On the Shoulders of Giants
From the earliest days of recorded medical history, physicians struggled with the problems of pelvic organ prolapse ( Fig. 1.1 ), urinary incontinence, and vesicovaginal fistula. An inadequate understanding of pelvic anatomy plagued practitioners prior to the nineteenth century. Ignorance of asepsis, the absence of anesthesia, faulty suture materials, inadequate instrumentation, and suboptimal exposure delayed any consistent success until the mid-nineteenth century.
The evolution of pelvic surgery from the Hippocratic age to the antiseptic period is a fascinating one in which original theories occasionally fell from favor only to be resurrected and popularized by subsequent generations. Equally intriguing is the development of a wide array of innovative instrumentation and materials that often paralleled many surgical advances. This chapter is an attempt to touch upon the milestones that occurred along the way and to pay homage to the pioneers who helped shape a specialty and upon whose shoulders we stand. The author’s selection of important milestones in our specialty up to 1961 is shown in Box 1.1 . Note that this chapter emphasizes American contributions and milestones that influenced contemporary thought, patient care, and surgical practices. We are grateful for the works of Dr. Thomas Baskett, Dr. James V. Ricci, and, particularly, to Dr. Harold Speert, whose extensive research on the subject made this chapter possible.
| Second half first century CE Soranus ( De Morbis Mulierum ) first good description of the human uterus. | |
| 1561 | First accurate description of the human oviduct. Observationes Anatomicae by Gabriele Falloppio. |
| 1672 | First accurate account of the female reproductive organs and ovarian follicles (“Graafian follicles”) De mulierum Organis Generationi inservientibus by Reinier de Graaf. |
| 1677 | Description of the vulvovaginal glands, “Bartholin glands.” De Ovariis Mulierum by Caspar Bartholin. |
| 1691 | Description of the female inguinal canal. Adenographia by Anton Nuck |
| 1705 | Francois Poupart describes the inguinal ligament and its function. |
| 1727 | Jacques Garengeot modifies a trivalve speculum to better differentiate “vaginal hernias” during pelvic examination. |
| 1737 | Description of the peritoneum and posterior cul-de-sac. A Description of the Peritoneum by James Douglas. |
| 1759 | Description of the embryonic mesonephros or “Wolffian body and duct.” Theoria Generationis by Caspar Friedrich Wolff. |
| 1774 | William Hunter completes his monumental work, Anatomy of the Gravid Uterus, which remains the finest work on uterine anatomy to date. |
| 1801 | Joseph Claude Récamier popularizes the use of a tubular vaginal speculum to treat ulcers and infections of the vagina and cervix. |
| 1803 | Pieter Camper describes the superficial layer of abdominal fascia. |
| 1804 | Astley Paston Cooper describes the ligamentous covering of the pubis and its condensation above the linea ileopectinea as it extends from the pubis outwards. |
| 1809 | Ovariotomy performed by Ephraim McDowell. |
| 1813 | Conrad Johann Martin Langenbeck carries out the first planned and successful vaginal hysterectomy. |
| 1825 | Marie Anne Victoire Boivin devises the bivalve vaginal speculum. |
| 1836 | Charles Pierre Denonvilliers describes the rectovesical fascia. |
| 1838 | John Peter Mettauer uses lead sutures to perform the first surgical correction of vesicovaginal fistula in the United States. |
| 1849 | Anders Adolf Retzius describes prevesical space. |
| 1852 | James Marion Sims describes his knee-chest positioning of patients for vesicovaginal fistula repair. |
| 1860 | Hugh Lenox Hodge details the use of his pessary to correct for uterine displacement. |
| 1877 | Léon Le Fort describes his method of partial colpocleisis as a simple and safe means for treatment of uterine prolapse. |
| 1877 | Max Nitze introduces an electrically illuminated cystoscope. |
| 1878 | T. W. Graves designs a speculum that combines features of both bivalve and Sims specula. |
| 1879 | Alfred Hegar introduces his metal cervical dilator to replace laminaria. |
| 1888 | Archibald Donald and William Fothergill collaborate to develop the Manchester procedure for uterine prolapse. |
| 1890 | Friedrich Trendelenburg describes his technique for positioning patients to facilitate the transvesical approach in the repair of vesicovaginal fistula. |
| 1893 | Howard Atwood Kelly devises the air cystoscope for inspection of the bladder and identification and catheterization of the ureters. |
| 1895 | Alwin Mackenrodt provides a comprehensive and accurate description of the pelvic connective tissue and correlation with pelvic prolapse. |
| 1898 | Ernst Wertheim performs radical hysterectomy for cervical cancer. |
| 1899 | Thomas James Watkins performs his “interposition” operation for treatment of uterine prolapse associated with cystocele. Thus, the uterus is brought forth through an anterior colpotomy incision and sutured to the anterior vaginal wall and the cervix secured posteriorly. The markedly anteverted uterus essentially pivots on twisted broad ligaments thus producing antagonistic forces, because any dropping of the bladder increases the anterior displacement of the uterus and any prolapse of the uterus elevates the cystocele. |
| 1900 | David Todd Gilliam describes his method of uterine ventrosuspension whereby he ligated the proximal round ligament and attached it to the anterior rectus sheath lateral to the rectus muscle. |
| 1900 | Hermann Johannes Pfannenstiel introduces a transverse incision for laparotomy. |
| 1901 | Alfred Ernest Maylard advocated oblique transection of the rectus muscles to improve exposure. |
| 1901 | John Clarence Webster and John Baldy introduce their suspension technique for correction of uterine retroversion whereby the proximal round ligament is brought under an opening made under the utero-ovarian ligament and ultimately secured at just above the uterosacral ligament. |
| 1909 | George Reeves White notes that certain cases of cystocele are due to lateral, paravaginal defects and thus could be repaired by reconnecting the vagina to the “white line” of the pelvic fascia. |
| 1910 | Max Montgomery Madlener introduces a popular female sterilization technique employing ligation of the tube alone. |
| 1911 | Max Brödel becomes head of the world’s first department of medical illustration at The Johns Hopkins University. |
| 1912 | Alexis Victor Moschcowitz describes the passage of silk sutures around the cul-de-sac of Douglas to prevent prolapse of the rectum. |
| 1913 | Howard Atwood Kelly describes the Kelly plication stitch, a horizontal mattress stitch placed at the urethrovesical junction to plicate the pubocervical fascia and “reunite the sphincter muscle.” |
| 1914 | Wilhelm Latzko describes a technique for vaginal closure of vesicovaginal fistula following hysterectomy. |
| 1915 | Arnold Sturmdorf introduces his tracheloplasty technique. |
| 1917 | W. Stoeckle is the first to successfully combine a fascial sling and sphincter plication for treatment of urinary stress incontinence. |
| 1929 | Ralph Hayward Pomeroy devises a method of female sterilization involving ligation and resection of the tube. |
| 1940 | Noble Sproat Heaney describes his technique for vaginal hysterectomy using a clamp, needle holder, and retractor of his own design. His method for closing the vaginal cuff that incorporates peritoneum, vessels, and ligaments is known as the “Heaney stitch.” |
| 1941 | Leonid Sergius Cherney suggests a modified low transverse abdominal incision, whereby the rectus muscle is cut at its very insertion into the pubis to provide better access to the space of Retzius. |
| 1941 | Raoul Palmer popularizes the use of the laparoscope in gynecology. |
| 1942 | Albert H. Aldridge reports on rectus fascia transplantation as a sling for relief of urinary stress incontinence. |
| 1946 | Richard W. Te Linde continues the Johns Hopkins legacy in gynecology with the introduction of his text Operative Gynecology . |
| 1948 | Arnold Henry Kegel describes his progressive resistance exercise to promote functional restoration of the pelvic floor and perineal muscles. |
| 1949 | Victor Marshall, with Marchetti and Krantz, describes retropubic vesicourethral suspension for stress urinary incontinence. |
| 1957 | Milton L. McCall describes his posterior culdoplasty to prevent or treat enterocele formation at vaginal hysterectomy. |
| 1961 | John Christopher Burch introduces his method of urethrovaginal fixation for treatment of stress urinary incontinence. |
Gynecology in Antiquity
Gynecology in antiquity finds its roots in the Ebers papyrus (1500 BCE) that portrayed the uterus as a wandering animal, usually a tortoise, newt, or crocodile, capable of movement within its host. Hippocrates perpetuated this animalistic concept, stating that the uterus often went wild when deprived of male semen. He provided the earliest description of a pessary employing a pomegranate to reduce uterine prolapse and used catheters fashioned from tin and lead to irrigate and drain the uterus. The seven cells doctrine of the Common Era (CE) replaced the animalistic concept, depicting the uterine cavity as being divided into seven compartments whereby male embryos developed on the right, females on the left, and hermaphrodites in the center. Similar notions remained popular until the Middle Ages. Soranus of Ephesus (98–138 CE) is commonly considered the foremost gynecologic authority of antiquity. He described the uterus based on human dissection and performed hysterectomy for uterine prolapse. His writings provided the foundation for gynecologic texts up to the seventeenth century.
The ancients employed instruments fashioned from tin, iron, steel, lead, copper, bronze, wood, and horn. Those made of iron and steel were likely quite popular, but very few survived the oxidation of more than two millennia. Gynecologic instruments including forceps, catheters, scalpels, as well as massive bivalve, trivalve, and quadrivalve vaginal specula from the first century BCE were unearthed at Pompeii.
Medieval Medicine
The Dark Ages and Medieval Period (476–1453 CE), from the fall of Rome to the Goths to the fall of Constantinople to the Turks, is often referred to as the “Age of Faith” or “Era of Monastic Medicine” in which confidence in any one individual was replaced by divine trust. As such, Saint Benedict, founder of the Benedictine Order, encouraged his monks to tend to the sick but forbade any formal study of medicine. The struggle against leprosy, plagues, and prostitution were the focus of the day, and little was added to the fund of medical knowledge. Little surgery took place during the period, and the majority of physicians were itinerant practitioners, many of whom were quacks and charlatans.
The Renaissance
The Renaissance period was marked by the rebirth of individualism and the release from the ban of authority. The rise of universities, the printing press, and the subsequent emergence of self-education elevated medicine to the next level and provided for a clearer understanding of female anatomy. Leonardo da Vinci (1452–1519), founder of iconographic and physiologic anatomy, provided the basis for modern anatomic illustration. His illustrations of female pelvic anatomy provide the earliest accurate descriptions of the fetus in utero. Unfortunately, his sketches were seen by only a few of his contemporaries and were not published until the end of the nineteenth century.
The first authenticated report of vaginal hysterectomy was given by Giacomo Berengario da Capri (1470–1550) in 1521. He described two cases: one that he performed in 1507 and the other performed by his father. Ambrose Paré (1510–1590), a renowned military surgeon of the period, was the first to introduce vascular ligatures for hemostasis in place of cautery. However, the use of ligatures was not popularized until Sir Joseph Lister (1827–1912) introduced a longer-lasting aseptic suture in the mid-nineteenth century.
Andreas Vesalius (1514–1564) commissioned Jan Stephan van Kalkar to produce the most famous anatomic illustrations of all time, revolutionizing the science of anatomy and the manner in which it was taught. Among the first to successfully challenge the teachings of Galen of Pergamon, he asserted that the physician, to learn his art, must perform cadaver dissection firsthand. Hence, Vesalius made human dissection a viable and respectable profession. His illustrations provided an accurate description of the entire female urogenital tract and its vasculature, depicting for the first time the left ovarian vein entering the left renal vein. Distinguished pupils of Vesalius include Gabriele Falloppio (1523–1562) who provided the earliest accurate description of the human oviduct and who described the clitoris as a vasomuscular structure. Another pupil was Matthaeus Realdus Columbus (1484–1559) who is credited with the earliest use of the term labia , which he considered essential in protecting the uterus from dust, cold, and air. Lastly, his student Bartolomeo Eustachio (1520–1574) furnished the earliest accurate delineation of the uterine cavity and cervical canal.
Among the more comprehensive accounts of sixteenth century gynecologic surgery is Caspar Stromayr’s Practica Copiosa that contains beautifully executed watercolors depicting diseases of women. Included are illustrations of the examination of uterine prolapse and placement of a pessary comprising a sponge bound by twine, sealed with wax, and dipped in butter ( Figs. 1.2 and 1.3 ). Despite the many advances regarding pelvic anatomy during the Renaissance, the approach to most gynecologic problems changed very little from that which was popular during the classical period.
The Seventeenth Century
Throughout the seventeenth century, theories regarding physiology, generation, and anatomy were clarified. Reinier de Graaf (1641–1673) described ovarian follicles and uterine fibroids and provided the first accurate account of the ovary’s gross morphology, anatomic relations, and function. Pelvic surgery and instruments of the period are nicely portrayed by the engravings of Johannes Scultetus (1595–1645) in his Armamentarium Chururgicum . He was the first to employ a series of illustrations to provide a stepwise account of surgical procedures (see Fig. 1.4 ). Included are examples of treatment of imperforate hymen, hematocolpos, clitoral hypertrophy, and the use of a T-binder following vaginal surgery.
The Eighteenth Century
The eighteenth century is best characterized by the constant conflict that occurred between old and new ideas. As such, relatively few advances occurred in medicine while numerous notable contributions were made in the fields of natural philosophy including microscopy, physics, and biology. Surgery during the century began to rise above the skills of an individual surgeon with the founding of surgical societies and the publishing of various medical journals. Physicians, however, remained under close public scrutiny at the hands of popular medical caricaturists such as Thomas Rowlandson (1756–1827). Many outstanding contributions were made toward the understanding of pelvic anatomy during the period. In 1737, James Douglas (1675–1742) gave the first adequate description of the peritoneum, which helped pave the way to retroperitoneal surgery and the concomitant decrease in peritonitis that typically plagued abdominal procedures of the day. Later, in 1774, William Hunter (1718–1783) completed his monumental work, Anatomy of the Gravid Uterus . Thanks to the artistic talent of Jan van Rymsdyk, many regard this work as the finest anatomic atlas ever produced, as Choulant stated, “Anatomically exact and artistically perfect.” Vaginal specula continued to evolve with a modification in 1727 by René-Jacques Croissant de Garengeot (1688–1759) who devised blades with a distinctly concave surface. de Garengeot used the speculum for vaginal examinations and to differentiate the various “vaginal hernia” (presumably pelvic organ prolapse) as Ricci described ( Fig. 1.5 ).
