Hallmarks in the evolution of gynaecological cancer surgery: the famous pioneers in children

At the beginning of the 19th century, gynaecological cancer, mainly cancer of the uterus and cervix was a dreadful, incurable affection. However, the popularization of the three fundamentals in surgery, anesthesia, asepsis and haemostasis, ushered the golden age of operative gynaecology. During that period distinguished surgeons/gynaecologists such as Friedrich Benjamin Osiander (1759-1822), Elias von Siebold (1775-1828) and Joseph-Claude-Anthelme Récamier (1774-1852) contributed to the development of the operative techniques, providing a therapeutic solution in gynaecological cancer.

Ruptured ectopic pregnancy

It is thought-provoking to remember that until 1883 a ruptured ectopic pregnancy was a death sentence. In his book on this condition, by the physician, John Parry, published in 1876, we read “here is an accident which may happen to any wife in the most useful period of her existence which good authorities have said is never cured… no remedy, either medical or surgical has been tried with any success”. Among the suggested treatments were injection of narcotic material into the sac, electric shocks and copious and frequent bleeding, (which, of course, would have hastened the demise of the unfortunate patient). Parry himself, although a physician, suggested that the only remedy would be for a surgeon to open the abdomen and either to ligate the bleeding vessels or remove the ectopic sac entirely.

Establishing specialty jurisdictions in medicine: the case of American obstetrics and gynaecology

The profession of medicine has evolved into an extremely specialised occupation. Yet, recent research has neglected the intra-occupational processes influencing medical specialisation. This article aims to correct this oversight. It develops an historical account of intra-occupational factors influencing the decision to establish gynaecologic oncology as American ob/gyn's surgical subspecialty in 1972. Working within the framework initially developed by Everett C. Hughes and his students, the article examines this development as the outcome of a three-party relationship among gynaecologic oncologists, American ob/gyns, and gynaecologic pelvic surgeons. Aggressive movement by the gynaecologic pelvic surgeons challenging the established élite's identity definition for the ob/gyn specialty helped spur official recognition of gynaecologic oncology, a less threatening subspecialty. The article draws theoretical implications from the case regarding the role of a threatening other in influencing the specialisation process.

Joseph-Claude-Anthelme Récamier (1774-1852): forerunner in surgical oncology

Professor J.C.A. Récamier (1774-1852), the undisputed founder of modern gynecologic surgery, had also excelled in the field of oncology. In particular, he performed the first successful vaginal hysterectomy for cancer; he conducted extensive research on cancer metastatic process and he was the proponent of a cancer treatment method by compression.

Handling ovarian cancer FIGO III-IV : evolution over the last 30 years

The treatment of ovarian cancer FIGO III-IV has undergone substantial changes in the last 30 years. As I was involved as an oncological surgeon in the treatment of these patients since 1979 and made my PhD thesis on this subject, I consider myself a privileged witness of this evolution. In the late 1970's two major changes took place: the introduction of combination chemotherapy containing cisplatin and the concept of debulking surgery. In 1980 we embarked on an ambitious treatment plan combining maximal cytoreductive surgery, 6 cycles of chemotherapy, second look laparotomy and panabdominal irradiation. The results were analyzed in 1991 and gave rise to the following changes. Surgical cytoreduction could only be considered optimal if no residual tumor was left and residual tumor correlated with median survival. Upfront surgery was abandoned in FIGO IV and FIGO III with a very high tumor load. Panabdominal irradiation was too toxic. A recent randomized study has established equivalency of survival in FIGO IIIc between interval debulking after 3 cycles and upfront surgery. Initial tumor load remains a determinant of long- term cure and optimal upfront surgery is critical in patients with a metastatic tumor load of less than 100 gram. Retroperitoneal node dissection becomes important when complete resection of peritoneal metastases can be obtained. In experienced hands selection for primary debulking or for interval debulking seems possible at laparoscopic exploration.

[Doc. MUDr. Antonín Cernoch and his original technical surgery modifications]

Antonin Cernoch an outstanding gynaecologic surgeon, was head of the Czech institute for postgraduate medical education in the years 1960 - 1970. His important surgical work exhibited many stimulating ideas for contemporary gynaecology and obstetrics. The Cernoch's original modifications of surgical repairs of uterine cervix are presented in this article and are very important ideas for surgical practice. The original procedures repair damaged uterine cervix together with adjoining tissue as well as surgical removing advanced malignant ovarian tissue are documented in pictures. The effective treatment was used in more than 400 causes. Both, excellent surgery strategy and experience of doc. MUDr. A. Cernoch is of practical importance for gynaecologic surgeons.

Gynecological surgery from the Hippocratics to the fall of the Roman Empire

The article aims to explore advances in the Greco-Roman gynecological surgery with particular emphasis on the Roman Empire. The development and improvement of the Roman surgical instrumentarium occurred in tandem with surgical advances, gynecological as well as general. It might therefore be said that the approach taken in this paper is one based on material culture.

Infertility after fertility-preserving surgery for cervical carcinoma: the next challenge for reproductive medicine?

Radical trachelectomy is an operation developed as an alternative to radical hysterectomy for patients with small-volume, early stage cervical cancer, who wish to retain their fertility. The body of the uterus is left in place, so that future pregnancies can occur. Patients who have undergone radical trachelectomy may face problems conceiving naturally and may request assisted conception. This article explains the operation and the difficulties that those working in reproductive medicine may face.

[Influence of anesthesia and antisepsis on the earliest gynecologic laparotomies: historical notes on the bicentennial of the introduction of ovariectomy]

On the occasion of the bicentennial of the first ovariectomy, we reviewed the beginnings of abdominal gynecologic surgery in Spain in order to shed light on aspects that are still unclear in medical historiography and that are often wrongly presented. We consulted a large number of sources that allowed us to follow events in the last quarter of the nineteenth century, discovering information we consider definitive and that confirmed our initial hypotheses. The work of Dr Federico Rubio, the first to perform an ovariectomy in Spain, is highlighted among the early experiences of our Spanish surgeons. Emphasis is placed on the high mortality rate associated with this operation at the beginning. We also analyze the problems of anesthesia and antisepsis and the influence of each on the surgical procedure. The events uncovered were the work of a group of forward-thinking surgeons who made considerable progress against opposing groups with more conservative views and whose contributions to Spanish surgery were far less brilliant.

Salpingectomy for ruptured ectopic pregnancy

Not much more than a century ago, a ruptured ectopic pregnancy was a death sentence. In 1876, John Parry wrote in his book on this subject: 'Here is a wife in the most useful period of her existence, which good authorities have said is never cured; and for which, even in this age when science and art boast of such high attainments, no remedy, either medical or surgical, has been tried with a single success'. When we read that eminent authorities were advising the use of electric shocks, injection of narcotics into the sac and copious and frequent bleeding, one is hardly suprised. Parry himself suggested that the only remedy would be to open the abdomen and either tie the bleeding vessels or remove the sac entirely.

[M.A. Mendes de Leon (1856-1924), a founding father of gynaecology]

M.A. Mendes de Leon (1856-1924) was appointed private lecturer at the Department of Obstetrics of the University of Amsterdam in 1884. He promoted gynaecology in the Netherlands as a separate speciality, partly because of the new surgical possibilities following the discoveries of anaesthesia and antisepsis, but also due to the prevailing belief that the physiology of reproduction qualified the physical and psychological disorders of women. In his private gynaecological clinic he devoted himself to the surgery of ovarian tumours, uterus myomatosus and genital prolapse, but also to the diagnosis and treatment of supposed inflammations of the cervix and endometrium as cause of psychological disorders. In this he followed the opinions of contemporary English gynaecologists. As he was not aware of physiological histology, he nearly always found signs of inflammation. He treated this with curettage and drastic caustics, sometimes after using a dilation knife (hysterotome) for the cervix. At the turn of the twentieth century Dutch gynaecologists such as Treub and Nijhoff began to cast doubt on such theories of "reflex neurosis", but Mendes de Leon persisted in his views. Nevertheless, he can still be considered one of the founding fathers of gynaecology in the Netherlands, partly because of his surgical skills, but also due to his study into the interaction between gynaecological and psychological problems.

Sarah Bernhardt's ‘Doctor God’: Jean-Samuel Pozzi (1846-1918)

Samuel Pozzi was a major figure in the early development of modern gynaecological surgery. His textbook, A Treatise on Gynaecology, published in French in 1890 and rapidly translated into five other languages, was the first internationally acclaimed text integrating modern principles of anaesthesia, antisepsis, diagnosis, surgical technique and postoperative care, and in later editions remained a standard reference up to the 1930s. He was the author of more than 400 papers on gynaecological and general abdominal surgery and his technical expertise drew surgeons from all over the world to his theatre in the Hospital Broca, in one of the poorer parts of Paris. He was equally successful in several professional fields apart from medicine. However, his name is now little known in the English-speaking world. This short biography aims to re-introduce Pozzi to readers of English.

Thomas Spencer Wells, Bt FRCS (1818-97) and his contributions to naval medicine

Sir Thomas Spencer Wells (1818-97) is best remembered both as a gynaecological surgeon, who introduced ovariectomy, and as the one who introduced the surgical forceps named after him. Far less is known of his career in the Royal Navy (RN) as an assistant surgeon and then a surgeon, and his contributions to naval medicine. Wells enlisted for the RN at the age of 23 years and for most of his naval career (1841-56) he served at the Naval Hospital, Malta (1841-48). However, from 1851 to 1853 he was surgeon and sanitary officer on the sloop, HMS Modeste. Most of Wells' contributions to the health of sailors were of a preventive nature, especially involving ventilation, in RN ships. He was also an enthusiast for quarantine and vaccination.

Georg Kelling (1866-1945): the root of modern day minimal invasive surgery. A forgotten legend?

On 23 September 1901, at the 73rd meeting of the Society of German Natural Scientists and Physicians in Hamburg, following his lecture "On the inspection of the gullet and the stomach with flexible instruments", the surgeon and gastroenterologist Georg Kelling from Dresden performed a laparoscopy on a dog. He called this procedure coelioscopy. Kelling's ingenious idea to connect his oral insufflation device with the Fiedler trocar and the Nitze cystocope, led to the coelioscopy in 1901 and marked the hour of birth of laparoscopy. Until today, Georg Kelling has not experienced the appreciation he is entitled to. He is the forgotten pioneer of a method that today plays an important role in diagnostics and therapeutics. The present standard of endoscopy has confirmed the anticipations of Georg Kelling that he had hundred years ago. His name therefore deserves a fixed place in the history of medicine and especially in the history of endoscopy. Georg Kelling and his wife were killed during the heavy air raids on Dresden on 13 and 14 February 1945, but his vague footprints are still in the sands of medical history.

[Mexican surgery in gynecology and obstetrics during the 19th century]

We present a historical framework for the initiation and development of obstetrical-gynecological (OB-Gyn) surgery during the 19th century in Mexico. The importance of a new vision is underlined, and the founders of medical science, the Romanticist surgeons who initiated the teaching of modern medicine and surgery, supported the change. The French influenced the advent of anesthesia, asepsis, antisepsis and transfusion, which has a major significance for the accomplishment of OB-Gyn Surgery. Important persons in this field of medicine are mentioned and we conclude with techniques of contemporary surgery in the next century, integrated with medical care.

The "ineffable freemasonry of sex": feminist surgeons and the establishment of radiotherapy in early twentieth-century Britain

In 1924 the London Committee of the Medical Women's Federation was instrumental in establishing a clinic for the purpose of investigating the radium treatment of cervical cancer. The scheme was later to evolve into a hospital, the Marie Curie, where adherence to the methods developed in Stockholm served to establish radiotherapy as an alternative to surgery in cancer of the cervix. This article examines the women's contribution in the light of feminist and professional struggles over the relative merits of surgery and radiotherapy. It argues that radiotherapy was an issue of special interest to women surgeons, not only because of the long history of feminist opposition to gynecological surgery, but also because it could widen women's access to the medical profession in the face of male exclusion from training posts and honorary appointments at voluntary hospitals.

The Sims' speculum

An instrument that is taken for granted in gynaecological clinics, operating theatres and GP surgeries all over the world is the humble Sims' speculum. How would we manage without it? In the fourth article of this biographical series, Professor Ellis looks at the work of James Marion Sims.

The forgotten hysterectomy: the first successful abdominal hysterectomy and bilateral salpingo-oophorectomy in the United States

BACKGROUND

The history of gynecology and surgery in America has been well documented. However, a landmark operation took place in 1856 that has gone unrecognized in modern surgical texts.

CASE

William J. Baker and associates performed the first successful abdominal hysterectomy with bilateral salpingo-oophorectomy in Knoxville, Tennessee on November 13, 1856. The patient recovered uneventfully and lived for 34 years after her procedure.

CONCLUSION

This case has yet to be noted in modern medical history texts. It is important that the accomplishments of Dr. Baker and his associates be recognized among the surgical pioneers of their day.

Gender and cancer in Britain, 1860-1910: the emergence of cancer as a public health concern

Historical work on cancer has suggested that a range of political, social, and medical concerns stimulated the emergence of cancer as a public health problem in the early 20th century.I argue that anxiety about cervical cancer mortality was instrumental in establishing cancer as a major focus of concern for the British public health service. This development was closely bound to assumptions about the association of gender with cancer, the redefinition of cancer as a surgical problem, the politics of empire, and the climate of public and medical disquiet about gynecological surgery engendered by feminist and antivivisectionist critiques of medical science.

J. Marion Sims, the father of gynecology: hero or villain?

J. Marion Sims (1813-1884) has been called the "Father of Gynecology" for his revolutionary approach to treating the diseases of women. He rose from humble origins to become a successful surgeon, teacher, and writer. His innovations included the first successful treatment for vesicovaginal fistula, the first gallbladder surgery, and the introduction of antiseptic principles in all areas of surgical treatment. The "Sims position" and "Sims speculum" are eponymic tributes to his accomplishments. In recent years Sims has, however, become a focus of controversy because of his experimental surgeries on slave women. His powerful personality and messianic attitude led him to minimize moral problems, and to bristle against opposition. Ethical principles of autonomy and beneficence are important criteria for evaluating Sims' research. An exploration of the nature of Sims' work and the atmosphere in which he practiced will illuminate the critical ethical questions surrounding Sims' use of slave women as experimental subjects.

The Pfannenstiel or so called "bikini cut": still effective more than 100 years after first description

The original Pfannenstiel incision is discussed including the technique, history, current indications, advantages, and disadvantages. Excellent cosmetic results, principles of less traumatic surgery, and a rare incisional hernia complication rate of about 0-2%, as well as long-time use characterise this access path to the pelvic organs first described by the German gynaecologist in 1900. Complications of nerve damage, however, should be recognised, especially when extending the incision too far laterally.

[History of vaginal reconstruction]

The paper presents the outline of the history of vaginal reconstruction since antiquity, mainly in vaginal agenesis. The review presents first concepts of vaginoplasty originating from Hippocrates and Celsus, a few attempts of vaginal reconstruction in 18th-19th centuries nad moderate advances in the USA in 19th century. A breakthrough in this field was related to introduction of split thickness skin graft for covering neovaginal channel by Abbe at the turn of 19th and 20th century. Subsequent evolution of surgical techniques was based on Abbe's concept and was directed to finding an ideal material accelerating the epitheliazation of vaginal channel. At the turn of 20 and 21st century medical technology development e.g. laparoscopy played its role in this field of surgery too. Tissue engineering and molecular biology will definitely play increasing role in vaginal reconstruction. Conservative and minimally invasive methods of vaginal creation were also briefly discussed. The considerable input of Polish scientist into the development of both experimental and clinical problems of vaginoplasty is presented.

The Manchester Procedure

This article describes the historical development for the Manchester Surgical Procedure for the correction of genital prolapse.

[Gynecologic surgery evolution during the 50 years of professional career in surgery]

This is a retrospective analysis of how gynecological surgery has changed over the last 50 years; these practices have been modified from mutilative and extirpative to conservative and with the least invasion possible. The major breakthroughs-apart from changes in pathology-have been those with use of microsurgery techniques, endoscopic surgery, and assisted reproductive techniques; this highlights the fact that each day surgeon gynecologists are better prepared. Also, there has occurred the notable evolution of methods of detection and diagnosis such as laboratory test, MRI, ultrasound, CT, etc. as well as anesthetic procedures. We describe the most notable changes of gynecological surgery techniques with different examples and figures. Surgical obstetric procedures will be shown in another communication.