Operative Gynecology Before the Era of Laparoscopy: A Brief History
Paul M. Allen
DEFINITIONS
Cadaveric particles—Elements associated with the transmission of puerperal sepsis as described by Dr. Ignaz Semmelweis before the development of germ theory by Robert Koch and Louis Pasteur later in the 19th century. Dr. Semmelweis hypothesized that medical students were transmitting disease to parturient patients by carrying cadaveric particles on their hands from the anatomical dissection room to the First Obstetrical Clinic of the Vienna General Hospital in 1847.
Humors and dyscrasias—Before the development of germ theory, disease conditions were thought to result from an imbalance of the four bodily humors resulting in dyscrasias.
Kelly air cystoscope—An instrument designed in 1893 by Dr. Howard Kelly to allow visualization of the female urinary bladder and catheterization of the ureters by placing the patient in the knee-chest position to allow distention of the bladder from gravity and posture. Dilatation of the urethra is generally required prior to introduction of this instrument into the urethra and bladder.
Knee-chest position—Dr. J. Marion Sims and later Dr. Howard Kelly realized the value of placing the patient in this position to allow distention of the vagina as well as the urinary bladder from the effects of gravity and posture.
Miasmas—Before the development of germ theory, diseases were thought to be transmitted through miasmas (bad air).
Modified Kelly air cystoscope—An instrument designed by Drs. Paul Allen and Gordon Davis in 1992 similar to the Kelly air cystoscope in which the shaft of the speculum is shortened, widened, and brazened to prevent reflection of a laser beam off the surface of the speculum. This instrument is used for urethral colposcopy, a technique previously undescribed. Use of this instrument requires dilatation of the urethra prior to introduction into the female urethra.
Ovariotomy—The term used by Dr. Ephraim McDowell to describe the first successful abdominal operation involving a laparotomy with drainage of the contents of an ovarian tumor followed by an oophorectomy.
Stereo clinics and stereograms—Teaching tools developed by Dr. Howard Kelly to demonstrate surgical techniques and procedures. Stereograms were photographs taken by Anthony Murray, a Baltimore photographer, showing all aspects of a surgical procedure stepwise.
Gynecology, also spelled gynaecology, is defined by the Oxford English Dictionary as “that department of medical science which treats of the functions and diseases peculiar to women.” The word was first used as such in the middle of the 19th century. In 1867, gynecology represented the physiology and pathology of the nonpregnant state. Although most histories of gynecology trace its roots back to antiquity, the field of medicine we call by that name today really has had a fairly recent origin. The successful removal of an ovarian tumor by Ephraim McDowell in 1809 was as rare an event as it was a spectacular one. In the preceding centuries, the history of gynecologic surgery was closely tied to the history of general surgery, and the obstacles that had to be overcome were the same. Infection, hemorrhage and shock, and pain were all effective barriers to any but emergency surgical procedures in the days before anesthesia.
“The history of gynecology,” Howard Kelly wrote in 1912, “seems to me more full of dramatic interest than the evolution of any other medical or surgical specialty.” Himself an accomplished historian of medicine, Kelly noted that, “It was, notably, anesthesia which robbed surgery of its horrors, asepsis which robbed it of its dangers, and cellular pathology which came as a godsend to enable the operator to discriminate between malignant and non-malignant growths.” Here, in a nutshell, we have the landmarks of much of the history of gynecology of the last 150 years. Ann Dally was correct when she noted that until recently, much of what has been written about the history of gynecology was written by gynecologists themselves, who picked their own heroes. With the rise of the new history of women and the social history of medicine since the 1970s, a much more balanced view has emerged.
There are many ways to approach the history of a medical and surgical specialty such as gynecology. The usual practice in textbooks that make an attempt to include some history is to tell the story in terms of who discovered what and who did which operation first. These facts are of interest but hardly constitute the history of the field. Besides the surgical operations of gynecology, the techniques devised, and the instruments to carry them out, there is much to be learned from the changing picture of diseases and their diagnoses; from the professionalization of the field, including the societies, journals, and textbooks that have been created; and from the education required to master the science and practice of operative gynecology. It is in these terms, rather than in tracing simply the great ideas and their creators, that this historical introduction proceeds.
Any major medical textbook can itself serve as a convenient window through which we can see history unfold. Robert Hahn has vividly described the changing world view of obstetrics by examining the succeeding editions of Williams
Obstetrics since its first edition in 1903. Likewise, the 50 years that have elapsed since the first edition of Richard Wesley Te Linde’s Operative Gynecology provide an equal opportunity to describe the major developments in the companion field of gynecology.
Obstetrics since its first edition in 1903. Likewise, the 50 years that have elapsed since the first edition of Richard Wesley Te Linde’s Operative Gynecology provide an equal opportunity to describe the major developments in the companion field of gynecology.
In recounting the history of the development of operative gynecology in the United States, we can appreciate that the highly energetic pioneers of the 19th century who successfully completed theretofore unprecedented surgical procedures all manifested extraordinary personal and professional attributes of courage, persistence, tenacity, dedication, and commitment, on the scale manifested by Navy SEAL and Special Forces commandoes in contemporary times.
Capturing the inventive and imaginative spirit of these pioneer gynecologic surgeons is of salient importance to understanding our heritage as pelvic surgeons for women. Despite being embroiled repeatedly in controversy surrounding their discoveries and their respective work, they all ultimately emerged from the shadow of doubt and criticism into the light of acclaim as successful pelvic surgeons with enormous contributions of epochal surgical impact. They paved the way for the development of lifesaving and life-enhancing surgical procedures for women patients. These pioneers modeled for us the professional lives we live today as surgical gynecologists. For all of us that are, will be, or ever have been gynecologic surgeons, facing our own daunting challenges and dealing with our own controversies, the stories of these Herculean historical figures offer a deep, if not bottomless, cornucopia of inspiration and strength.
Offsetting this are the equally dramatic and moving stories of patients who endured the pain and suffering of their pathologic conditions. These were their compelling motivations for undergoing early attempts at selected surgical procedures. They endured the consequent pain and suffering of withstanding these operations without the benefit of anesthesia and without the benefit of antiseptic measures for infection prevention and control as we know them today. The travails of these patients matched the drama of a Greek tragedy, and should touch us deeply as surgeons, not only to feel compassion and sympathy for these vulnerable women patients, but also to celebrate their ultimate victories in realizing the successful outcomes of the surgical procedures they had undergone in the hope of a cure.
BARRIERS TO SURGICAL PROGRESS
In ancient times, the lack of real anatomic knowledge was a barrier to the development of surgery. It is sometimes said that because the ancient Egyptians had effective techniques for the evisceration of bodies for mummification, they must have had a good knowledge of the body. However, removal of the internal organs during the embalming process was performed by technicians who did not concern themselves with the structure of the bodies they were preparing.
Anatomy was pursued in Alexandria during the Hellenistic period, but it had few, if any, practical applications until a later time. By the end of the 13th century, anatomic dissection again became more common, but often, it was limited to one or two public dissections a year or the study of animals. Surgeons were responsible for the few autopsies that were performed to determine the cause of death. This was especially important if a crime was suspected or drowning had to be established.
Soranus, the Roman physician and writer who practiced in the reigns of the Emperors Trajan (98-117) and Hadrian (117-138), is perhaps best known for his text entitled Gynecology. This book is somewhat mistitled because it is mostly devoted to what we would call obstetrics. Soranus wrote about prenatal and postnatal problems, as well as those associated with delivery itself. This ancient text has been translated and has an excellent introduction by Owsei Temkin. Recently, it has been reissued in a paperback edition.
Although Soranus’ Gynecology still makes interesting reading, it hardly qualifies as an early text on the subject of operative gynecology. However, like other physicians of his time, Soranus clearly noted that the best midwife was one who was trained in all branches of therapy, “… for some cases must be treated by diet, others by surgery, while still others must be cured by drugs.”
In the 1840s, the Hungarian obstetrician Ignaz Semmelweis showed clearly that puerperal fever could be prevented by disinfecting the hands of doctors before they examined their patients during the course of delivery. Despite good statistical evidence, his method of washing hands in chlorinated lime solution was not widely adopted. In fact, it met with outright resistance from most physicians.
Another obstacle to the development of operative gynecology was the understanding of principles of antisepsis and infection control and prevention. Ignaz Semmelweis (1818-1865) was a Hungarian physician born in Budapest. He began studying law at the University of Vienna in 1837 and then switched to studying medicine at that institution the following year. After receiving his doctorate in medicine degree there in 1844, he decided to specialize in obstetrics, after failing to receive an appointment to an internal medicine clinic in Vienna. He was appointed assistant to Professor Johann Klein at the First Obstetrical Clinic at Vienna General Hospital on July 1, 1846. His responsibilities in this position included examining patients each morning before the professor made rounds, teaching obstetrics to medical students, supervising difficult deliveries, and being the clerk of records. Dr. Semmelweis was quite disturbed to know that the puerperal sepsis mortality rate was considerably higher on his service than on the second service staffed by midwives. In his publication, he said that “it made me so miserable that life seemed worthless.” Dr. Semmelweis searched fastidiously for predictor variables that might account for the outcome variable, eliminating such factors as crowding, climate, and even religious factors. He realized that the only difference in operating the two clinics was the staffing pattern.
In 1847, his friend and colleague, Dr. Jakob Kolletschka, a professor of Forensic Medicine, died after an accidental puncture with a student’s scalpel in performing a postmortem examination. Dr. Kolletschka’s own autopsy revealed the findings similar to those of patients with mortality from childbed fever. Dr. Semmelweis concluded that he and the medical students carried “cadaveric particles” from the autopsy table to the First Obstetrical Clinic, unlike the midwives staffing the Second Obstetrical Clinic.
It is important to understand that at this juncture in history, the germ theory of disease had not been discovered by Louis Pasteur and Robert Koch and subsequently applied to antisepsis in the operating room by Dr. Joseph Lister.
Dr. Semmelweis instituted a policy on his service of using a solution of chlorinated lime for medical students and physicians to wash their hands between conducting autopsies and subsequently examining patients in labor. He selected the chlorinated lime solution because it effectively removed the putrid smell of infected autopsy tissue. As a result of implementing this policy, the mortality rate in the First Obstetrical Clinic dropped 90%. This then became equivalent to the mortality rate in the Second Obstetrical Clinic staffed by midwives.
Dr. Semmelweis’ conclusions were not consonant with established medical and scientific opinions of that era. Disease states were thought at that time to be caused by an imbalance
of bodily humors that resulted in dyscrasias and were often treated with bloodletting. Factors thought to be causative of the spread of disease were miasmas. Thus, Semmelweis’ findings were contrary to such thought. Consequently, his ideas were rejected. Physicians felt that their social status as gentleman was inconsistent with the idea that their hands could be unclean. Dr. Semmelweis did not publish his findings until 1858, although they were reported by his colleagues. In this country, the Harvard anatomist and writer Oliver Wendell Holmes (1809-1894) met similar disbelief and resistance when he suggested in 1842 that it was the physicians themselves who were carrying the dreaded puerperal infections to their patients.
of bodily humors that resulted in dyscrasias and were often treated with bloodletting. Factors thought to be causative of the spread of disease were miasmas. Thus, Semmelweis’ findings were contrary to such thought. Consequently, his ideas were rejected. Physicians felt that their social status as gentleman was inconsistent with the idea that their hands could be unclean. Dr. Semmelweis did not publish his findings until 1858, although they were reported by his colleagues. In this country, the Harvard anatomist and writer Oliver Wendell Holmes (1809-1894) met similar disbelief and resistance when he suggested in 1842 that it was the physicians themselves who were carrying the dreaded puerperal infections to their patients.
Although there were instances of anatomical study in earlier times, we generally begin the story with the work of Andreas Vesalius and the publication of his De humani corporis fabrica in 1543. Before this time, anatomic knowledge was not tied to the teaching and practice of medicine. The tradition of the surgeon-anatomists, of whom Vesalius was a stellar example, culminated in the late 18th century with the work of the English surgical teacher John Hunter (1728-1793) and his older brother William (1718-1783). It was William’s classic book about the gravid uterus with its detailed engravings that shed new light on the structures of the female pelvis.
In the 19th century, for all types of surgery, the problems of pain, hemorrhage, and infection had to be solved before operations could be undertaken safely. The problems of surgical dressings and postoperative infections were generally a matter of trial and error. The Scottish surgeon and gynecologist Sir James Simpson (1811-1870) urged his surgical colleagues to perform their operations on the kitchen tables of their patients to avoid the dangers of hospital infections, or “hospitalism” as it came to be called.
In the middle 1860s, Joseph Lister (1827-1912), while working in Glasgow, began experiments using carbolic acid, a phenol derivative, to clean the instruments, sutures, and dressings he was using in his operations. He based his work on an understanding of the germ theory of disease, which was then just in its infancy as a major theory of disease causation. Lister believed it was important to prevent the germs present in the air or on instruments and sutures from entering the wound, which would prevent the formation of the heretofore much desired laudable pus. Lister, too, met much opposition to his method of antisepsis. Partly because of the frequent changes in the system he was developing, which made it difficult for others to follow him, and because of the inadequate understanding of the germ theory by most surgeons, it took nearly two decades for antiseptic surgery to become routine. In Lister’s case, as was also true for Holmes and Semmelweis, some of the resistance undoubtedly stemmed from the fact that doctors never like being told that what they are doing is actually causing harm to their patients.
Lister encountered a great deal of opposition, particularly in his own country. Lawson Tait (1845-1899), an active and polemical gynecologist who settled in Birmingham, was staunchly opposed to Lister’s system of antisepsis. Tait paid much attention to general cleanliness when he was operating, and he actually achieved quite good results. However, his older colleague, Spencer Wells (1818-1897) of London, was a devoted follower of the antiseptic system in his many ovarian operations, perhaps because he had a clear grasp of the role of microbes. In 1864, the year before Lister began using carbolic acid in Glasgow and 3 years before he published his first results, Wells published a paper in the British Medical Journal entitled “Some Causes of Excessive Mortality after Surgical Operations.” Wells clearly described the recent work on germs by Louis Pasteur (1822-1895) in France. There is no definite proof that Lister was aware of the paper, but it is hard to imagine that he did not know what was appearing in the national medical journal. Thus, gynecologists probably had a much greater hand in the development of safe surgery in the last century than is usually acknowledged.
Dr. Crawford W. Long was a graduate of the University of Pennsylvania School of Medicine. Practicing in his native Jefferson, Georgia, this young dandy bachelor doctor hosted ether-sniffing parties for his friends at his office. Dr. Long noticed that his frolicking, partygoing friends, when intoxicated, would sustain without wincing falls and blows that would ordinarily cause pain. He noticed his own painless bruises sustained during his ether jags. James Venables, an intimate in Dr. Long’s circle of friends, complained of two small tumors on the back of his neck. Mr. Venables winced and procrastinated when Dr. Long offered to excise the tumors surgically. Visiting his patient and friend in March 1842, he offered to excise the tumors while Mr. Venables sniffed ether, and the patient was amenable to such an offer. Dr. Long had procured the bottle of ether from his friend, Robert Goodman, of Athens, Georgia.
“Dear Bob: I am under the necessity of troubling you a little. I am entirely out of ether, and wish some by tomorrow night. We have some girls in Jefferson who are anxious to see it taken, and nothing could afford me more pleasure than to take it in their presence and to get a few sweet kisses. You will please hand the order below to Dr. Reece, and if you can meet with the opportunity to send the medicines to me tomorrow, you will confer a great favor by doing so. If you cannot send them tomorrow, get Dr. Reece to send them by the stage on Wednesday. I can persuade the girls to stay until Wednesday night, but would prefer receiving the ether sooner. Your friend, Crawford W. Long.”
It was in such a spirit of simplicity, good fellowship, and joy of living without pretense that Dr. Crawford Long set the stage for his revolutionary discovery at the age of 26 years. On March 30, 1842, Dr. Long invited his friend and patient to position himself on a table in his office and poured ether on a towel as he was accustomed to doing at his parties. James Venables’ classmates and the headmaster at the Academy were spectators. Feeling his patient’s pulse and testing sensation with pinpricks, he incised and then excised the tumor in about five minutes. The patient sat up after the towel was removed from his face and had to be shown the tumor to believe that it had been excised.
Long’s discovery was not received well with his medical colleagues, who believed his claims were ridiculous and that he might kill a patient using ether for anesthesia. Dr. Long’s practice dwindled because of this. We acknowledge Dr. Long and his discovery annually on Doctors Day, March 30.
Known as the Father of Modern Pathology, Rudolf Virchow (1821-1902) introduced the concept that the cell was the basic unit that had to be studied to understand disease. He founded the field of cellular pathology and pathologic histology. He was the first to discover leukemia cells. Like Dr. Howard Kelly, who studied with Dr. Virchow in Berlin on one of his trips to Europe, Dr. Virchow was an ardent civic reformer and the founder of social medicine. Here is his direct quote on this topic:
“Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution… The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.”
The pioneering works of Andreas Vesalius, Ignaz Semmelweis, Crawford Long, and Rudolf Virchow launched the processes of removing obstacles to the development of operative gynecology. Each of them was subjected to considerable criticism professionally, because they were ahead of their times with their ideas. Ultimately, each of them prevailed, and all of them are honored today for their watershed contributions.
BEGINNINGS OF GYNECOLOGIC SURGERY IN 19TH-CENTURY AMERICA
Opening the abdominal cavity to remove extrauterine pregnancies was successfully accomplished several times in the later 18th century but did not become routine until the advent of anesthesia and antisepsis/asepsis. Ephraim McDowell (1771-1830) (Fig. 1.1) made surgical history with his successful removal of a large ovarian cyst in his patient Jane Todd Crawford, who in 1809 rode 60 miles to her doctor’s house in Danville, Kentucky, to undergo an untried operation without any assurance of cure and without the benefit of anesthesia. Although McDowell is often referred to as a backwoods physician, he was in fact a well-trained surgeon. His Edinburgh training probably gave him confidence in his diagnosis and courage to attempt a surgical cure rather than have his patient face certain death from her relentlessly growing tumor. During his study tour in Scotland, he probably heard that in the previous century, the popular surgical teacher John Hunter had suggested such an operation, believing that “women could bear spaying just as well as did animals.”
The drama of McDowell’s case is best described in the words of the surgeon himself:
“In December, 1809, I was called to see a Mrs. Crawford, who had for several months thought herself pregnant. She was affected with pains similar to labor pains, from which she could find no relief. So strong was the presumption of her being in the last stage of pregnancy, that two physicians, who were consulted on her case, requested my aid in delivering her. The abdomen was considerably enlarged, and had the appearance of pregnancy, though the inclination of the tumor was to one side, admitting of an easy removal to the other. Upon examination, per vaginum, I found nothing in the uterus; which induced the conclusion that it must be an enlarged ovarium. Having never seen so large a substance extracted, nor heard of an attempt, or success attending any operation, such as this required, I gave to the unhappy woman information of her dangerous situation. She appeared willing to undergo an experiment, which I promised to perform if she would come to Danville. … With the assistance of my nephew and colleague, James McDowell, M.D., I commenced the operation, which was concluded as follows: Having placed her on a table of the ordinary height, on her back, and removed all her dressing which might in any way impede the operation, I made an incision about three inches from the musculus rectus abdominis, on the left side, continuing the same nine inches in length, parallel with the fibers of the above named muscle, extending into the cavity of the abdomen, the parietes of which were a good deal contused, which we ascribed to the resting of the tumor on the horn of the saddle during her journey. The tumor then appeared in full view, but was so large that we could not take it away entire. We put a strong ligature around the fallopian tube near to the uterus; we then cut open the tumor, which was the ovarium and fibrinous part of the fallopian tube very much enlarged. We took out fifteen pounds of a dirty, gelatinous looking substance. After which we cut through the fallopian tube, and extracted the sack, which weighed seven pounds and one half. As soon as the external opening was made, the intestines rushed out upon the table; and so completely was the abdomen filled by the tumor, that they could not be replaced during the operation, which was terminated in about twenty-five minutes. We then turned her upon her left side, so as to permit the blood to escape; after which, we closed the external opening with the interrupted suture, leaving out, at the lower end of the incision, the ligature which surrounded the fallopian tube. Between every two stitches we put a strip of adhesive plaster, which, by keeping the parts in contact, hastened the healing of the incision. We then applied the usual dressing, put her to bed, and prescribed a strict observance of the antiphlogistic regimen. In five days I visited her, and much to my astonishment found her engaged in making up her bed. I gave her particular caution for the future; and in twenty five days, she returned home as she came, in good health, which she continues to enjoy.”
 FIGURE 1.1 Ephraim McDowell (1771-1830), one of the earliest abdominal surgeons. |
McDowell’s patient long outlived her surgeon. He did not publish his feat until 1816, by which time he had performed several more oophorectomies. McDowell is sometimes cited as a pioneer of early ambulation, unwitting as it was in his case. If his sturdy patient had not recovered so well, her failure would surely have been blamed on rising too early from her bed after such extensive surgery. McDowell also did not mention the intense drama of this Christmas day operation. When the townsfolk of Danville heard about his plan, they were incensed. They gathered in a tense group outside his house, with a rope slung over a tree, ready to lynch the surgeon if his “experiment” proved a failure. McDowell certainly had the nature of a true pioneer.
T. G. Thomas, in his 1876 centennial review of obstetrics and gynecology, reported that Alexander Dunlap of Springfield, Ohio, claimed he did his first ovarian operation in 1843. Dunlap said he sent the report of this case to a medical journal, which sent it back to him saying that they “could not publish the case of such an unjustifiable operation.”
By 1876, Thomas wrote, “It is to estimate the amount of good this operation has bestowed upon humanity. Practiced today in every civilized country in the world, yielding the statistics of seventy to seventy-five per cent of recoveries, and daily being improved in its various steps, it may well be regarded as one of the greatest surgical triumphs of the century.”
In the middle decades of the 19th century, another American surgeon working in the South helped to popularize gynecologic surgery by another set of pioneering feats. James Marion
Sims (1813-1883) (Fig. 1.2) told the dramatic tale of his development of a successful technique to repair vesicovaginal fistulas in his widely read autobiography The Story of My Life, which was published the year after his death. He described his repeated attempts to achieve a permanent closure of these fistulas in a few of his young slave-women patients. Sims began his experiments in 1845 and continued them for 4 years. In these preanesthesia and preantiseptic days, Sims produced remarkable results. He had had no experience in pelvic surgery, and in fact claimed that he disliked it. It was his custom to turn away patients with pelvic disorders, referring them to other doctors in his Alabama neighborhood. Many of his planter friends owned slaves, some of whom suffered from vesicovaginal fistulas as a result of traumatic births. These wounds were considered incurable and made the young women unacceptable for household work. After several entreaties to help one of his planter friends who had such a slave, Sims began with a small group of women, operating on some of them repeatedly over the course of 4 years.
Sims (1813-1883) (Fig. 1.2) told the dramatic tale of his development of a successful technique to repair vesicovaginal fistulas in his widely read autobiography The Story of My Life, which was published the year after his death. He described his repeated attempts to achieve a permanent closure of these fistulas in a few of his young slave-women patients. Sims began his experiments in 1845 and continued them for 4 years. In these preanesthesia and preantiseptic days, Sims produced remarkable results. He had had no experience in pelvic surgery, and in fact claimed that he disliked it. It was his custom to turn away patients with pelvic disorders, referring them to other doctors in his Alabama neighborhood. Many of his planter friends owned slaves, some of whom suffered from vesicovaginal fistulas as a result of traumatic births. These wounds were considered incurable and made the young women unacceptable for household work. After several entreaties to help one of his planter friends who had such a slave, Sims began with a small group of women, operating on some of them repeatedly over the course of 4 years.
Sims’ many failures only increased his determination to succeed. The colleagues who at first assisted him at the operations abandoned him, and his friends, he claimed, begged him to give up what was considered to be a hopeless effort. He trained other young slave patients to assist him, and on his 29th operation on one of the patients, he finally succeeded. In reviewing his work in 1852, Sims did cite several successful cases by other American surgeons between 1839 and 1849. He claimed originality for:
“1st. for the discovery of a method by which the vagina can be thoroughly explored, and the operation easily performed [the Sims, or lateral, position]. 2nd. For the introduction of a new suture apparatus, which lies imbedded in the tissues for an indefinite period without danger of cutting its way out, as do silk ligatures. And 3rd. For the invention of a self-retaining catheter, which can be worn with the greatest comfort by the patient during the whole process of treatment.”
The new “suture apparatus” used silver wire. This provided the breakthrough needed for the successful repair of vesicovaginal fistulas. Sims used silver in many of his other operations. In a 10th anniversary lecture at the New York Academy of Medicine in 1857, Sims somewhat immodestly told his august audience that the use of silver suture was one of the great achievements of 19th-century surgery. Sims wrote and spoke frequently about his development of a successful procedure for the definitive cure of vesicovaginal fistula, but never more eloquently than in his Anniversary Address in November 1857, in which he described his work with silver sutures over the previous 12 years. The audience included several past presidents of the academy and most of the distinguished colleagues at the Woman’s Hospital. After 4 years of fruitless effort, Sims proclaimed a new dawn on June 21, 1849. Since that day, he claimed, he had used no other suture in any of his surgical work.
 FIGURE 1.2 James Marion Sims (1813-1883). |
It is worth noting that Sims’ early patients—the slave women of Montgomery, Alabama, and the poor Irish servant girls who were predominant patients of the Woman’s Hospital in New York—were equally vulnerable, so it is not hard to see why some recent historians have been very critical of Sims and his coworkers. Yet with the advent of anesthesia and the use of antiseptic techniques, such surgery became increasingly routine. The repair of vesicovaginal fistulas and the removal of ovaries for a wide variety of indications were the beginning of the field of operative gynecology as it is known today. The story is, of course, not purely an American one. The English, French, and German contributions were important and can be found in any general history of medicine or of obstetrics and gynecology. In 1876, Sims became president of the American Medical Association, and in the same year, he and others founded the American Gynecological Association.
Even with the advent of effective and relatively safe anesthesia after 1846, it was several decades before surgeons were ready to increase the number of their operations. At midcentury and during the Civil War in the 1860s, surgery was generally confined to amputations after accidents; hernia repair when the intestine became incarcerated in the hernia sac, thus threatening life; an occasional ligation of a major vessel for aneurysm; and cystotomy for bladder stones. Therefore, Sims, operating in the 1840s, was truly a pioneer.
Also pioneers in the field of gynecologic surgery by midcentury were the Atlee brothers of Lancaster, Pennsylvania. They rediscovered oophorectomy, which was also being done in England by the 1860s, and were among the early leaders who performed myomectomy for fibroid tumors of the uterus.
Of semantic interest is the changing terminology for ovarian surgery. Ovariotomy, often used imprecisely to refer to removal of the ovary, actually was first used in that way in the 1850s by James Simpson and other British gynecologists. Ovariotomy means to cut into the ovary for removal of a cyst or tumor. In the 1870s, gynecologists such as Edmund Peaslee of New York, in his book on ovarian tumors, stated that oophorectomy was a more precise and distinctive term for removal of the ovary.
John Light Atlee (1799-1885) actively practiced medicine for 65 years, during which time he performed more than 2,000 operations and attended 3,200 births. John Atlee performed 78 ovarian operations between 1843 and 1883, with 64 recoveries and only 14 deaths. Thus, he validated McDowell’s work of the early part of the 19th century. Atlee’s younger brother, Washington Lemuel Atlee (1808-1878) (Fig. 1.3), also was involved in some of the ovarian cases but deserves separate credit for being one of the first to successfully treat the problem of uterine leiomyomata.
The Atlee brothers were relatively conservative gynecologic surgeons. It was their careful approach coupled with their obvious successes that gave other surgeons increasing confidence to operate. Thus, they played an important role in the early stages of operative gynecology as it developed into the
specialty it would become in the next generation. Ovariotomy, the most controversial of gynecologic procedures, was also the key to making it a surgical specialty. Indeed, some gynecologists claimed that operating for ovarian cysts and tumors laid the groundwork for all abdominal surgery in the last decades of the 19th century.
specialty it would become in the next generation. Ovariotomy, the most controversial of gynecologic procedures, was also the key to making it a surgical specialty. Indeed, some gynecologists claimed that operating for ovarian cysts and tumors laid the groundwork for all abdominal surgery in the last decades of the 19th century.
 FIGURE 1.3 Washington Lemuel Atlee (1808-1878). |
By the 1880s, the specialty of gynecology, or the science of women, as some historians have called it, was well on its way to being established as one of the subdivisions of medical labor. Ornella Moscucci, in her perceptive history of gynecology in Britain, quotes the eminent surgeon from Birmingham, Lawson Tait, in his aptly entitled book of 1889, Diseases of Women and Abdominal Surgery:
“The great function of woman’s life has for years made her the subject of specialists, male and female, the obstetricians. The subsidiary relations of her special organs and the special requirements of her physique, based upon these, have necessitated the establishment of another class of specialist, the gynecologist.”
The evolving settings in which these surgical procedures were performed have a captivating history as well, from the table in the surgeon’s home in which the first ovariotomy was completed on Christmas Day in 1809; through the operating rooms in the earliest Women’s Hospitals in New York, Philadelphia, and Baltimore; and more recently to the safe, sanitary, and secure environment of an accredited, office-based gynecologic surgical facility, such as the one of the earliest of these venues developed by the author of this chapter some 20 years ago.
The scope of operative gynecology has evolved in a paradoxically undulating and intriguing manner as well. As the discipline of operative gynecology was unfolding in the 19th century, urogynecologic procedures were developed to treat vesicovaginal fistulas that defined and distinctively characterized the emerging discipline of surgical gynecology. These fistulas were sustained as complications of childbirth and were consequent to dystocia resulting from fetopelvic disproportion with protracted labor patterns, intrapartal fetal demise, and subsequent postpartal necrosis and sloughing of the vaginal and bladder walls prior to the development of modern operative obstetrics. As time passed, the operative urogynecology that heralded the early definition of surgical gynecology fell away from the discipline for more than 50 years in the 20th century, only to be reintegrated into operative gynecology by Dr. Jack Robertson (Fig. 1.4
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