The Gynaecological speculum - past, present and future
The Gynaecological speculum - past, present and future |
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Key words: History, speculum, obstetrics and gynaecology
Introduction
Speculum in obstetrics and gynaecology, is one of the most important diagnostic
tools in everyday practice, constituting an essential instrument for pelvic
examination. Galen (130 - 200 AD) is attributed the honour of introducing the
first specula which were found in the excavations of Pompeii. The present day
instruments followed the development of bivalve speculum in the eighteen century
by Heisler 1768 and Brambilla 1782 and latterly with the introduction of double
ended duckbill speculum by James Marion Sims in 1845.
Early days
Speculum is an instrument for dilating an orifice to allow for examination of
the passage or cavity beyond. The word speculum is of latin origin (speculum - a
mirror: specere - to look at) and has evolved from the idea of a human hand with
the fingers closed in a cone shape for introduction and spread outwards for
exploration1.
In obstetrics and gynaecology, the design of speculum is usually with two opposing portions that after being inserted can be pushed apart for examining the vagina and the cervix. There are, of course, other shapes and designs to suit the different purposes of obstetrical and gynaecological examination. There is ample evidence from Graeco-Roman texts and inscriptions that obstetrics and gynaecology were important areas of ancient medicine and invariably speculum was undoubtedly one of the most important diagnostic tools used in everyday practice2. The origin of vaginal speculum has become incorporated in the mists of antiquity and revered medical authors of the past. Hippocrates, Galen or Soranus made reference to the instrument. Deep in the folklore of lay and scholarly writings of Egyptians, Greeks and Romans, it is obvious that the instrument was available and used in their time. It must have been available to the ancient Jews, long before the Christian era. The first evidence that a speculum was used in antiquity is found in the Talmud about 1300B.C., some 800 years before Hippocrates. This speculum was a cylinder made initially of bamboo or the stem of a gourd and later of metal. The present name of speculum was adopted in the Roman era, and it was Galen (AD 130-200) who made the first record of a speculum3. In 1818 in the excavation of Pompeii two specula were found which were estimated to have been buried in AD 79. These were bronze dilators; one with three and the other with four blades which diverged when a centrally located screw is turned and they were used in the time of Galen and Celsus (27 BC to A.D.50) and very likely in the Middle Ages. At about the second century, speculum was described in several medical books of the time. Soranus of Ephesus, Arateus, Archingenes, Aspasia and Leonido, are few of the physicians who recognised the association of speculum with anorectal and gynaecological examination. Leonido mentioned the important role of vaginal speculum when he described anal dilatation.
Aetius in the 6th Century and Paulus of Aegina in the 7th century described the first generation of speculum and used the cylinder type of vaginal speculum. They described a conical and a valvular type with a single or several blades. The lithotomy position featured prominently in the famous gynaecological book by Aetius entitled ‘Tetrabiblion’ at this time. Albucasis, an Arabic writer and the first to describe ectopic pregnancy, described in 1085 the next generation of specula made of ebony and boxwood4. From then on many centuries passed with hardly any mention of the speculum.
Modern era
In the sixteenth century Pierre Franco, Ambrose ParÈ, Guillemean, Hans Von
Gersdoff and Jacob Rueffus of Zurich vividly described the use of this
instrument (fig1) purely in gynaecological work, in particular for visualization
of the uterine cervix in cases of cervical cancer.
Fabricius and Johann Scultetus described two and three bladed dilators in the following century. In the eighteenth century, Laurentius Heister in 1753 and Brambilla in 1782, were amongst those who described for the first time bivalve specula as used today. Further developments on design along similar lines were introduced by Cusco, Rizzoli, Chaniere and Trelat. The tubular speculum is probably of equal antiquity to the bladed type and was initially in 1801 a telescopic type - Racamiere or Segala’s speculum, which was afterwards modified by Protheroe in 1830. It was believed at this time that flexibility and efficiency of speculum was dependent on the number of blades. Consequently, David Davis in 1830, introduced a four bladed instrument with a fitting plug, initially made of wood and later of vulcanite. A few years later Columbat devised a speculum with five or six blades on a metal collar. In 1837 a most ingenious invention was made by Beaumont, an English surgeon who afterwards migrated to Canada. It consisted of four or five blades each having its own screw and capable of being opened independently. In the 19th Century a glass bladed speculum was introduced and also Plum and Weiss invented a three bladed dilator which was operated by a screw in the handle and was recommended for both vaginal and rectal examinations. Robert Fergusson who was the first Professor of Obstetrics and Gynaecology at King’s College Hospital, London introduced a straight tubular glass speculum. This instrument was initially made of metal only and later modified with glass mirrored inside and several layers of gum-elastic coat outside. The first record of a mirror being used to reflect light into an internal organ is credited to Albucasis who used the device to inspect a cervix5. James Marion Sims (1813-1883) of Women’s Hospital in New York developed the present day speculum. In his time, he was probably best known for his work with repairing vesico-vaginal fistulae originally in slaves, and also being the first to perform artificial insemination in the USA. In 1845 he introduced his double - ended duckbill speculum with the use of which he performed his history making vesico-vaginal fistula repair operation in 1847. His achievement was published in the “American Journal of Medical Science” in 1852 and his name printed in every textbook of gynaecology ever since. Marion Sims also developed two other types of this speculum, the “lever speculum” and the “single detachable blade” speculum used with depressor. There are two versions of how he invented the speculum. The first version was best told by John Allen Wyeth in “with sabre and scalpel” who says:
“ on that eventful day in June 1845, a woman was thrown from horseback. She was carried to her home and when Dr Sims reached her, she complained of great pain in her back and pelvic organs. A careful examination revealed a backward displacement of the uterus. Placing her in the genu-pectoral position (knee chest position) and in the further manipulation to replace the uterus, the accidental advent of atmospheric air dilated the cavity (vagina) and at the same time suddenly restored the uterus to its normal position. The quick eye of the genius at once took in the entire significance of this accident. Almost overcome with his discovery, he said to himself, “if I can accomplish this by the use of the atmospheric pressure, why can I not employ the same agency in attempting to relieve these incurable cases of vesico-vaginal fistula?” Enthused with this idea, he hurried back to his office, stopping only at a hardware store on the way to buy a large pewter spoon and from this was evolved at once the speculum which bears the name of his inventor”. The other version was stated by him in the “history of my life” where he admits that he discovered the speculum by chance.
He says that when journeying to visit a patient at a distance one day, finding he had forgotten his speculum, he stopped at a hardware store and bought a long pewter gravy spoon. By bending each end backwards at right angles, he improvised an instrument which proved to the purpose excellently. Other specula have been developed for more specific role including, an endocervical speculum, disposable - self retaining single bladed and weighted vaginal speculum. An endocervical speculum devised for use with the colposcope in the evaluation of abnormal cytologic smears. Disposable , self retaining single bladed vaginal speculum, consists of a thin elastic plastic sheet, which rolled into the shape of a narrow tube, which can then be introduced into the vagina6. The weighted speculum is a self supporting vaginal speculum for the control of cervical haemorrhage7. Other modifications allowed patients to be examined in bed; have artificial donor insemination or used in the post partum period.8,9,10. The specula of different era is summarised in Table I .
The Future
The main problems with the use of speculum has always been the need for a source
of light, pain to the patient and presumed indecency. The following extract from
Hints to Husbands shows what respectable opinion was like in 1857:
“We allude to the speculum. The adoption of this instrument as we are informed is now becoming general; and its employment plunges its wretched victim, woman, into the lowest depths of infancy and degradation. We will not pollute these pages by describing its methods of action: suffice it to say, that, to the sense of touch, common to all midwifery practices, is added, in its application, that of sight; exposing the most complete of all modesty even in the most abject of all races, invariably conceals”. However, more recent reviews of women’s experiences and preferences during speculum examination revealed predominantly favourable attitudes to both examination and gynaecologists11,12. In particular women appreciated an explanation of the procedure, a warm speculum and a relationship with the doctor showing sensitivity to the women’s feeling at examination. In a more recent study13 embarrassment and apprehension were emotions experienced by 50% of patients at pelvic examination. The speculum examination was uncomfortable to more women than the bimanual examination. However, less than 10% found pelvic examination worse than they had anticipated.
The way forward would be the need for gynaecologists to be sympathetic and become better informed about female psychology and sexuality and adapting to women’s changing needs. The last hurdle is to address the issue of source of light. It should be an easy problem in the current atmosphere of exciting revolutionary development in endoscopic surgery.
Table 1: Specula of different era
Date Type of Speculum Inventor
1300 BC Bamboo cylinder Unkown
Source: Talmud
AD 79 Bronze – three and four bladed dilators Unknown
Found in Pompeii
AD 130-200 First record of speculum Galen; also Celcius, Hippocrates, Soranus, Arateus. Archingenes, Leonardo, Aspasia
6th Century Cylinder type with a valve Aeitus and Parlus of Aegina
1085 Ebony or boxwood Albucasis
16th Century Speculum Matricis (Figure 1) Rueff, Pierre Franco, Pare, Hans Von Gersdoff, Guillemeau
17th Century Three bladed dilators Fabricius and Sculteus
18th Century Bivalve type (Figure 2) (Cusco, Heister and Brambilla
Trelat, Rizzoli, Charriere)
19th Century
1801 Telescopic type Recaimer, Segalas and Prothero
1830 Four bladed type with a fitting plug Davis
1835 Five or six bladed type Columbat
1837 Four or five bladed type with each having Beaumont
its own screw and able to open independently
Bivalve or Duckbill (Figure 3) Ricord
Skeleton bladed type Paltrey
Three bladed type operated by a screw Plum and Weiss
1845 Double ended Duckbill lever type and Marion Sims speculum with detachable blades of various sizes (Figure 4)
1870 Gum elastic tubular type (metal or glass) mirrored inside (Figure 5) Fergusson
1990’s Transparent bivalve speculum Simpler Plastics Ltd. Cardiff
References
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