Evolution of Gynecology1

Unlike Obstetrics, which is as old as mankind, Gynecology is a comparatively recent subject added to medical education. Previously it was dealt with by general surgeons. This is linked with the evolution of knowledge of anatomy, development of antisepsis and asepsis, discovery of anesthesia and antibiotics and establishment of blood bank services in recent decades, besides others. A few important milestones are described in the chapter.

Only ancient Egyptian technicians had some knowledge of anatomy as they routinely did evisceration of dead bodies for mummification. In the thirteenth century, surgeons were responsible for autopsies to determine the cause of death. Though the first textbook “Gynecology” was written by Soranus, a Roman physician (120 AD) but it contained only Obstetrics. Vesalius (1543) published the first authentic work on human anatomy. He was a surgeon. Later William Hunter (1918–1983) wrote about the structure of the female pelvis.

Sir James Simpson (1811–1870) (Fig. 1.1) brought out the subject of hospital infection. Semmelweis (1818–1865) was the first to say that infection (puerperal sepsis) is caused by the physician himself. He suggested washing of hands with chlorinated lime solution before examination, to prevent infection. But his idea was not taken kindly by his medical colleagues. The same fate awaited Oliver Wendell Holmes in 1842 (Fig. 1.2) when he made the statement that doctors themselves were carrying the infection of puerperal infection to their patients. Joseph Lister (1827–1912) (Fig. 1.3) used carbolic acid for cleaning the instruments, sutures and dressing for use in the operations. It was Louis Pasteur (1822–1895) (Fig. 1.4) who gave the concept of germs in France. By all these discoveries the era of asepsis and antisepsis dawned making surgeries safer.

Gynecology as a specialty in medical sciences was well established only by the 1880s. Hysterectomy was first described by Soranus in a case of uterovaginal prolapse; he presumably performed amputation of cervix. In the sixteenth century an Italian, Berengario de Capri wrote about excision of uterine portion in prolapse of uterus. However, Langenbeck (1813) first performed planned vaginal hysterectomy. The indication at that time was most often cervical carcinoma.

Ephraim McDowell of Kentucky (1809) performed the first laparotomy for ovarian tumor without anesthesia. The first abdominal hysterectomy was attempted by Charles Clay (1843) at Manchester. Repair of vesicovaginal fistulae was done by James Marion Sims (1840) (Fig. 1.5) on slave women (also without anesthesia) in a lateral position named after him. This operation of his played a major role in establishing gynecology as a separate specialty.

Improvement in anesthesia (after 1846) and antisepsis led to better outcome. The abdominal hysterectomies were mostly subtotal.

Rubber gloves were invented by William Stewart Halsted in 1889–1890 and used by Hunter Robb (1894), a gynecologist, at Johns Hopkins Hospital. Early post-operative mobility was advocated by Emil Ries (1899); he was a professor of Gynecology in Chicago.

Pioneering work was done by Howard Atwood Kelley. He was the head of Obstetrics and Gynecology in the newly opened Johns Hopkins Hospital (1889). He concentrated on Gynecology and Pathology and trained leading Gynecologists of his time. His stitch (Kelly's stitch) is still used in urinary incontinence. Kelly also started radical hysterectomy.

The concept of early detection of cancer was conceived by Thomas Stephen Cullen (1900), the successor of Kelly. GN Papanicolaou along with H Trant published the findings of detection of uterine cancer by smear. Recognition of cancer in situ was also started by Cullen in 1912. It was only in 1943 that Richardson first carried out total abdominal hysterectomy. Philipp Bozzini (1805) thought of visualizing the lumen or cavity by an endoscope. The hysteroscope was constructed by Desormeaux (1865). However, after development of physics for light source, Robert Neuwirth (1971) started laparoscopic tubal ligation and removal of adhesions. The design of the endoscopes has improved and now we have both uterine (hysteroscopic) and laparoscopic surgeries of any conceivable type. Transcervical resection of endometrium (TCRE) was introduced in 1981 by Milton Goldrath. During the 1960s, Kurt Semm, a German gynecologist, created the automatic insufflator. Later he described a technique for laparoscopic assistance in vaginal hysterectomy in 1984 which was subsequently called laparoscopically assisted vaginal hysterectomy (LAVH). Harry Reich performed the first laparoscopic hysterectomy (LH) in January, 1988 in Pennsylvania. Lyons developed the minimally invasive laparoscopic supracervical hysterectomy (LSH) in 1990.

Victor Bonney (1930) and Washington Atlee (1845) were the pioneers in myomectomies. Laparoscopic myomectomy was frequently preformed since 1991 by Jean-Bernard Dubuisson and associates. Uterine artery embolism was initially started by Ravina and coworkers in 1995. Different energy sources (cold, laser and electric current) are now being experimented with to destroy a tumor.

The first assisted reproductive technology baby was born under the treatment of Robert Edwards and Patrick Steptoe (Fig. 1.6). Edwards is awarded Nobel Prize in Physiology and Medicine in October 2010. The first baby born is Marie Louise Brown. In our country also Subhas Mukhopadhyay (Fig. 1.7) was the first Indian Obstetrician and Gynecologist to perform IVF in October 3rd, 1978. The name of the first IVF child is Durga barely 67 days after the world's first IVF baby. Though his work was not recognized.

In this chapter we followed the evolutions of Gynecology over the years. It should be noted that Gynecology is still an evolving discipline and progress is expected to be made especially in the fields of cancer therapy, robotic surgery and stem cell therapy.