Surgical Instruments in Greek and Roman Times

CHAPTER IX

BLADDER AND GYNAECOLOGICAL INSTRUMENTS

Catheter.

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

‘When urine is not passed 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 passed 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 sex 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 penis, then we must draw the penis up to the umbilicus (for at this part there is a bend in the passage), and in this position push the instrument onwards. When in the perinaeum it approaches the anus we must bend the penis with the instrument in it down to its natural position, for from the perinaeum to the bladder the passage 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 sex. 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 Petit 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 HÔpital Militaire Romain, planche ix).

The female catheter in the Naples Museum is 0·98 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 classics to the manoeuvre 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??). Soranus (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 classical 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 latitudinis; 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 passage 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 passage 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 passed 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 passage, 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 passage in Paul:

‘Sometimes from the pressure of the finger or fingers at the anus 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 entitle 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 crassitudinis 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 passage 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:

?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 anus, as we do the female vagina, with the anal 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 O·15 m. in length, and the greatest stretch of the blades is O·07 m. It represents an instrument used to dilate the vagina as well as the rectum, and got its name ‘small dilator’ in contradistinction to the other vaginal 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 vaginal 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 anal 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).

Vaginal Speculum.

Greek, d??pt?a; Latin, speculum magnum matricis (late).

Soranus is the first author who makes mention of the speculum specially made for the vagina. The original Greek of this chapter of Soranus is lost, but we have a Latin translation of it preserved to us by Moschion. The heading of this chapter in Soranus, which was No. xxxiv, 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 altitudinem 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 nobis 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 manus alligabis, ita ut patefacti pedes ventri eius cohaereant. Deinde accepto organo et uncto priapisco, quem Graeci loton dicunt, in aliquantum ad prunas calefacere (debes), deinde sine quassatione priapiscum inicere, susum scilicet axe posito, iubere etiam ministro ut aperiendo organo axem torquere incipiat, ut paulatim partes ipsae aperiantur. Cum vero post visum organo tollere volueris, ministro iubere ut iterum axem torqueat quo organum claudi possit, ita tamen ut cum 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 Soranus:

‘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 vagina, 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 vagina, folded compresses are to be laid on the labia 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 assistant, so that the blades of the tube (t?? ?p??s?t?? t?? ??t??) being separated, the vagina may be expanded.’

We have little difficulty in recognizing among the instruments found in Pompeii three of the vaginal specula referred to in these passages. 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 0·09 m. The whole instrument is 0·23 m. long. Another instrument on a similar principle but with a quadrivalve priapiscus was discovered in 1882 (Pl. XLIX). It is 0·315 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 Institute 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, acuminis 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 vulvae ore id tentatum est, non emittente eo, infans abrumpitur, et unci acumen in ipsum os vulvae delabitur; sequiturque nervorum distentio, et ingens periculum mortis. Igitur, compressa vulva, conquiescere; hiante, leniter trahere oportet; et per has occasiones paulatim eum educere. Trahere autem dextra manus uncum; 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 circumstance. 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 passage in Soranus 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 pubes, 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 BibliothÈque 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 passage, 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).

Midwifery Forceps.

Had the Greeks and Romans a forceps for extracting the child alive? Probably not. We have no mention of any such instrument by Soranus or Paul, both accomplished obstetricians, nor can any description of such an instrument be found in the voluminous pseudo-Hippocratic works on women. Adams, in a note to Paul, III. lxxvi, says that though the Roman and Greek writers do not mention the forceps, Avicenna does so, and he says that a forceps was dug up in the house of an obstetrix at Pompeii bearing a considerable resemblance to the modern forceps. The only passage I have met with in the slightest degree supporting the notion that the ancients ever delivered the child alive with instruments is one in the pseudo-Hippocratic treatise De Superfoetatione, where we are told that:

‘If the woman has a difficult labour, and the child delay long in the passage and be born not easily but with difficulty and with the mechanical aids (??a?a??) of the physician, such children are of weak vitality, and the umbilical cord should not be cut till they make water or sneeze or cry’ (i. 465).

We are not entitled to translate ??a?a?? by ‘instruments’, because it may mean any mechanical aid such as a fillet, or even assistance with the fingers of the accoucheur; but, even granting that it refers to instruments, it might mean no more than, e. g., the embryo hooks already described. With them, terrible as they were, the child must frequently have been born alive, though mutilated. A child would have had a far better chance of being born alive with them than with the murderously toothed forceps of Albucasis (Pl. XLI, figs. 3, 4), with which probably no child could have been born alive. As regards the statement that Avicenna knew of the forceps, his directions are that the fillet is to be applied, and, if that fail, the forceps is to be put on and the child extracted with it. If that fail, the child is to be extracted by incision, as in the case of a dead foetus. This passage, says Adams, puts it beyond doubt that the Arabians were acquainted with the method of extracting the child alive with the forceps.

This is, however, not quite correct. A full consideration of Avicenna’s words seems to me to lead to the conclusion that he is describing no more than extraction with a craniotomy forceps. If the forceps fail the child is to be extracted by incision, as in the case of a foetus already dead (and decomposed so that the forceps would not hold).

As regards Adams’ statement that a forceps like ours was dug up in Pompeii one may ask, ‘Where is that forceps now?’ It is certainly not in the Naples Museum, where all the finds from Herculaneum and Pompeii have been stored since the excavations were commenced. Adams has probably been misled by some notice of the ‘Pompeian forceps’ (Pl. XLIII), which many consider adapted for removing the cranial bones when the child’s head is broken up in cephalotripsy. It is, however, a sequestrum forceps.

Uterine Curette.

Hippocrates (ed. Van der Linden, vol. ii, p. 394) says:

If the menses form thrombi ... we must wind the skin of a vulture or a piece of vellum round a curette and curette the os uteri (?a? pe?? ??st?a? pe??e????a? ??p?? d??a ? ???a, d?a??e?? t? st?a t?? ?t????).

??st?a may of course mean the strigil, and some forms of strigil, such as the one shown in Pl. XXV, fig. 1, are not ill adapted for the purpose.

Instrument for destroying foetus in utero.

Greek, ????sf??t??; Latin, aeneum spiculum.

Apart from the destruction of the foetus in criminal abortion, which was so common at Rome in the time of the Empire, we have mention of an instrument for legitimately producing the death of the foetus from humane motives before forced delivery. It is mentioned by Tertullian in his sermon De Anima, and the passage is so interesting that I give it in full. It is, moreover, an example of the unexpected places in which information regarding the surgery of the ancients crops up. Tertullian is arguing that the foetus is alive in utero, and does not, as others hold, simply take on life in the act of birth, and to support his conclusions he uses the following argument:

Denique et mortui eduntur quomodo, nisi et vivi? qui autem et mortui, nisi qui prius vivi? Atquin et in ipso adhuc utero infans trucidatur necessaria crudelitate, quum in exitu obliquatus denegat partum; matricida, ni moriturus. Itaque et inter arma medicorum et organon est, quo prius patescere secreta coguntur tortili temperamento, cum anulo cultrato, quo intus membra caeduntur anxio arbitrio, cum hebete unco, quo totum facinus extrahitur violento puerperio. Est etiam aeneum spiculum, quo iugulatio ipsa dirigitur caeco latrocinio; ????sf??t?? appellant de infanticidii officio, utique viventis infantis peremptorium. Hoc et Hippocrates habuit et Asclepiades et Erasistratus et maiorum quoque prosector Herophilus et mitior ipse Soranus, certi animal esse conceptum, atque ita miserti infelicissimae huiusmodi infantiae, ut prius occidatur ne viva lanietur.

‘Finally there are cases of children that are dead when they are born, how so unless they have also lived? For who are dead unless they have previously been alive? And yet, an infant is sometimes by an act of necessary cruelty destroyed when yet in the womb, when owing to an oblique presentation at birth delivery is made impossible and the child would cause the death of the mother unless it were doomed itself to die. And accordingly there is among the appliances of medical men an instrument by which the private parts are dilated with a priapiscus worked by a screw, and also a ring-knife whereby the limbs are cut off in the womb with judicious care, and a blunt hook by which the whole mass is extracted and a violent form of delivery in this way effected. There is also a bronze stylet with which a secret death is inflicted; they call it the ????sf??t?? (foeticide) from its use in infanticide, as being fatal to a living infant. Hippocrates had this (instrument), Asclepiades and Erasistratus, and of the ancients also Herophilus the anatomist, and Soranus, a man of gentler character. Who, being assured that a living thing had been conceived, mercifully judged that an unfortunate infant of this sort should be destroyed before birth to save it from being mangled alive.’

We have here apparently a different instrument from the embryotome, which we saw was a form of knife. This is a pointed spike-shaped instrument. It must have had much the shape of one of the huge bodkins in the Naples Museum (Pl. LI, fig. 1).

Apparatus for fumigating the Uterus and Vagina.

Fumigation formed an important part of the treatment of all varieties of disease of the uterus and vagina. The notion that the uterus was an animal within the body which could wander about on its own initiative and which was attracted by pleasant smells and repelled by disagreeable smells, was responsible for much of the treatment of gynaecological diseases by the ancients. To make a fumigation, Hippocrates directs us to take a vessel which holds about four gallons (d?? ??t?a?), and fit a lid to it so that no vapour can escape from it. Pierce a hole in the lid, and into this aperture force a reed about a cubit in length so that the vapour cannot escape along the outside of the reed. The cover is then fixed on the vessel with clay. Dig a hole about two feet deep and sufficiently large to receive the vessel, and burn wood until the sides of the hole become very hot. After this remove the wood and larger pieces of charcoal which have most flame, but leave the ashes and cinders. When the vessel is placed in position, and the vapour begins to issue out, if it is too hot wait for some time; if, however, it be of the proper temperature the reed should be introduced into the uterine orifice and the fumigation made. Oribasius, quoting Antyllus (Coll. X. xix) varies the treatment somewhat by placing a vessel similarly prepared underneath an obstetrical chair, which had an opening in the seat, allowing a leaden pipe connected with the tube of the fumigating vessel to be passed into the vagina.

A fumigating apparatus of a more portable nature is mentioned by Soranus (xxiii) who tells us that Strato, a pupil of Erasistratus, used to place in a small vessel of silver or bronze, closed by a cover of tin, herbs of various kinds, and, having adjusted a small tube to the vessel, the mouth of the tube was placed in the vagina, and the vessel was then gently heated. Soranus admits that severe burning might follow this practice if unskilfully used.

Pessaries.

Greek, ??a???, pess??, pess??; Latin, pessum, pessus, pessulum.

Pessaries are frequently mentioned. They are usually bags filled with medicaments and not mechanical supports. However, in ii. 824, Hippocrates says that prolapse of the womb is to be reduced and the half of a pomegranate is to be introduced into the vagina. Soranus says that in prolapse Diocles was accustomed to introduce into the vagina a pomegranate soaked in vinegar. He also says that a large ball of wool may be introduced after reduction, and Aetius, Oribasius, and Paul copy him.

Hippocrates (iii. 331) says that in cases of fistula in ano, after the introduction of a medicated plug of lint, a pessary of horn is to be inserted (??a??? ???e?? ?e?at????). This would appear to be partly to distend the rectum, but partly also most likely to carry medicament, like the leaden tubes full of medicaments which were inserted into the uterus.

A pessary of bronze was found in Pompeii (Pl. LI, fig. 2), and is described by Ceci. It is hollow and has a plate perforated with holes (evidently for stitching it on a band, to fix it round the body). Heister figures a similar instrument. It is impossible to say whether this specimen was intended for rectal or vaginal use.

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