BLEEDING CUPS, CLYSTERS, ETC.

Bleeding Cups.

Greek, s???a, ??a???; Latin, cucurbitula.

The extraction of blood by means of cups has been practised from remote antiquity. The Hindoo Vedas mention it, and it is interesting to note that one of the methods was to apply a gourd with fire in it, for both the Latin cucurbitula and Greek s???a signify a gourd. The usual theory as to its action was that in a diseased part there was a vicious p?e?a which required removal.

Celsus (II. xi) thus describes the different kinds of cups:

Paul says:

From Oribasius (Med. Coll. VII. xvi) we learn that sometimes the lips were flat (?p?peda t? ?e??ea) and sometimes concave (ses????a t? ?e??ea). This does not, however, mean that the border was guttered, but that the whole lip instead of lying in one plane was arched.

From a passage in Aretaeus we learn that one reason for the cup being bellied out above was that there was oil floating free in the instrument, which might otherwise escape and scald the patient. Aretaeus says:

Antyllus says there are three materials of which cups are made, glass, horn, and bronze. He rejects the silver ones because they heat too readily. The bronze are the ones most commonly used. Glass is used where we wish to mark the quantity of blood extracted. Horn ones are useful about the head, where bronze ones would be difficult to remove, and also in the case of nervous persons who dread the flame. Bronze and glass cups may be used without flame like horn ones if a hole is bored in the summit and the air sucked out, and the finger or a piece of wax is applied immediately (Oribasius, Collect. VII. xvi).

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. XXXIII.

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

There are four very small cups in the museum at Mainz. These are 2·5 to 3 cm. in height and 3 to 3·5 cm. in diameter. Two of these are shown in Pl. XXXVI, figs. 1, 3.

There are ten cups of glass in the Athens museum. They are of the general shape of the Mainz cups, but vary in height from 4 cm. to 6·8 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. XXXVII, 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 glass, specially shaped and worked by suction. Pl. XXXVI, fig. 2 shows the shape illustrated 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. XXXVII, fig. 2) shows a cup of ordinary flattened form, divided into two by a diaphragm. Two tubes pass through the fundus, one passing 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 passage from Heister (anno 1739) is interesting as showing exactly the method of its manipulation:

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:

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

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. xxxii we learn that the injection pipe varied in length also, for Oribasius says that in making injections into the rectum 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 rectum unless this is done (Oribas. viii).Hippocrates (ii. 276) mentions inflation of the rectum 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. XXXVIII, fig. 2).

Vaginal and Intrauterine Clysters.

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

It is difficult to separate ancient descriptions of injections into the vagina 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 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. XXXVIII, 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 passages 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 vaginal 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:

It is highly improbable that with an ear syringe the injection would have passed 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.

Greek, f?sa.

In cases of volvulus, Hippocrates bids us insert a purgative suppository and administer an enema. If these means are not successful:

Nasal Syringe.

Greek, ???e???t??; Latin, rhinenchytes.

A special nasal syringe with a double tube is mentioned by Aretaeus (ed. Adams, vol. ii. 459). The medicament is made into liquid form and is injected by means of a nasal pipe. The instrument consists of two pipes united together by one outlet so that we can inject by both at one time, for to inject each nostril separately is a thing which could not be borne.

Galen also mentions a nasal syringe (???e???t??), though he does not describe it (xi. 125).

Scribonius Largus also mentions it:

Aspiration Syringe and Sinus Irrigator.

Greek, p???????.

Galen (xi. 125) says:

This passage shows that the pyulcus differed in principle from the syringe formed by fixing a bladder on a tube. Hero (De Spiritalibus, c. 57) shows that it was a syringe formed of a cylinder of metal with a well-fitting plunger.

Hero says:

Note that Hero’s description does not tally with the drawings which accompany the edition of his works which we possess (Pl. XXXVIII, figs. 3, 4, 5). These show an instrument with a piston formed by a plug at the end of a rod, whereas Hero says the piston is to be formed of a second tube fitting inside the first. This is interesting, because it is much easier to get a well-fitting piston in this way than in the other; and this principle has been reverted to in many of our best hypodermic syringes and in some of the best air pumps, such as Edwards’s.

Ear Syringe.

Greek, ?te???t??, ?t???? ???st??; Latin, oricularius clyster.

The ear syringe is very frequently referred to by both Greek and Latin writers; in fact, Celsus uses the term so often to denote a syringe for a large variety of uses that it is evident that it is almost a general term for any small syringe.

In addition to its use in washing out the ear in cases of foreign bodies, impacted cerumen, &c. he uses it to wash out the foreskin in balanitis, to syringe fistulae, to wash out the bladder through a lithotomy wound, &c.

In cases of foreign bodies in the ear he says:

Aetius and Paul tell us it was used to wash out the vagina, and Paul says it might be used to make injections into the bladder. Oribasius says:

From a consideration of the various uses to which this instrument was put, and from the fact that it is contrasted at times (e. g. in Paul, VI. lix) with syringes formed by adding a bladder to a tube, I am of the opinion that this instrument, like the pyulcus, was a syringe of the form of a metal cylinder with a plunger like the ear syringe of to-day, and used, as the ear syringe was a few years ago, for flushing sinuses and irrigating wounds, and as a handy instrument for all general purposes of the kind. This is borne out by the fact that the ear syringe, described in detail by Albucasis (p. 157), is a cylinder of bronze or silver, wide above and narrowed to a point with a small opening in it and with a well-fitting plunger wrapped with a little cotton at one end. His figure, though quite intelligible, is too conventionalised to give any additional information.

Insufflator for Powder.

Insufflation in powder form was a common method of applying medicaments to the throat and nose. All writers mention this, but the fullest description of the tube used is given by Oribasius, who says (Collect. xii):

Alexander Trallianus (IV. viii) describes the insufflation of the woolly hairs of the platanus to stop epistaxis, and Aretaeus mentions the insufflation of sternutatories (459, vol. ii), and again (408, vol. ii) he says medicines may be blown into the pharynx by a reed, or quill, or wide long tube (?a??? ? pt??? ? ?a??? pa?e? ?a? ?p???e?).A fine example of a bronze insufflator was discovered among the instruments of the surgeon of Paris. It is 15½ cm. in length, and 5 mm. in diameter. It is formed by a plate of bronze bent round and soldered. It terminates in a little elliptical shovel slightly cup-shaped, of which the transverse diameter is 3 cm. and the longitudinal 3 mm.; it had originally been overlaid with gold (Pl. XL, fig. 4).

Cannulae for draining Ascites and Empyema.

Celsus describes the cannula for draining ascites (VII. xv):

The following passage from Paul shows that the tip was bevelled off like a writing pen:

Two instruments answering to the above description are to be seen in the museum on the Capitol at Rome.

Another, answering more closely to the description of Celsus, is to be seen at Naples (Pl. XXXIX, fig. 2). It consists of a bronze tube, 9 cm. in length, 7 mm. wide at one end, narrowing to 4 mm. at the other end, which is bevelled off as described by Paul. Surrounding the tube and 2·5 cm. from the bevelled tip is a ring 2·5 cm. in diameter.

A more elaborate form of the cannula for ascites is seen in another specimen, also in the Naples Museum (Pl. XXXIX, fig. 3). A tube 6·5 mm. in diameter and 39·2 cm. long, has one end rounded and closed, except for a small hole in its tip and another in the side near the first. The other end carries a circular plate 2·5 cm. in diameter. Near the middle of the tube there is a slightly raised projection as if to carry a circular disc. Inside the cannula is fixed by oxidation an obturator, which carries on its end a small handle fixed on in T-fashion. Scoutetten described this to the Royal Academy of Medicine of Paris as a trocar and cannula, but the formation of the end is not such that the instrument could have pierced its own way through. It is rather an instrument which could be inserted in an incision made by a scalpel, and which could be closed after the abstraction of a certain amount of fluid—the obturator acting as an improvement on the pledget of wool described by Celsus—but otherwise inserted like the previous example. A tube on similar principles to the ascites cannula was employed in empyema (Hippocrates, ii. 259):

Tubes to prevent Contractions and Adhesions.

Greek, ?t?? ??????; Latin, plumbea fistula.

After operations on the nose, rectum, vagina, &c. it was usual to insert a tube of lead, bronze, or tin, to prevent contraction or adhesion and also to convey medicaments.

Celsus says that after the operation for occlusion of the vagina a tube of lead is to be inserted during cicatrization:

A similar tube is recommended by Celsus and Paul for insertion after operations on the rectum and vagina. Hippocrates (ii. 244) and Paul (VI. xxv) direct a leaden tube to be inserted in the nostril after the abstraction of nasal polypus.

After dilation of the cervix uteri a hollow tube was put in to keep it open. The tube was also filled with medicaments which were intended to have a beneficial effect on the interior of the uterus. The fullest description of this is given by Hippocrates (ii. 799). After describing the dilation of the womb with graduated dilators, he says:

‘It is necessary to insert a leaden tube, similar in shape to the largest dilator but hollow so as to contain substances, and the width of the bore will be the same as that used for ulcers, in order that the mouth of the tent may be smooth and do no damage, and it will be prepared like the wooden dilators. When the tent has been prepared fill it with rubbed down mutton fat, and when ready extract the wooden dilator and insert the leaden one.’