?pt??? ?ata????a? t?? ?????p?? ?at?pt??? ?at?d?? t? d?ae?????? t?? ?????.

'Laying the patient on his back and examining the ulcerated part of the bowel by means of the rectal speculum' (iii. 331).

Again, a little further on, he mentions its use in the treatment of piles; and Paul (VI. lxxviii) says:

'With regard to blind fistulae Leonidas says: "We dilate the a.n.u.s, as we do the female v.a.g.i.n.a, with the a.n.a.l or small speculum"' (t?

?d??d?ast??e? (t? ???? d??pt??? ????) d?aste??a? t?? ?d?a? ?? ???a??e??? ???p??).

There is a rectal speculum in the Naples Museum (No. 78,031). It is a two-bladed instrument, working with a hinge in the middle. It is O15 m.

in length, and the greatest stretch of the blades is O07 m. It represents an instrument used to dilate the v.a.g.i.n.a as well as the r.e.c.t.u.m, and got its name 'small dilator' in contradistinction to the other v.a.g.i.n.al speculum, which we shall see was worked by a screw, and was called the speculum magnum. The rectal speculum was also called ?at?pt??, in contradistinction to the v.a.g.i.n.al speculum which was called d??pt?a. In Galen's Lexicon they are explained as follows:

?at?pt???, t? ?a?????? ?d??d?ast??e?, ?spe? ?e ?a? d??pt?a ? ???a???? d?ast??e??.

'The catopter, which is called the a.n.a.l dilator, in the same way as the diopter is called the female dilator.'

Pl. XLVI, fig. 1 shows one of two similar rectal specula from Pompeii (Naples Museum).

_v.a.g.i.n.al Speculum._

Greek, d??pt?a; Latin, _speculum magnum matricis_ (late).

Sora.n.u.s is the first author who makes mention of the speculum specially made for the v.a.g.i.n.a. The original Greek of this chapter of Sora.n.u.s is lost, but we have a Latin translation of it preserved to us by Moschion.

The heading of this chapter in Sora.n.u.s, which was No. x.x.xiv, was ?e??

d??pt??s??. I shall give part of this chapter from Moschion:

QUA DISCIPLINA ORGANO APERIENDAE SINT MULIERES.

Scio me retro ad inspiciendam alt.i.tudinem mulieris frequentius organi mentionem fecisse quod Graecitas dioptran vocat. Et quoniam nisi insinuata fuerit disciplina quatenus hoc ipsud fieri possit, occurrente necessitate obstetrices facere non audent, idcirco placuit n.o.bis ut etiam hoc gynaeciis adderemus, ut ex rebus huic corpori necessariis nihil dimisisse videamur. Itaque supinam iactans eam quae inspici habet, accipies fasciam longam et in media parte eius duobus laqueis factis, ita ut inter se cubitum unum habeant laquei illi, duabus vero manibus mulieris missis, medietatem quae interest cervici eius inducis. Deinde reliqua fasciae sub anquilas missa ad ma.n.u.s alligabis, ita ut patefacti pedes ventri eius cohaereant. Deinde accepto organo et uncto priapisco, quem Graeci loton dic.u.n.t, in aliquantum ad prunas calefacere (debes), deinde sine qua.s.satione priapisc.u.m inicere, susum scilicet axe posito, iubere etiam ministro ut aperiendo organo axem torquere incipiat, ut paulatim partes ipsae aperiantur. c.u.m vero post visum organo tollere volueris, ministro iubere ut iterum axem torqueat quo organum claudi possit, ita tamen ut c.u.m adhuc in aliquantum patet sic auferatur, ne universa clusura aliquas teneat et nocere incipiat.

We have also preserved by Paul a chapter by Archigenes on abscess of the womb (VI. lxxiii), in which the different parts of the speculum are again named, and from it also we learn that there were different sizes of the instrument proportioned to suit different ages. The patient having been fixed in the lithotomy position in the manner described by Sora.n.u.s:

'The operator is to make the examination with a speculum (d??pt?a) proportioned to the age of the patient. The person using the speculum should measure with a probe the depth of the woman's v.a.g.i.n.a, lest the priapiscus of the speculum (t?? t?? d??pt?a? ??t??) being too long it should happen that the uterus be pressed on. If it be ascertained that the tube is longer than the woman's v.a.g.i.n.a, folded compresses are to be laid on the l.a.b.i.a in order that the speculum may be laid on them.

The priapiscus is to be introduced while the screw (t?? ???????) is uppermost. The speculum is to be held by the operator. The screw is to be turned by the a.s.sistant, so that the blades of the tube (t??

?p??s?t?? t?? ??t??) being separated, the v.a.g.i.n.a may be expanded.'

We have little difficulty in recognizing among the instruments found in Pompeii three of the v.a.g.i.n.al specula referred to in these pa.s.sages. All are excellent specimens of the instrument maker's skill. They are in the Naples Museum. The first discovered (No. 78,030) was found in the house of the physician at Pompeii. The blades are at right angles to the instrument (Pl. XLVII), and when closed form a tube the size of the thumb. On turning the screw a cross-bar forces the two upper blades outwards, till sufficient dilation is got for operative purposes. The diameter of the tube at its maximum of expansion is 009 m. The whole instrument is 023 m. long. Another instrument on a similar principle but with a quadrivalve priapiscus was discovered in 1882 (Pl. XLIX). It is 0315 m. long. It is now fixed by oxidation, so that the blades cannot be moved. On turning the screw the lower blades could be drawn downwards, at the same time separating slightly, while the upper blades diverged also (No. 113,264 Naples Mus.). Lately a third, similar to that shown in Pl. XLVII, has been found in Pompeii. Note that the screw in the three-bladed instrument is a left-handed one. That in the four-bladed instrument is right-handed. This causes right-handed motion to open the instrument in either case. There is, however, an instrument similar to these trivalve instruments in the museum at Athens. It differs in having the screw right-handed (Pl.

XLVIII). Mr. Bosanquet, late of the British Inst.i.tute of Archaeology at Athens, was kind enough to procure me a photograph of this instrument, but he tells me that there is no satisfactory account of its provenance and its authenticity is doubtful. It seems possible that it is a copy of one of the Naples specimens by some one who has omitted to observe that the screw in these is left-handed.

_Traction Hook for Embryo._

Greek, ?????????; Latin, _uncus_.

Celsus has an interesting chapter on the removal of the foetus in difficult labour. He says (VII. xxix):

Tum, si caput proximum est, demitti debet uncus undique laevis, ac.u.minis brevis, qui vel oculo, vel auri, vel ori, interdum etiam fronti recte iniicitur; deinde attractus infantem educit. Neque tamen quolibet is tempore extrahi debet. Nam, si compresso v.u.l.v.ae ore id tentatum est, non emittente eo, infans abrumpitur, et unci ac.u.men in ipsum os v.u.l.v.ae delabitur; sequiturque nervorum distentio, et ingens periculum mortis. Igitur, compressa v.u.l.v.a, conquiescere; hiante, leniter trahere oportet; et per has occasiones paulatim eum educere.

Trahere autem dextra ma.n.u.s unc.u.m; sinistra intus posita infantem ipsum, simulque dirigere eum debet.

'Then if the head presents there ought to be inserted a hook, smooth all round, with a short point which is properly fixed in the eye or the ear or the mouth, sometimes even in the forehead, which being drawn on extracts the child. Nor is it to be drawn on without regard to circ.u.mstance. For if the attempt is made with an undilated cervix, not getting exit the foetus is broken up, and the point of the hook catches on the cervix and inflammation follows and much danger of death. Therefore, it is necessary with a contracted cervix to wait quietly, with a dilated one to make gentle traction, and during these times to extract it gradually. The right hand ought to make the traction on the hook, the left place inside to draw the child and at the same time to direct it.'

The following pa.s.sage in Sora.n.u.s shows that it was customary also to insert a second hook opposite the first and to make traction on both at the same time:

'The best places for the insertion of the hooks are in head presentations, the eyes, the occiput, and the mouth, the clavicles, and the parts about the ribs. In footling cases the p.u.b.es, ribs, and clavicles, are the best. Warm oil having been applied as a lubricant the hook is to be held in the right hand; the curvature concealed in the left hand is to be carefully introduced into the uterus, and plunged into some of the places mentioned till it pierce right through to the hollow part beneath. Then a second one is to be put in opposite to it (?atape??e?? d? ?a? ??t??et?? t??t? de?te???), in order that the pulling may be straight and not one-sided' (II. xix).

Aetius (IV. iv. 23) and Paul (VI. lxxiv) copy this.

Hippocrates (ii. 701) bids us break up the head with a cephalotribe in such a way as not to splinter the bones, and remove the bones with bone forceps; or, a traction hook (t? ????st???) being inserted near the clavicle so as to hold, make traction but not much at once, but little by little, withdrawing and again inserting it.

There are three traction hooks from Pompeii in the Naples Museum. One of these is given in Pl. L, fig. 1. They are of steel, with handles of bronze. Hooks on the same principle, and differing in appearance very little from the Pompeian hooks, are still used by veterinary surgeons.

_Decapitator._

Of transverse presentations, Celsus says:

Remedio est cervix praecisa; ut separatim utraque pars auferatur. Id unco fit, qui, priori similis, in interiore tantum parte per totam aciem exacuitur. Tum id agendum est ut ante caput deinde reliqua pars auferatur.

'The treatment is to divide the neck so that each part may be extracted separately. This is done with a hook which, though similar to the last, is sharpened on its inside only, along its whole border.

Then we must endeavour to bring away the head first, and then the rest of the body.'

Decapitation has now given way before Caesarean section; but the decapitator, little altered since the days of Celsus, still finds a place in surgical instrument catalogues.

Paul and Aetius both mention division at the neck, but do not describe a special instrument. A ring knife for dismembering the foetus has already been discussed among the cutting instruments; but this seems to be a different variety with a handle, which it is convenient to discuss in proximity to the embryo hook. Pl. L, fig. 2 shows a knife on this principle in the Bibliotheque Nationale.

_Cranioclast._

Greek, p?est???, ???????st??, ???st??;

The cranioclast is mentioned by Hippocrates (ii. 701).

S??sa?ta t?? ?efa??? a?a???? ??p??sa? ??a ? ??a?s? t? p??st?? ?a?

t? ?st?a ???e?? t? ?ste?????.

'Opening the head with a scalpel, break it up with the cranioclast in such a way as not to splinter it into fragments, and remove the bones with a bone forceps.'

The nature of the cranioclast is pretty well indicated by this pa.s.sage, and in Galen's Lexicon we find p??st?? defined as t? ???????st?

?a??????. I give drawings from Albucasis of a 'forceps to crush the child's head' (Pl. LI, fig. 3).

_Cephalotribe._

Whether or not the instrument last described was used also for the operation of cephalotripsy, or whether there was a special instrument, we cannot say, but it is certain that the operation of crushing the head and delivering the child without removing the bones was practised. In Aetius (IV. iv. 23) cephalotripsy is thus described:

'But if the foetus be doubled on itself and cannot be straightened, if the head is presenting, break up the bones of it without cutting the skin. Then to some part of it fix on a traction hook and make traction, and the legs becoming straightened out we get it away.'

Though there is an essential difference between the operations of cephalotripsy and cranioclasie there is no essential difference between the instruments necessary for carrying out the same, and it is possible that the instrument used may be the same as the last. The cephalotribe figured by Albucasis is not essentially different from his cranioclast (see Pl. LI, fig. 4).