CHAPTER IX

BLADDER AND GYNAECOLOGICAL INSTRUMENTS

_Catheter._

The catheter is very frequently referred to. Galen (xiv. 787) thus describes it:

'When urine is not pa.s.sed on account of excessive dilatation of the bladder so that it cannot contract, we draw off the urine with a catheter. Therefore an instrument like the Roman letter S is let down into the bladder by the urethra. A thread is pa.s.sed into it which has in its tip a little wool dipped in urine. Then it is drawn out and the urine follows it like a guide.'

This method of preparing the catheter and the reasons for so doing are discussed at somewhat greater length in the following selection from Paul (VI. xix):

'Wherefore taking a catheter proportionate to the age and s.e.x we prepare the instrument for use. The mode of preparation is this: having bound a little wool round with a thread and introduced the thread by means of a sharp rush into the pipe of the catheter, and having cut off the projecting parts of the wool with a pair of scissors, we put the catheter into oil. Having then placed the patient on a convenient seat and used fomentation, if there be no contra-indication we take the catheter and introduce it direct down to the base of the p.e.n.i.s, then we must draw the p.e.n.i.s up to the umbilicus (for at this part there is a bend in the pa.s.sage), and in this position push the instrument onwards. When in the perinaeum it approaches the a.n.u.s we must bend the p.e.n.i.s with the instrument in it down to its natural position, for from the perinaeum to the bladder the pa.s.sage is upwards, and we must push the instrument onwards till we reach the cavity of the bladder. We afterwards take out the thread fastened into the opening of the catheter, in order that the urine, being attracted by the wool, may follow as happens in syphons.'

It is occasionally, in cases of cancer of the prostate, of service to adopt this proceeding to prevent the eye of the catheter from getting blocked before the bladder is entered, but it is strange that Galen should have fallen into the mistake of thinking that it is necessary to set up a syphon action, as he was well aware of the expulsive power possessed by the bladder; in fact, his explanation of the physiology of urination is almost up to date.

Celsus gives a good description of the catheter both male and female (VII.

xxvi):

Res vero interdum cogit emoliri manu urinam, quum illa non redditur, aut quia senectute iter eius collapsum est, aut quia calculus vel concretum aliquid ex sanguine intus se opposuit: ac mediocris quoque inflammatio saepe eam reddi naturaliter prohibet. Idque non in viris tantummodo, sed in feminis quoque interdum necessarium est. Ergo aeneae fistulae fiunt; quae ut omni corpori ampliori minorique sufficiant, ad mares tres, ad feminas duae medico habendae sunt; ex virilibus maxima decem et quinque digitorum, media duodecim, minima novem, ex muliebribus maior novem, minor s.e.x. Incurvas vero esse eas paulum, sed magis viriles, oportet, laevesque admodum; ac neque nimis plenas neque nimis tenues.

There are fine specimens of the catheter, both male and female, in the Naples Museum. The male catheter is from the 'House of the Physician' in Pompeii. It is 24 cm. in length and is about the size of a No. 11 English.

It has two gentle curves, so that it closely resembles the instrument reintroduced by Pet.i.t in the eighteenth century. See Pl. XLV, fig. 1. A catheter of similar shape, but broken in three pieces, was found by some workmen at Baden in the Seventies. They were given by Dr. Wagner, of Baden, to Mr. Atkinson, M.P., London, and are possibly now in some English collection (Brunner, _op. cit._ p. 42).

In the excavation of the Roman Military Hospital at Baden, 1893, a fragment of a catheter was found, and is now in the possession of M.

Kellersberger. It consists of the curved part of a catheter, and it is 13 cm. long and about the size of a No. 10 English. The curve is considerably greater than that of the Naples specimen (Un Hopital Militaire Romain, planche ix).

The female catheter in the Naples Museum is 098 m. long, and of the same diameter as the male one. It is straight (Pl. XLV, fig. 2).

_Bladder Sounds._

Had the ancients solid bladder sounds? They must have been well aware of the characteristic grating sensation conveyed to the skilled hand on striking a stone with a metal instrument, for we have several references in the cla.s.sics to the manuvre of pushing back, by means of a catheter, a stone impacted in the urethra. Rufus of Ephesus (?e?? ?????s?? ??ste??) says of impacted urethral calculus: 'Those that are stuck fast push back with the catheter if you prefer not to do lithotomy' (??e?d??ta? ??? e? ?

?????? t??e?? ?p?sa? t? a???s??). Sora.n.u.s (II. xviii) says if a stone is the cause of dystocia we must push it out of the neck of the bladder into the bladder with a catheter (?a?et??). The word Rufus uses puts it beyond doubt that a hollow tube is meant, or we might have argued that ?a?et??

did not necessarily mean a hollow tube, since Hippocrates uses it in the sense of a uterine plug (ii. 830). Yet strange to say, the sensation conveyed to the hand and ear on striking a stone with a metal instrument is nowhere definitely given as a cardinal symptom by a cla.s.sical writer.

Rufus describes the symptoms of vesical calculus at length and finishes with instructions for searching the bladder. The word he uses (???s??) at first sight seems to indicate that this was done with a sound, but it turns out to be bimanual rectal examination only which he describes. The use of the sound as a staff in lithotomy, or as a dilator of a strictured urethra, was not known to the ancients, and thus we have no evidence from the literature that a solid bougie existed. Some instruments have come down to us, however, which seem undoubted solid bladder sounds. There are three sounds of bronze in the Naples Museum, which have the identical appearance of our modern bladder sounds. It might be argued that these have not quite the shape of the catheter described by the ancients, but there is an instrument in the Mainz Museum against which even this objection cannot be brought. It is a solid sound of the double curvature described by Celsus, and is identical in shape with the catheter from the Pompeian surgeon's house (Pl. XLV, fig. 3).

_Lithotomy Scoop._

Greek, ?????????; Latin, _uncus_, _ferramentum quo in sectione calculus protrahitur_.

Celsus thus describes the extraction of calculus through a perineal incision by means of a lithotomy scoop:

Quum vero ea patefacta est, in conspectum calculus venit; in cuius colore nullum discrimen est. Ipse si exiguus est, digitis ab altera parte propelli, ab altera protrahi potest; si maior, iniiciendus a superiore parte uncus est, eius rei causa factus. Is est ad extremum tenuis, in semicirculi speciem retusae lat.i.tudinis; ab exteriore parte laevis, qua corpori iungitur; ab interiore asper, qua calculum attingit. Isque longior potius esse debet; nam brevis extrahendi vim non habet. Ubi iniectus est in utrumque latus inclinandus est, ut appareat an calculus teneatur; quia si apprehensus est, ille simul inclinatur.

'When it is opened there comes into view the calculus, the colour of which is unmistakeable. If it is small it is to be pushed by the fingers from one side and pulled from the other. If too large the hook for the purpose is to be put in above it. The hook is slender at the end and flattened out in the shape of a semicircle, smooth externally where it comes in contact with the tissues, rough internally where it meets the calculus. The hook should be pretty long, for a short one has no power of extraction. When it has been inserted it should be inclined to either side, so that it may be seen whether the calculus is caught, because if it is held it also is inclined to the side'

(VII. xxvii).

The above pa.s.sage gives a very complete account of the lithotomy scoop.

The only thing it leaves undecided is the breadth. Was it a broad, spoon-like scoop, or was it a hook-like instrument? That the latter was the case is proved by the following pa.s.sage also from Celsus (VII. xxvi):

Nonnunquam etiam prolapsus in ipsam fistulam calculus: quia subinde ea extenuatur non longe ab exitu inhaerescit. Eum, si fieri potest, oportet evellere vel oriculario specillo, vel eo ferramento quo in sectione calculus protrahitur.

'Sometimes also a stone slips into the urethra itself and lodges near the meatus, because at that part there is a constriction. It should if possible be extracted either with an ear probe, or with the instrument for the extraction of calculus in lithotomy.'

This shows that the scoop must have been quite a narrow instrument, or it could not have pa.s.sed into the urethra. It must have had very much the same appearance as the modern 'Ferguson's Scoop'. We have two extant specimens of the ancient lithotomy scoop in the Naples Museum, one of which is shown in Pl. IV; and in the marble _ex voto_ tablet in the Athens Museum, to which I have already referred, there is a representation of a manubriolus curved so as to serve as a lithotomy scoop (Pl. XLVI, fig. 2).

Rufus of Ephesus mentions this form of scalpel handle.

_Lithotomy Forceps._

Was there a forceps for extracting calculus from the bladder? The sixteenth-century translation of Aetius (IV. iv. 94) by Cornarius has the following pa.s.sage, under the treatment of calculus in the female:

Et tunc paululum supra pudendi alas, quo loco calculus occurrit sectionem facito et per calcularium forcipem extrahito.

The original Greek of this part of Aetius has not yet been published, but from a pretty intimate knowledge of Cornarius's methods I have a strong suspicion that 'calcularium forcipem' may be a free translation of ?????????, as in the following pa.s.sage in Paul:

'Sometimes from the pressure of the finger or fingers at the a.n.u.s the stone starts out readily at the same time as the incision is made, without requiring extraction. But if it does not of itself start out we must extract it with the instrument called the stone extractor'

(t?? ?????????) (VI. lx).

Adams translates ????????? by 'forceps for extracting stone', but this is not quite a justifiable translation. The instruments whose names end in -??????, and which are derived from ????, are certainly in many instances forceps, e. g. e???????, a forceps for extracting weapons, but in other cases they are as certainly not. I need only refer to ?????????, which is conclusively described as a hook for extracting the dead foetus. Thus while it is possible that the ????????? may have been a forceps, the etymology of the word does not ent.i.tle us to translate by any term more definite than 'stone extractor'. Galen (xiv. 787) uses the word ????????, which has a more definite meaning. The majority of words compounded of -???? means some variety of forceps, e. g. sa???????, tumour vulsellum.

The etymological evidence thus leaves the matter open, with a slight balance in favour of there having been a forceps. I should have had no hesitation in translating ???????? to mean a forceps, had it not been that Celsus evidently had no cognizance of a stone forceps. Galen, however, lived after Celsus, and we may note that the Arabians used such an instrument. Albucasis says that if the stone does not start out it must be seized with a forceps or a hook, and failing removal by these means it is to be broken up with forceps. One forceps in the Naples Museum, from the house of the physician, seems to be suited for the operation (Pl.

XLVI, fig. 3). The handles are short in proportion to the blades, and it seems better suited to grasp some substance inside the bow than between the jaws. The unfinished condition of the tips of the handles indicates that they had been inserted into handles of wood.

_Lithotrite._

Latin, _ferramentum_.

A sort of chisel by which a calculus was split is thus described by Celsus:

Si quando autem is maior non videtur nisi rupta cervice extrahi posse, findendus est; cuius repertor Ammonius ob id ????t??? cognominatus est. Id hoc modo fit: uncus iniicitur calculo sic ut facile eum concussum quoque teneat, ne is retro revolvatur; tum ferramentum adhibetur cra.s.situdinis modicae, prima parte tenui, sed retusa, quod admotum calculo, et ex altera parte ictum, eum findit.

'If at any time it seems too large and impossible to be extracted without splitting the cervix, it is to be split. The originator of this is Ammonius, hence called the lithotomist. It is performed in this manner. A scoop is put over the calculus in such a way that it easily holds it even when struck from sliding back; then there is applied an instrument of moderate thickness, slender at the tip, but blunt, which being placed against the calculus and struck on the other end splits it' (VII. xxvi).

The above paragraph really gives us all the information we possess about the instrument. It is evidently a slender chisel. A pa.s.sage in Aretaeus (_Morb. Chron._ ii. 9) is held by some to refer to lithotripsy (digital).

The reading, however, is dubious.

_Rectal Speculum._

Greek, ?d??d?ast??e??, ????? d??pt????, ?at?pt??.

The earliest mention of the rectal speculum is to be found in the treatise on fistula by Hippocrates: