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 before 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.

Figure 1-1 Sixteenth-century woodcut showing examination of women with uterine prolapse.

(From Stromayr C. Die Handschrift des Schnitt-und Augenarzles Caspar Stromayr, Lindau Munscript, 1559.)

The evolution of pelvic surgery from the Hippocratic age to the antiseptic period is a fascinating one, where 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 Table 1-1. Note that this chapter emphasizes American contributions and milestones that influenced contemporary thought, patient care, and surgical practices. I am grateful for the works of Dr. Thomas Baskett, Dr. James V. Ricci, and, particularly, Dr. Harold Speert, whose extensive research on the subject made this chapter possible.

Table 1-1 Timeline of Milestones Related to Pelvic Surgery and Female Urology

GYNECOLOGY IN ANTIQUITY

Gynecology in antiquity finds its roots in the Ebers papyrus (1500 BC) 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, using a pomegranate to reduce uterine prolapse and using catheters fashioned from tin and lead to irrigate and drain 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. Similar notions remained popular until the Middle Ages. Soranus of Ephesus (AD 98 to 138) is commonly considered the foremost gynecologic authority of antiquity. He described the uterus based on human dissection and performed a hysterectomy for uterine prolapse. His writings provided the foundation for gynecologic texts up to the seventeenth century. The ancients used 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 from the first century BC were unearthed at Pompeii, including forceps, catheters, scalpels, as well as massive bivalve, trivalve, and quadrivalve vaginal specula.

MEDIEVAL MEDICINE

The medieval period (Middle Ages) (AD 476 to 1453), from the Fall of Rome to the Goths to the Fall of Constantinople to the Turks, are often referred to as the Age of Faith or Era of Monastatic Medicine, when confidence in any one individual was replaced by divine trust. As such, St. 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 was the focus of the day, and little was added to the fund of medical knowledge. Surgery rarely 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 performed by him in 1507 and the other 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 Baron Joseph Lister (1827–1912), a British surgeon, introduced a longer lasting aseptic suture in the mid-nineteenth century.

Andreas Vesalius (1514–1564) commissioned Jan Stefan 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. He was among the first to successfully challenge the teachings of Galen (ancient Greek physician) and asserted that the physician must perform cadaver dissection firsthand to learn the art. 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 the left ovarian vein entering the left renal vein for the first time. 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 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. Last, 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, which contains beautifully executed watercolors depicting diseases of women. Included are illustrations of the examination of uterine prolapse and placement of a pessary comprised of 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.

Figure 1-2 Sixteenth-century woodcut depicting placement of a pessary to treat uterine prolapse.

(From Stromayr C. Die Handschrift des Schnitt-und Augenarzles Caspar Stromayr, Lindau Munscript, 1559.)

Figure 1-3

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