The surgical treatment of cancer of the cervix is the primary operation that spawned the specialty of gynecologic oncology. Therefore, a review of the history of the radical hysterectomy and pelvic lymph node dissection is of significance. For this review, I draw heavily from the book, “Surgical Treatment of Cancer of the Cervix,” by Joe V. Meigs, published in 1954.

In the 19th century, the diagnosis of cancer of the cervix “is enough to make a physician’s heart sink as it is ipso facto a prognosis of death.”

John G. Clark, of Philadelphia, and E. Reis, of Chicago, published the first experience in the United States with the radical abdominal operation for cancer of the cervix. Ernst Wertheim, of Vienna, performed his first operation in 1898 and published his result of the first 27 patients in 1900. In 1912, he published his results of 500 women who had the Wertheim operation performed from 1898 to 1911. The staging of cancer of the cervix was termed operable, borderline, and inoperable in patients. Operable was defined by disease confined to the cervix without extent to the parametrium. Borderline consisted of patients with doughy or edematous feel to the parametria. Inoperable was disease extended to the broad ligament, sidewall, bladder, or bowel. The surgical treatment of the cancer of the cervix was compromised by the low rate of operability, ranging from 15% to 40%, the high mortality of the operation from hemorrhage and infection (5% to 26%), and at best a 39% 5-year cure rate (Clark). These were the discouraging statistics in 1917.

Radium was discovered in 1898 and clinical use began in 1903. Howard Kelly at Johns Hopkins was an early adapter of radium for cervical cancer and reported 213 cases treated from 1909 to 1915. He stated it wasn’t until 1912 that they secured enough radium to employ it systematically. Of the first 14 “operable” patients, 10 were treated with surgery followed by prophylactic radium and 4 were treated with radium alone. All 14 of the patients were disease free at 2 years, indicating that treatment with radium alone could cure operable patients.

By 1920, most hospitals had adopted radium even in operable patients and were reporting 50% curability in the operable group. The mortality rate was nil. Compared to the 5% to 26% mortality from surgery and the significantly lower cure rates of 20% to 40%, it was easy to understand the enthusiasm for radium. Even John G. Clark, one of the developers of the radical hysterectomy, incorporated it into his program (1923).

Clark also pointed out that the divergent results of either treatment probably were due to the inconsistent method of categorizing patients as operable or nonoperable. Some reports included a “borderline” category. In 1928, the Radiological Sub-Commission of the Health Organization of the League of Nations under guidance of Dr. J. Heyman of the Radiumhemmet produced 4 stages very similar to those utilized by FIGO in 1958: stage 1 confined to the cervix; stage 2 parametrial spread; stage 3 fixed to the pelvic wall; stage 4 metastasis.

Joe V. Meigs is given credit for the rebirth of the radical hysterectomy in North America. He began his internship in 1917 when the enthusiasm for radium was building. After years of satisfaction for radium and later roentgen-ray therapy, he noted that patients would fail radium treatment when they should have been cured with surgery. This observation and the decrease in operative mortality with the introduction of blood transfusion after WWI and the discovery of sulfa drugs in 1935 led to a resurgence in the radical hysterectomy.

Meigs visited the prominent surgeons who had continued to perform the operation—Bonney in London, Adler in the Wertheim clinic in Vienna, Wanekros in Dresden, and Taussig in St. Louis—to see their technique and results.