The specimen shown in Pl. XXVIII, fig. 2, from the Naples Museum, is interesting as being stamped with the name of the maker, Acachcolus.

We have now to consider an interesting variation produced by extending the extremity of the blade to one side so as to increase the width of the blade (coudee type). This is a rare type.

Pl. XXIX, fig. 1 represents one of two from the find of the surgeon of Paris. It is 17 cm. long, and the legs of the forceps are 8 mm. wide. The jaws debouch to one side at an obtuse angle for a distance of 2 cm. and end in a fairly sharp point. The jaw is thus increased to 2 cm. in breadth. They are finely toothed. They are concave internally and convex externally. The other forceps was 145 cm. long and 8 mm. wide. The Museum at Naples has a forceps of this type, but having a sliding ring to fix the jaws after they have been applied (Pl. XXIX, fig. 4).

This angled type of forceps may be the one referred to by Paul in his description of the plastic operation on the eyelid for trichiasis (VI.

viii), when he directs us to raise the redundant skin of the lid with a fixation forceps and cut it off with a scalpel (?efa???at??? ?d??, t??t'

?st? p??? t?? pe??f??e?a? t?? ?ef???? ?s?at?s??? ??ate??a?te? t?

pe??tt?? d??a, s???? ?p???pt??s?). It may be noted that this coudee type of forceps has considerable affinity with the type of forceps presently to be described for strangling haemorrhoids and the relaxed uvula, the only essential difference being that the blades are not crossed here.

_Uvula Forceps._

Greek, staf?????a.

In Aetius (II. iv. 12) we have an interesting description of the amputation of the uvula by first crushing it in a forceps so as to prevent haemorrhage and then cutting it off:

'Then inserting a vulsellum and making traction on it, the uvula crusher (t?? staf?????a?) is fitted on about the middle of the uvula or a little below it, and then it is pulled and twisted (by the vulsellum). By the torsion it becomes lifeless and, as it were, snared off; it curls up, becomes livid and comes off without much effusion of blood. Wherefore it is well to wait some time and hold it till the patient can stand it no longer, and then cut it off--the cut being made close to the vulsellum but nearer the tip than to it.'

The staf?????a therefore corresponds in its action to a pile-crusher. This instrument I believe to be represented by the type of forceps shown in Pl.

x.x.x, fig. 1. It is in the British Museum. The two branches of the forceps cross like scissor blades, and at their ends the jaws are formed in such a way as to project forwards and enclose a cavity 1 cm. deep and 18 mm.

long. Over all the forceps is 18 cm. long. The jaws are finely toothed.

There is in the same museum another instrument similar in all respects except that it is 1 cm. shorter, and that in each blade, which is 16 mm.

long (Pl. x.x.x, fig. 2), there is a small hole near the proximal end. A posterior view of a similar instrument is seen in Pl. x.x.xI, fig. 1. It is from the find of the surgeon of Paris. A similar specimen is in the Mainz Museum.

Pl. x.x.xII, fig. 3 shows a smaller specimen from the Naples Museum. It is 11 cm. in length. A large powerful variety with a different arrangement of the handles is seen in Pl. x.x.xI, fig. 2 from a specimen in the Antiquarian Museum at Basle. It is 20 cm. long.

A forceps which I take to be a staphylagra occurs on the coins of Atrax in Thessaly (_circa_ 400 B. C.). The forceps stands alongside a bleeding cup.

The object of the holes in several of the specimens is to permit the insertion of a cord to bind the jaws firmly together, and thus keep up the strangulation of the part for some time, as Aetius directs. The application of a ligature in this way would, of course, not be possible while the instrument was applied to the uvula, but the following pa.s.sage from Leonidas (Paul, vi. 79) shows that the uvula crusher was also used to clamp piles in the same way:

'Having seized the haemorrhoids and held them there for some time with the uvula crusher (staf??????) he cuts them off with a scalpel.'

In such a case the application of a cord to clamp the jaws together would be a distinct convenience. The short variety is more suitable for external operations, as for haemorrhoids; the long variety for manipulations in the throat.

Hippocrates mentions the uvula crusher as one of the instruments necessary for the outfit of the physician (i. 63).

_Forceps for applying Caustic to Uvula._

Greek, staf????a?st??.

A remarkable variety of forceps, of which there is only one extant specimen (which is in the Vienna Museum) is shown in Pl. x.x.xII, fig. 2. It is formed of two branches which cross and are fixed by a rivet near the middle of the instrument. The jaws are 35 cm. long, concave internally, and fit accurately together, enclosing an oval cavity 1 cm. in diameter.

This forceps is, I believe, the one which Paul describes as used for destroying the uvula with caustic. He says (VI. xxi) that if from timidity the patient decline excision of the uvula, we are to take the caustic used for operations on the eyelids, or some such caustic, and fill with it the hollows of the caustic holder for the uvula (t?? staf????a?st?? t??

?????t?ta?), and directing the patient to gape wide, and getting the tongue pressed down with a tongue depressor, we open the instrument sufficiently and grasp with it as much of the uvula as we cut off in the other operation. The medicament must neither be of too liquid consistence, lest it run down from the uvula and burn the adjoining parts, nor very hard, that it may quickly act on the uvula. And if from one application the uvula becomes black this will be sufficient, but if not, we must use it again. In VI. lxxix he says that some, filling the hollows of the staphylocaustes (t?? ?????a? staf????a?st??) with caustic, burn off haemorrhoids in the same way as they do the uvula. An interesting use of this instrument is mentioned by the same author in the chapter above referred to, while describing the method of treating haemorrhoids by the ligature:

'By means of the forceps for applying caustic to haemorrhoids, or the forceps for applying caustic to the uvula (t? a??????d??a?st? ? t?

staf????a?st?), we surround them close to the jaws of the instrument (p??? t? ?e???) with a five-ply thread of lint, and strangle the haemorrhoids separately with this ligature.'

It would seem then that, just as there was a long instrument for crushing the uvula and a short one for crushing haemorrhoids, there were corresponding instruments for cauterizing these parts, probably differing from each other only in the length of the handle.

The pa.s.sage above quoted has given much trouble to the scribes and commentators apparently from a lack of knowledge of the instrument referred to. About a third of the codices omit t? a??????d??a?st?, and Cornarius and Dalechamps reject the words t? a??????d??a?st? ? t?

staf????a?st? as superfluous and interpolated. Apparently they were unaware that both instruments were forceps of similar principle but different lengths, and quite suitable for putting a haemorrhoid on the stretch. The reason why these instruments are preferred, for this purpose, to the staphylagra is apparently that not being toothed like the latter instrument they would be both less painful and less likely to cause bleeding.

_Pharyngeal Forceps._

Greek, ? ??a???????.

Paul (VI. x.x.xii) describes a forceps for removing foreign bodies from the pharynx:

'p.r.i.c.kles, fish-bones and other substances are swallowed in eating and stick in different places. Wherefore such as can be seen we are to extract with the special fish-bone forceps' (t??? ?d??? ??a????????

p??sa???e??????? ??????e?).

This is the only reference to the acanthobolus I have met with, and it gives us no information as to the appearance of the instrument. It is noteworthy, however, that Paul in his chapter on the removal of spiny bodies from the pharynx is copying Aetius, and the instrument Aetius names is an epilation forceps. He says 'bones stick near the tonsil or back of the pharynx and can be seen, and if a considerable part projects out of the tonsil it can be removed with an epilation forceps (t?????a??)'. A forceps of the epilation type, but angled in its length, is figured by Vedrenes. It was found in Pompeii. This forceps is eminently suitable for pharyngeal work (Pl. x.x.xII, fig. 1). Albucasis figures an acanthobolus with an up-and-down, not lateral, movement.

CHAPTER VI

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:

Cucurbitularum vero duo genera sunt; aeneum, et corneum. Aenea, altera parte patet, altera clausa, est; cornea, altera parte aeque patens, altera foramen habet exiguum. In aeneam linamentum ardens coniicitur, ac sic os eius corpori aptatur, imprimiturque donec inhaereat. Cornea per se corpori imponitur; deinde ubi ea parte qua exiguum foramen est ore spiritus adductus est, superque cera cavum id clausum est, aeque inhaerescit. Utraque non ex his tantum materiae generibus, sed etiam ex quolibet alio recte fit. Ac si cetera defecerunt, caliculus quoque, aut pultarius oris compressioris, ei rei commode aptatur. Ubi inhaesit, si concisa ante scalpello cutis est, sanguinem extrahit; si integra est, spiritum.

'There are two kinds of cups, bronze and horn. The bronze is open at one end and closed at the other, the horn, open at one end, as in the previous case, has at the other end a small foramen. Into the bronze kind burning lint is placed, and then the mouth is fitted on and pressed until it sticks. The horn one is placed empty on the body, and then by that part where the small foramen is, the air is exhausted by the mouth, and the cavity is closed off above with wax, and it adheres in the same way as before. Either may advantageously be constructed not only of these varieties of material but of any other substance.

If other things are not to be had a small cup or a narrow mouthed jar will answer the purpose. When it has fastened on, if the skin has previously been cut with a scalpel it extracts blood; but if it be entire, air.'

Paul says:

'When we are about to apply the empty instrument, having placed the limb in an erect position, we fasten it to the side, for if we apply the light above when lying down, the wick falling upon the skin with the flame burns in a painful manner, and for this there is no necessity. It is necessary that the size of the instrument be proportionate to the part to which it is applied, and on that account there is great difference of cupping-instruments with regard to the smallness and greatness of size. Moreover those which are made with longer necks and broader bellies are possessed of a strong power of attraction' (VI. xli).

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 pa.s.sage 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:

'Apply plenty of heat so as to warm the part as well as attract. The cup should be light earthenware (?e?ae??? ???f??) and adapted to the side (?????? t? p?e???), or bronze with flat lips (p???? t? ?e??ea) so as to comprehend the parts affected with pain, and we are able to place inside it much fire with oil, so that it may keep alive for a considerable time. We must not apply the lips closely to the skin, but allow access to the air so that the fire may not be extinguished' (_De Morb. Acut._ i. 10).

Antyllus says there are three materials of which cups are made, gla.s.s, horn, and bronze. He rejects the silver ones because they heat too readily. The bronze are the ones most commonly used. Gla.s.s is used where we wish to mark the quant.i.ty 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 gla.s.s 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).