History of Pelvic Surgery
The Evolution of Pelvic Surgery
Anthony Tizzano, MD , Marie Fidela R. Paraiso, MD
From the earliest days of recorded medical history physicians struggled with the problems of pelvic organ prolapse and vesicovaginal fistula. An insufficient understanding of pelvic anatomy plagued practitioners prior to the nineteenth century. Ignorance of asepsis, the absence of anesthesia, faulty suture materials, inadequate instrumentation and difficult exposure delayed any consistent success until the mid-19th century.
The story of pelvic surgery from the Hippocratic to the antiseptic age is a fascinating one where original theories occasionally fell from favor, only to be resurrected and popularized by subsequent generations. What follows is an effort to brush upon the milestones that occurred along the way.
GYNECOLGY IN ANTIQUITY finds its roots in the Ebers Papyrus (1500 B.C.) which portrayed the uterus as an independent 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 gives us the earliest description of a pessary employing a pomegranate to reduce uterine prolapse and he used catheters of tin and lead to irrigate the uterus. The seven cells doctrine of the Common Era 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. Such notions remained popular until the middle ages. Soranus of Ephesus (A.D. 98-138) is commonly considered the foremost gynecologic authority of antiquity. He described the uterus based on human dissection and recognized vaginal atresia as being congenital or the result of inflammation. Soranus packed the uterus for hemorrhage and performed hysterectomy for uterine prolapse. His writings provided the foundation for gynecologic texts up to the seventeenth century.
THE DARK AGES or MEDIEVAL PERIOD (476-1453), from the Fall of Rome to the Goths to the Fall of Constantinople to the Turks is frequently referred to as the “Age of Faith” where confidence in the individual was replaced by divine trust. As such, St. Benedict, founder of the Benedictine Order, encouraged his monks to care for 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 knowledge of medicine let alone pelvic surgery.
THE RENAISSANCE (1453-1600) marks the rebirth of individualism and the release from the ban of authority. The rise of universities, printing and self-education raised medicine to the next level and provided a more clear understanding of female anatomy. Leonardo Da Vinci (1452-1519), founder of iconographic and physiologic anatomy, provided the format for modern anatomical illustration. His work included pelvic anatomy and provides the earliest accurate description 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. Jacob Rueff (1500-1558) provides the first illustration of a vaginal speculum, which appears little changed from Greco-Roman times. His contemporary, Ambrose Pare’ (1510-1590) was a renowned military surgeon who was the first to introduce vascular ligatures for hemostasis in place of cautery. Use of ligatures did not come into vogue until Lister popularized aseptic suture in the mid-nineteenth century. Pare was also the first to suggest amputation of the cervix in cases of malignancy.
Andreas Vesalius (1514-1564) produced the most famous anatomical illustrations of all time revolutionizing the science of anatomy and the manner in which it was taught. He was among the first to successfully challenge the teachings of Galen and asserted that the physician himself must perform the dissection of cadavers. By virtue of his strong and engaging personality he made human dissection a viable and respectable profession. Vesalius provided the first accurate description of the entire female genital tract and its vasculature, depicting the left ovarian vein entering the left renal vein for the first time. Distinguished pupils of Vesalius include Gabriele Fallopio (1523-1562) who produced the earliest clear description of the human oviduct and described the clitoris as a vasomuscular structure. Another was Matthaeus Columbus (1484-1559) who employed the earliest use of the term ‘labia’ which he considered essential to protect the uterus form dust, cold and air. Lastly, Bartholomeo Eustachio (1520-1574) provided the earliest accurate delineation of the uterine cavity and cervical canal.
Among the most comprehensive accounts of sixteenth century surgery is Caspar Stromayr’s Practica Copiosa which contains 186 water-colors depicting the surgical diseases of both men and women. Included are illustrations of the examination of patients with prolapse and the replacement of a prolapse using a pessary comprised of a sponge bound by twine, sealed with wax and dipped in butter. Despite the great many advances in pelvic anatomy during the Renaissance, gynecologic therapy changed very little from that which was popular during the Classical Period.
THE SEVENTEENTH CENTURY was the century of ‘systems’ whereby theories on physiology, generation and anatomy were clarified. Reinier De Graff (1641-1673) described ovarian follicles and uterine fibroids for the first time giving the earliest accurate account of the ovary’s gross morphology, anatomic relations and function. The first known illustrations of pelvic surgery are found in the engravings of Johannes Scultetus (1595-1645) in his Armamentarium Chirurgicum, which provides an excellent account of surgical procedures and instrumentation of the period. He was the first to use a series of illustrations to provide a step-by-step account of surgical procedures. Included are examples of incision for imperforate hymen, amputation of the hypertrophied clitoris and the use of a T-binder following vaginal surgery.
Throughout the EIGHTEENTH CENTURY old and new ideas remained in constant conflict. Relatively few advances occurred in medicine while numerous contributions were made in the fields of natural philosophy with respect to microscopy, physics and biology, etc. Surgery during the century rose beyond the isolated skills of an individual surgeon as surgical societies were formed and journals were published. Physicians remained under public scrutiny at the hands of popular medical characterizes such as Thomas Rowlandson. Many outstanding contributions were made towards the understanding of pelvic anatomy during the period. In 1737 James Douglas gave the first accurate description of the peritoneum which helped pave the way to retroperitoneal surgery and the concomitant decrease in peritonitis. Later, William Hunter (1718-1783) completed his Anatomy of the Gravid Uterus in 1774. This work was among the finest anatomy atlases ever produced “Anatomically exact and artistically perfect –Choulant”.
The evolution of pelvic surgery gained momentum during the later half of the nineteenth century when advances in gynecologic therapy were unparalleled in the entire realm of medicine. For more than two millennia therapy was primarily medical and in less than half a century it became surgical and spectacular. In America, during the first half of the century, prior to the aseptic age: Ephraim McDowell performed an ovariotomy in 1809; William Dewees published the first American textbook on Gynecology in 1826; and James Marion Sims repaired a vesicovaginal fistula in 1838.
In 1845 Sims began a series of surgical experiments on his now legendary slaves, Anarcha, Betsy, and Lucy, who suffered from vesicovaginal fistulas. After some forty or so fruitless attempts at fistula repair, over the course of six years, Sims finally succeeded. His triumph was due, in part, to his use of silver sutures and the exposure provided by a speculum of his own design employed with the patient in his knee-chest position. Sims initially reported on his technique in January of 1852 and again in Silver Sutures in Surgery, his 1857 anniversary discourse before the New York Academy of Medicine. An immodest man, Sims declared “silver as a suture is the greatest surgical achievement of the nineteenth century”. In a later narrative by Sims he describes the events surrounding his conception and application of the knee-chest position:
“Full of thought I hurried home-and the patient (with vesicovaginal fistula) was placed in the position described, with an assistant on each side to elevate and retract the nates. I cannot, nor is it needful to describe my emotions, when the air rushed in and dilated the vagina to its greatest capacity, whereby its whole surface was seen at one view, for the first time by any mortal man. With this sudden flash of light, with the fistulous opening seen in its proper relations, all the principles of the operation were presented to my mind. . .And thus in a moment, in the twinkling of an eye, new hopes and new aspirations filled my soul, for a flood of dazzling light had suddenly burst upon my enraptured vision, and I saw in the distance the great and glorious triumph that awaited determined and persevering effort. . .I thought only of relieving the loveliest of all God’s creations of one of the most loathsome maladies that can possibly befall poor human nature. . .Full of sympathy and enthusiasm, thus all at once I found myself running headlong after the very class of sufferers that I had all of my professional life most studiously avoided. ”
Although, historians may argue that Sims was not the first to employ silver sutures in surgical repairs, most will concede that he was the one to popularize the first great innovation in pelvic surgery.
Washington Atlee performed a myomectomy in 1844 and the first successful abdominal hysterectomy was done by Walter Burnham in 1853. The ever increasing frequency of successful surgery was made possible by the advent of anesthesia in 1846, Joseph Lister’s treatise on asepsis in 1867 and his introduction of aseptic suture (silk soaked in carbolic) in 1869. The extraordinary range of pelvic surgical techniques performed prior to the last quarter of the nineteenth century is beautifully illustrated in Jean-Baptiste Marc Bourgery’s and Nicolas-Henri Jacob’s magnificent Traite complet de l anatomie comprenant la medecine operatorie 1831-54. “In the entire literature of medicine during the 19th century there is nothing to compare with the 749 hand-colored folio-sized lithographs, nearly all of which are in the very realistic style of Nicolas Jacob”. Roberts and Tomlinson’s – Fabric of the Body.
The latter half of the century saw many noteworthy contributions to pelvic surgery and further elucidation of pelvic anatomy. Anders Adolf Retzius (1796-1860) defined the boundaries of the prevesical space in 1849. The cause and cure of uterine prolapse was put forth by Alwin Mackendrot (1859-1925) in 1895, with his accurate description of the pelvic connective tissue including the cardinal ligaments. Soon thereafter Archibald Donald and William Fothergill developed the Manchester operation uniting the parametric and paravaginal tissues to one another and to the cervix anteriorly to counter uterine prolapse. Leon Le Fort developed his partial colpocleisis in 1877. The simplicity and safety of Lefort’s operation accounts for its continued utility in the correction of uterine prolapse in the poor risk patient. Thomas Watkins proposed a novel approach to uterine prolapse and cystocele reduction by using the uterus as a prosthesis. In 1898 he introduced his interposition operation, contending that it was ill advised to remove the uterus in any case of prolapse unless it was diseased. Thus, Watkins would amputate the cervix, rest the bladder on the posterior wall of the uterus and thereby elevating the lower uterine segement. Thus, the prolapsing of the bladder and uterus become antagonistic forces.
Lastly, Howard Atwood Kelly is often regarded as the father of American gynecology due to his importance in establishing gynecology as a surgical specialty in this country. Kelly, an avid historian and bibliophile stated – “No group should ever neglect to honor the work of forebears upon which their contributions are based. Great is the loss to anyone who neglects to study the lives of those he follows. ” – Kelly.
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Garrison FH. An Introduciton to the History of Medicine. Philadelphia: WB Saunder Inc. , 1929.
Kelly HA. Operative Gynecology. New York: Appleton and Co. , 1898, N. Abrams, Inc. , 1978.
Ricci JV. The Development of Gynaecologic Surgery and Inctruments. Philadelphia: The Blakiston Company, 1949.
Ricci JV. The Genealogy of Gynecology. Philadelphia: The Blakiston Company, 1950.
Rueff J. DeConceptu et Generatione Hominis. Froschouer, 1554.
Scultetus J. Armamentarium Chirurgicum. Ulmae Suevorum: Balthasari, 1655.
Sims MJ. Clinical Notes on Uterine Surgery. London: Robert Hardwicke, 1866.
Sims MJ. Silver Sutures in Surgery. The Anniversary Discourse, before the New York Academy of Medicine. New York: Samuel S. & William Wood, 1858.
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Stromayr, AC. Die Handschrift des Achnitt-und Augenarzies Caspar Stromayr, Lindau Munscript. 1559.