in the chamber shut off by the diaphragm. By rotating the pistons these openings can be placed in apposition or not at will, thus forming valves. Open valve A by placing the holes in apposition. Close valve B by turning the holes away from each other. The inner chamber of the cup is now shut off except for the small hole A. Apply the mouth to the valve A and suck the air out of the chamber. Close valve A. Apply the cup to the affected part. Open valve B and the negative pressure draws on the affected part. The advantage of this arrangement is that the affected part is not directly sucked upon by the mouth, and the instrument is therefore more pleasant for the operator to use. Bleeding cups occur on the coins of Epidaurus (300 B. C.), Atrax (400 B. C.) and Aegale (200 B.

C.).

_Clysters._

The ancients made frequent use of injections into the various orifices of the body. The apparatus used was a bladder or skin of an animal fixed to a tube. This form of instrument remained in use till the beginning of the nineteenth century, although the elaborate enema syringe, on the principle of the force pump, had been in use since the fifteenth century at least.

The following pa.s.sage from Heister (anno 1739) is interesting as showing exactly the method of its manipulation:

Pl. x.x.xVII, fig. 3 machinam clysteri iniiciendo adaptam designat, qua Germani ut et Batavi vulgo utuntur. Litt. AA vesicam denotant c.u.m liquore contento; quae vero in adultis duplo vel triplo amplior quam hic indicatur esse solet, pro libra circiter, et quo D excedit, liquoris continenda; BB tubulum sive fistulam osseam ano immittendam, per quam liquor in intestina iniicitur; CC vinculum superius, quod, postquam fistula in ano est, solvitur ac removetur; DD vinculum inferius, quo vesica clauditur, ne liquor immissus elabi queat (vol.

ii. p. 1117).

The rectal apparatus is called by Galen ???st??, the uterine ?t?e???t??, and the bladder injector is called ?a?et??. In x. 328 we find all these three terms used in one paragraph:

?? ta?ta ?? ??? d?? =???st????= e?? ?t?a? d? d?? =?t?e???t??= t??

?p?t?de??? t? fa????? ???ee? ?spe? ?e ?a? e?? ??st?? d?? t??

e???t??t?? ?a?et????.

The different varieties of injection apparatus which are specially named are as follows:

(1) Rectal: Greek, ???st??, -????; Latin, _clyster_.

(2) v.a.g.i.n.al: Greek, ?t?e???t??; Latin, _clyster_.

(3) Uterine: Greek, ?t?e???t??; Latin, _clyster_.

(4) Bladder: Greek, e???t??t?? ?a?et??; Latin, _clyster_.

(5) Nasal: Greek, ???e???t??; Latin, _rhinenchytes_.

(6) Ear: Greek, ?te???t??; Latin, _oricularius clyster_.

(7) Sinus: Greek, p???????; Latin, _oricularius clyster_.

_Rectal Clyster._

Early Egyptian writings refer to rectal enemas: numerous prescriptions, including several for nutrient enemas, are given.

Oribasius gives us many interesting particulars about enemas (_Collect._ VIII. xxiv). The amount necessary is less for men than for women. In any case the largest amount is three heminae (t?e?? ??t????), the smallest one hemina (a small half pint). In dysentery and other cases where the parts would be easily hurt, and where a prompt evacuation was required, cannulae with the opening placed in the side were used. Cannulae with the opening in the end of the instrument were used where a large evacuation was desired to be brought down from the higher parts. To destroy ascarides, cannulae with a circle of small holes placed laterally were used.

From ch. x.x.xii we learn that the injection pipe varied in length also, for Oribasius says that in making injections into the r.e.c.t.u.m for affections of the bladder (e. g. to excite expulsion of urine in cases of retention), the tube (t? ???a? t?? ???st????) ought to be short.

In the case of nutrient enemas Mnesitheus says the tube ought to be extremely long, and in admitting an injection one ought to keep up compression of the empty part of the clyster because it often happens that the injection returns from the r.e.c.t.u.m unless this is done (Oribas. viii).

Hippocrates (ii. 276) mentions inflation of the r.e.c.t.u.m with air by an enema in cases of ileus. A bladder is to be attached to a tube and the air injected with this. It is then to be removed and a clyster injected.

In the excavations of the Roman Hospital at Baden there was found the tube of a clyster in bronze. It is cast in one piece of stout bronze (Pl.

x.x.xVIII, fig. 2).

_v.a.g.i.n.al and Intrauterine Clysters._

Greek, ?t?e???t??.

It is difficult to separate ancient descriptions of injections into the v.a.g.i.n.a from those into the uterus, for the terms for the two parts are frequently interchangeable. It is undoubted, however, that actual intrauterine injections were made. Hippocrates (iii. 17) says:

'The end of the enema (i. e. the tube) is smooth like a sound. The tube is of silver. A perforation will be made in the side not far from the small tip of the tube (?a?et??). There will also be other perforations, which will be placed at equal distances on each side of the tube throughout its length. The extremity of the injection tube will be solid, all the rest hollow. To the tube will be attached the bladder of a sow, which has first been well sc.r.a.ped. Place the milk of a mare in the bladder, having taken the precaution to close the perforations in the tube with a linen rag. The bladder is then closed with a cord and given to the woman herself, and she, when the cord shutting off the bladder has been removed, puts it inside the uterus.

For she herself will know where it ought to be placed. Then you press the bladder with your hand as long as pus escapes.'

The description quoted already from Heister will help to make clear the description of the manipulation. There is in the Naples Museum (No.

78,235) an injection tube of bronze answering to the description given. It is 13 cm. long, and it has at the end a small opening, while on the side, not far from the tip, eight small holes are arranged in two superposed rings (Pl. x.x.xVIII, fig. 1).

There is a similar but slightly smaller instrument in the same museum.

_Bladder Clyster._

Greek, e???t??t?? ?a?et??.

There are frequent references to injection of the bladder. Although from some pa.s.sages it is clear that the injection really reached the bladder, it is probable that at other times, under the heading of 'Injection of the Bladder', only irrigation of the urethra is meant, just as sometimes by irrigation of the uterus only v.a.g.i.n.al douching is meant. Irrigation was practised by means of a bladder fixed to the end of a catheter. Galen (x.

328), however, calls the bladder syringe e???t??t?? ?a?et??, which may indicate that the eye was in the tip and not in the side, as in the ordinary catheter, for a catheter with a straight bore would not reach the male bladder.

Paul (VI. lix) says:

'But since we often have occasion to wash out an ulcerated bladder, if an ear syringe be sufficient to throw in the injection it may be used, and it is to be introduced in the manner described above. But if we cannot succeed with it we must tie a skin, or the bladder of an ox, to a catheter and throw in the injection through its lumen.'

It is highly improbable that with an ear syringe the injection would have pa.s.sed the triangular ligament and have actually reached the bladder in the male; but the use of the ear syringe may refer to irrigation of the female bladder, and then an ear syringe would suffice.

_Blacksmith's Bellows._