Hysterectomy: a historical perspective CHRIS

SUTTON*

MA, MBBCh, FRCOG

Consultant Gynaecologist and Minimal Access Surgeon Chelsea and Westminster Hospital, University of London

Director Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Guildford, Surrey GU2 5XX, UK

In the relatively long history of man, surgery has been a comparatively recent development; the abdomen was first deliberately opened to remove an ovarian cyst by Ephraim McDowell in Kentucky in 1809. The first abdominal hysterectomy was performed by Charles Clay in Manchester, England in 1843; unfortunately the diagnosis was wrong and the patient died in the immediate post-operative period. The following year, Charles Clay was almost the first to claim a surviving patient, however she died post-operatively and it was not until 1853 that Ellis Burnham from Lowell, Massachusetts achieved the first successful abdominal hysterectomy although again the diagnosis was wrong. Vaginal hysterectomy dates back to ancient times. The procedure was performed by Soranus of Ephesus 120 years after the birth of Christ, and the many reports of its use in the middle ages were nearly always for the extirpation of an inverted uterus and the patients rarely survived. The early hysterectomies were fraught with hazard and the patients usually died of haemorrhage, peritonitis, and exhaustion. Early procedures were performed without anaesthesia with a mortality of about 70%, mainly due to sepsis from leaving a long ligature to encourage the drainage of pus. Thomas Keith from Scotland realized the danger of this practice and merely cauterized the cervical stump and allowed it to fall internally, thereby bringing the mortality down to about 8%. Hysterectomy became safer with the introduction of anaesthesia, antibiotics and antisepsis, blood transfusions and intravenous therapy. During the 1930s, Richardson introduced the total abdominal hysterectomy to avoid serosanguineous discharge from the cervical remnant and the risk of cervical carcinoma developing in the stump. Apart from this innovation, and the transverse incision introduced by Johanns Pfannenstiel in the 1920s, there was little advance in hysterectomy techniques until the advent of endoscopic surgery and the performance of the first laparoscopic hysterectomy by Harry Reich in Kingston, Pennsylvania in 1988. The refinement and increasing safety of laparoscopic hysterectomy suggests that it will be used increasingly in the future, although developments in pharmacology and photodynamic therapy and interventional radiology may reduce the traditional indications for the operation.

Key words: history of surgery; hysterectomy; photodynamic therapy; endometrial resection; myolysis; embolization. * Correspondence to: Waterden Road Clinic, 8 Waterden Road, Guildford, Surrey GU1 2AW, UK. BailIikm ~ Clinical Obstetrics and Gynaecology--

Vol. 11, No. 1, March 1997 ISBN 0-7020-2262-4 0950-3552/97/010001 + 22 $12.00/00

1 Copyright © 1997, by Bailli~re Tindall All rights of reproduction in any form reserved

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H I S T O R Y OF T H E H Y S T E R E C T O M Y Christmas day 1809 was the first time the human abdomen was deliberately opened in order to remove a diseased organ, in this case a massive ovarian cyst. The pioneering surgeon, Ephraim McDowell (1771-1830) (Figure 1) a Scotsman who had trained in Edinburgh operated on Jane Todd Crawford, a distant cousin of Abraham Lincoln. McDowell visited the patient on December 13, at her home in Greensburgh, Kentucky and found that the 47 year old had a massive tumour which was causing breathing difficulties and making her life a complete misery. They agreed an operation was the only solution and she rode to McDowell's home in Danville, 60 miles away, with the tumour resting on the pommel of the saddle. In those days there was no anaesthesia, antisepsis or antibiotics and the procedure was performed on McDowell's kitchen table, whilst the patient recited psalms to distract her attention. In these litigious times surgeons are naturally apprehensive of the outcome of their work, but pity poor Ephraim McDowell who had to contend with the knowledge that several of his townsfolk were erecting a gallows for him, should the patient die at the hands of 'the dreadful doctor'. McDoweU made a 9 inch paramedian incision, ligated the left tube and the ovarian pedicle close to the uterus, and emptied some gelatinous fluid from the tumour enabling him to deliver it through the incision. The turnout weighed 10.2 kg and McDowell had to tilt the patient to spill out any blood from the peritoneal cavity and then replace the bowel and sew the pedicle to the lower end of the wound, which he closed with interrupted sutures. The entire operation took only 25 minutes and 5 days later the patient was up and about and able to make her own bed in McDowell's house. She rode home to Greensburgh 20 days later in excellent health and apparently lived to a ripe old age. Although this was the first successful major abdominal operation through the peritoneum, McDowell did not publish the event until about 9 years later, after which time he had performed several other 'ovariotomies'. During his life time he performed 13 of these procedures and only one patient died. This was an extraordinary record for those times when sepsis and peritonitis exacted a frightening toll following laparotomy. Others tried to emulate him and a fellow student from Edinburgh, John Lizzars, made his first attempt 14 years later. However, the patient died and he then made three more successful attempts in 1825. In spite of these successes, it was the English surgeon, Charles Clay (1801-1893) (Figure 2), who was the first to introduce the word 'ovariotomy'; a strange choice for the title of this operation, in an age when surgeons were usually reared in the classics and therefore etymologically correct (Morton, 1965). Clay was regarded as the greatest ovariotomist in Europe. He performed his first operation on September 13, 1842, when, in the presence of several of his medical colleagues, he operated at the patient's house in Ancoats, Manchester. The tumour he removed weighed 17 lb 5 oz and the operation took 40 minutes. The patient, who only had brandy and milk for analgesia, made a satisfactory recovery. In his

HYSTERECTOMY: A HISTORICAL PERSPECTIVE

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Figure 1. Ephraim McDowell, who pertormed the world's fi~,'sttaparotomy in Danville, Kentucky, in 1809.

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Figure 2. Charles Clay, who performed the world's first hysterectomy in Manchester, Enghmd.

lifetime, Clay performed 395 ovariotomies with a mortality of only 25. Although he accepted the need for anaesthesia following its introduction by Morton in Boston in 1846, he nevertheless felt that it interfered with his good results, because he clearly was of the opinion that patients who

HYSTERECTOMY: A HISTORICAL PERSPECTIVE

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had the fortitude to undergo surgery without it were imbued with a greater will to survive.

The first abdominal hysterectomy Clay was born at Bredbury, near Stockport, England, in 1801. He was brought up by his uncle in Manchester, where his school career was disrupted and on the whole unsatisfactory. He spent his early medical career as an apprentice to Kinder-Wood, at Manchester's St Mary's Hospital. Clay studied at the Manchester Royal Infirmary and later spent time in Edinburgh before settling down to a busy surgical practice in Ashton-underLyne, 10 miles to the east of Manchester. After 16 years there, during which time he gained a reputation for his surgical work, he moved to the centre of Manchester where, in 1839, he established his practice. The world's first hysterectomy was performed by Clay in his consulting rooms in Piccadilly, Manchester (Figure 3) currently above a sports shop. In a contemporary illustration (Figure 2) we see him at the peak of his surgical career, complete with top hat, looking profoundly confident. He was in fact a contemporary of my great, great, great grandfather, who had established a large Chartered Surveyors and Auctioneers business in Spring Gardens, half a mile to the west. All of Clay's first five ovariotomies survived, but his sixth case was not so lucky. He had diagnosed a large ovarian tumour but, on making the incision, the patient coughed and extruded a huge uterine fibroid

Figure 3. Charles Clay's consulting room in Piccadilly, Manchester, site of the world's first abdominal hysterectomy.

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which he was unable to replace. He therefore had no choice but to continue with a subtotal hysterectomy; this took place on November 17, 1843. Coincidentally, a few days later, A.M. Heath, of Manchester, also opened an abdomen suspecting a large ovarian tumour and found a massive fibroid; in both cases the women died from massive haemorrhage soon afterwards. The following year, Clay found himself in a similar situation and again proceeded to perform a subtotal hysterectomy, having placed a ligature of Indian hemp round the supravaginal cervix. On this occasion the patient survived the operation but died 15 days post-operatively, having fallen out of bed. This was sad, not only for the patient, but for Clay also, as the patient had in fact survived the critical immediate postoperative period and not succumbed to sepsis, the usual cause of death. However, reading the contemporary accounts of this patient's postoperative course, it is difficult to determine the exact mode of death. Some accounts suggest that she had a secondary bleed and died of haemorrhage after falling out of bed; it is not inconceivable that the ligature had included both ureters and the woman fell out of bed owing to uraemic coma. It is, however, suggested that she was dropped on the floor by a pair of porters whilst the nurses were changing the bed linen. If this is true, the death was entirely unrelated to the operation and Clay could have claimed to have performed the world's first successful hysterectomy. It was not for a further 20 years that Clay was able to claim the first successful hysterectomy in Europe.

The first successful abdominal hysterectomy Ellis Burnham, of the USA, performed the first successful hysterectomy with a patient surviving (Graham, 1951; Benrubi, 1988) This took place in Lowell, Massachusetts in 1853; again the diagnosis was incorrect and Burnham thought he was operating on a massive ovarian cyst. On this occasion when the abdomen was opened the patient vomited and, as with Clay's case, extruded a large fibroid. Burnham tied off both uterine arteries and carried out a subtotal hysterectomy from which the patient survived. This was an amazing achievement and he performed 15 further hysterectomies during his 13-year career; sadly only three patients survived, the rest dying from peritonitis, sepsis, haemorrhage and, somewhat surprisingly, exhaustion. Early records of the first abdominal hysterectomies read like a disaster saga until Burnham produced the first survivor, but even in that instance the diagnosis was wrong (Table 1). However, later the same year Kimball, of Massachusetts, carried out the first deliberate hysterectomy owing to a fibroid turnout, and the patient survived the operation (Kimball, 1855; Benrubi 1988). The patient made a full and complete recovery, although the protruding ligatures were still causing inconvenience 8 months later. In the early years of hysterectomy the ligatures were brought through the lower part of the incision and left long in order to encourage the drainage of pus. Long ligatures were the custom of the day when the main vessel in an

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Table 1. A summary of the abdominal hysterectomies performed in the early years (1843-1863). Date

Operator

Diagnosis

Outcome

t 843 1843 1844 1846 1853 1863 1863 1863

Clay Heath Clay Bellinger Burnham Kimball Clay Koeberld

Ovarian tumour Ovarian tumour Ovarian turnout Fibroids Ovarian tumour Fibroids Fibroids Fibroids

Haemorrhaged a few hours after the operation and died Haemorrhaged a few hours after the operation and died Fell into a coma on day 15 and died Haemorrhaged on day 5 and died Survived Survived Survived Survived

amputated limb was tied. In fortunate circumstances the ligature became detached some weeks after the procedure, but it is obvious now that a retained ligature was a contributing factor to sepsis. It is difficult to understand why gynaecologists adopted this technique. It may be that both Kimball's case and that of John Lizzars, in which a patient died from a short ligature being allowed to drop into the wound, prompted a whole generation of surgeons to use the long ligature. However, this extraordinary practice retarded the progress of gynaecological surgery for almost half a century. Introduction of anaesthesia

Kimball's patient was also the first to reap the benefits of anaesthesia, in this case chloroform. In the early days, surgery made very slow progress because of the severe limitation of effective analgesia during surgery, as well as post-operative infections. Before the discovery of anaesthesia, surgeons relied on opiates, plants containing hyoscyamus and mandragora, and alcohol in order to desensitize their patients to the pain of surgical procedures. In 1772, Joseph Priestly discovered nitrous oxide gas, later known as 'laughing gas' because of its ability to induce amusement and euphoria. Humphrey Davey (1778-1829), the inventor of the miner's safety lamp, noted a reduced sensitivity to pain in people who tried the gas and suggested that it might be useful during surgery. Unfortunately, no one followed up his suggestion. By 1831, ether, nitrous oxide and chloroform, the three basic anaesthetic agents, had been discovered, although their analgesic properties had not been applied medically. Probably the first use of anaesthesia in surgery was by Crawford W. Long (1815-1878) of Georgia who, in 1842, used nitrous oxide during three minor surgical procedures. However, he did not realize the significance of this and made no effort to publicize his discovery until several years later when anaesthesia had been hailed as a major breakthrough. Dentistry was the first profession to use anaesthesia, presumably because of the extreme sensitivity of the teeth and gums. A Connecticut dentist, Horace Wells (1815-1848), learnt of the peculiar properties of nitrous oxide in 1844 and tested them by having his tooth removed whilst under the influence of the

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gas. He was delighted with the results, and administered it to several patients before demonstrating it at Harvard, where, unfortunately, the patient cried out and Wells was booed and hissed out of the room. However, Wells' colleague and dental student, William T.G. Morton (1819-1868), demonstrated the effectiveness of sulphuric ether in inducing dental anaesthesia before the same medical class on October 16, 1846. This first successful public demonstration of surgical anaesthesia at the Massachusetts General Hospital became known as 'Ether day'. Morton is universally regarded as the world's first anaesthetist. Although ether became immediately popular the Boston medical community were at a loss to describe the condition induced by this new agent; Oliver Wendell Holmes suggested the name 'anaesthesia'. James Simpson of Edinburgh abandoned ether in favour of chloroform, because of its odour, irritating properties and long induction period. During the next century, chloroform continued to be the agent of choice in Europe until its toxicity and delayed liver damage became appreciated. Simpson employed anaesthesia in childbirth which was opposed and condemned by the Calvinist Church fathers as contrary to their beliefs. But this may have became more acceptable after John Snow (1813-1858) used it for Queen Victoria's delivery of Princess Charlotte. It was fortunate she did not suffer the liver damage associated with its use. When Clay presented his results to the Obstetrical Society of London in March 1863, he described 108 operations for ovarian tumours with 34 postoperative deaths. He was inclined to lay the blame for the worsening results on the advent of general anaesthesia. Clay said: 'I am not certain if chloroform has really added to the success of ovarian operations. The first 14 of my cases were undertaken before it was discovered and of these 14, nine recovered. But though I willingly admit the almost impossibility of obtaining the consent of females to submit to so formidable an operation without the aid of this valuable agent ... if it could be accomplished, I would infinitely prefer to operate without it, as the patient would bring to bare on her case a nerve and determination which would assist beyond all value the after treatment'. In spite of Clay's reservations there was no doubt that the invention of anaesthesia went a long way to making surgery more acceptable. Nowadays one can only wonder at the horrendous suffering that these women had to endure when they were split from sternum to symphysis pubis by a cold surgical knife, having little to comfort them but some milk and brandy or, in the case of Jane Todd Crawford, the comfort of reciting the psalms. Dawn of the new era

Clay used the long ligature procedure throughout his career and Lawson Tate, of Birmingham, the first surgeon to successfully operate on an ectopic pregnancy, believed that if the ligature was short and the wound completely closed, the mortality rate would probably fall to 6 or 8%. Such results were achieved by Isaac Baker Brown of St Mary's Hospital in Paddington,

HYSTERECTOMY: A HISTORICAL PERSPECTIVE

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London. Baker Brown cauterized the ligated ovarian pedicle in 40 patients before closure of the abdominal wound on 40 occasions with only four deaths. This man came from London's greatest teaching hospital, St Mary's Hospital in Paddington and sadly went the way of so many in our profession in the past and even in present times. He somehow went off at a

Fignrc 4o Thomas Keitt-~ who drastically ~cduccd the mortality a~ld morbidity of hysterectomy by his treatment of the cervicai stump.

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tangent and in 1865 published a paper on 'The cureability of some forms of insanity, epilepsy and hysteria by clitoridectomy'. Unfortunately, he also advertised the success of this procedure and as a result he fell from grace and was expelled from the Obstetrical Society of London and died in obscurity. Because of this, his technique of ovariotomy failed to be adopted and it fell to Thomas Keith (Figure 4), an apprentice of James Young Simpson, to rediscover this manoeuvre. Thomas Keith was probably the greatest analytical surgeon in our speciality during the late 19th-century. He was a wild looking man, born in the Manse of St. Cyrus, near Montrose in the Scottish Borders and was a lifelong sufferer from cysteine stones for which he required many operations which probably accounts for his rather startling appearance (Figure 4). His brother George was present at Simpson's first chloroform experiment, as was Matthews Duncan of placenta fame, and one can only hope that Thomas availed himself of chloroform when he underwent his repeated tithotomies. Thomas Keith perfol-med his first ovariotomy in September 1862, but the initial mortality was high. This was around the time that Lister was advocating antiseptic surgery, although Keith found that the carbolic spray did not help to reduce his operative mortality. He therefore turned his attention to the method of wound closure, abandoning the long ligature and exteriorized clamp that Spencer Wells had popularized and instead cauterized the pedicle and dropped it into the peritoneal cavity, which he then drained. He was also a vigorous opponent of the technique of bloodletting and out of 156 cases reported only six deaths (3.8% mortality). His hysterectomy results were no less impressive and by the time he left Edinburgh for London he had recorded 33 cases with only three deaths. Appalling results were achieved by Spencer Wells, a Society dilettante who considered himself the greatest gynaecological surgeon in Europe at that time and drove from hospital to hospital in London in his 'brougham and silver grey four' produced results that were appalling and out of 40 hysterectomies performed for fibroids, there were 29 deaths--a mortality rate of 73%. Wells' opponent, Lawson Tate, a rather aggressive character who loathed Spencer Wells, found that despite using carbolic spray he still had a 38% mortality with his first 50 ovariotomies. He then realized that it w a s not the spray that had given Keith his excellent results (indeed there is no evidence that Keith ever used it) but the intraperitoneal method of dealing with the pedicle. He immediately adopted this technique, abandoned the carbolic spray and of his next 73 patients only two died. Tate also learned the value of cleanliness from both Lister and Keith which was unusual in those days, as no surgeons wore gloves and very few washed their hands before operating. The early hysterectomies were sociable affairs and it was considered good form to bring along friends, both medical and non-medical, to witness these momentous surgical events (Figure 5). Tate summed up the end of this rather dark era in gynaecological surgery as 'the ovarian tumour was the battlefield whereupon the first abdominal engagements were fought. Whereas ovariotomy undoubtedly opened the gateway to abdominal surgery, Spencer Wells by his outmoded

HYSTERECTOMY: A HISTORICAL PERSPECTIVE

t 1

Figure 5. French gynaecolt~gist Pean perf~rmitag an early hys!erectomy before a crowd in Paris. Note the absence of gloves and masks.

technique and resultant mortality of 25% undoubtedly held back progress, because no one would subrnit women to such fearfl~l risk unless life were already threatened. Dr Thomas Keith ended this dark period by showing us how to operate on the abdomen without fear and with little risk' (Table 2).

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Date

Cases

Deaths

Mortality (%)

Tait Wells Koeberl6 Schroeder Pean Keith

1882 1882 1882 1884 1881 1883

30 40 19 100 51 25

10 29 10 32 18 2

33 73 52 32 35 8

The first successful hysterectomy in Europe Although Clay took great pride in his experience with ovariotomy, in his important presentation to the Obstetrical Society of London, he mentioned a successful case of the entire removal of the uterus and its appendages (Clay, 1863). This was the first successful hysterectomy in Europe and it is important to emphasize this, as many reference books give priority to Koeberl6 of Strasbourg who performed an operation on April 2, 1863. Clay performed his first successful hysterectomy with oophorectomy and salpingectomy on January the 3rd, 1863, 3 months before Koeberl6, and described it in his presentation to the Obstetrical Society of London on March the 3rd, 1863. He therefore superseded Koeberl6 by 3 months and would have been able to make this claim 19 years earlier if the patient had not fallen out of bed and died 15 days post-operatively. Clay's second successful operation was well authenticated by three doctors and immediately after the surgery Professor J.Y. Simpson of Edinburgh arrived. He was greatly interested in the case, took the specimen back to Edinburgh and, sometime later returned a description and a sketch, ending his letter 'your case may turn out as a precedent for operative interference in some exceptional cases of large fibroids of the uterus and I congratulate you most sincerely on the happy recovery of your patient'. Koerberl6 used a slightly different technique. The operation was planned and the diagnosis of fibroids was correct, but to obtain haemostasis he used a device called the serre-noeud (Figure 6). Wires were twisted around each half of the cervix, which was then exteriorized through the abdominal wound until it sloughed off and fell internally and the clamp could be removed. Unfortunately, mortality from the abdominal approach to hysterectomy was reported as exceeding 70%, even as late as 1880.

Early vaginal hysterectomies The origins of vaginal hysterectomy are obscure, but the first operation was reputedly performed by Soranus in the Greek city of Ephesus in AD 120, although there is an even more vague reference to the procedure having been performed 50 years before the birth of Christ by Themison of Athens (Lameras, 1975). According to the medical historian Richard Leonardo, Soranus removed an inverted uterus that had become gangrenous (Leonardo, 1944). The ureters and often the bladder were invariably part of

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Figure 6. The serre-noeud introduced by Koeberl6 of Strasbourg, who performed the first hysterectomy with survival in continental Europe,

these early surgical excisions and the patients usually died. Nevertheless, Alsaharavius, a physician in the llth century clearly stated that if the uterus had prolapsed externally and could not be reinserted, it should be surgically excised (Benrubi, 1988). It is unlikely he would have advocated this practice if death was the invariable result. In fact there are several reports of patients surviving vaginal hysterectomy in the middle ages, and these are referred to in medical writings in the 16th and 17th centuries. The first authenticated case of a partial vaginal hysterectomy was reported by Berengarius da Carpi who lived in Bologna in AD 1507 and was reputed to have performed a partial vaginal hysterectomy. Schenck of Grabenberg reported 26 cases during the early part of the 17th century and the operation was also performed by Andreas da Crusce in 1560 and Valkaner of Nuremburg in 1675, when the patients appeared to have survived. Modem medical historians are somewhat sceptical about some of these early reports and, as usual, have largely ignored the contribution of the midwives of Europe who, from time to time, amputated prolapsed or inverted puerperal uteri. They have overlooked an early example of selfhelp: in the case of Faith Howard, a 46 year old peasant woman, who performed the operation on herself. This case was well documented and reported in 1670 by Percival Willoughby, an early male midwife and lifelong friend of William Harvey, the discoverer of the circulation. Apparently, whilst carrying a heavy load of coal her uterus prolapsed completely and, frustrated by this frequent occurrence, she grabbed the organ, pulled as hard as possible and cut it off. In his report, Willoughby states that 'there was a mighty bleeding which eventually stopped' and she

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lived on for many years, 'water passing from her insensible day and night', obviously from a vesicovaginal fistula.

The first elective vaginal hysterectomies Baudelocque of France introduced the technique of artificially prolapsing and then, in favourable cases, cutting away the uterus and its appendages. He performed 23 of these procedures over 16 years from 1800, but credited Lauvariol with performing the first in France. This was well before the first abdominal operation performed by Clay in 1843. Most of these procedures were performed on puerperal uteri and were undertaken on an emergency basis, but the first planned procedure was by Osiander of Gottingen in 1801. He did not report the case until he had operated on his ninth patient. In 1810, Wrisberg , in a prize essay read before the Vienna Royal Academy of Medicine, advocated vaginal hysterectomy for cancer and 2 years later this was performed by Paletta despite being uncertain that he had extirpated the entire uterus. Conrad Langenbeck (Figure 7) of Gottingen, was a surgeon of such supreme swiftness that he once amputated a shoulder while a colleague, who had come to observe the procedure, turned his back for a moment to take a pinch of snuff. He was surgeon-general to the Hannoverian army, a professor of anatomy and surgery, and certainly the most distinguished surgeon of his day. He had read both Wrisberg's and Paletta's reports and was encouraged to perform the first deliberately planned vaginal hysterectomy for carcinoma in 1813. He did not, however, report the operation until 1817 and because of the abuse that he was subjected to, he probably regretted ever doing it. Langenbeck had little precedent to follow, so he devised his own plan for the removal of the entire uterus. He performed a retroperitoneal dissection, taking great care not to enter the peritoneal cavity. Unfortunately, towards the end of the operation the patient haemorrhaged and his assistant, debilitated by gout, was unable to rise from his chair fast enough. Langenbeck grasped the bleeding artery with his left hand and with his right passed a needle carrying a ligature through the tissues beyond the bleeding point. He tied the ligature by grasping one end between his teeth and secured the pedicle with a one handed slip knot tied with his fight hand. Following the procedure he could detect no opening into the peritoneal cavity and the patient made a surprising and uneventful recovery. Sadly, after such a display of surgical virtuosity, none of his colleagues believed the report of his operation when it was published 4 years later. The specimen had been lost so it never reached the pathology department, the assistant had died 2 weeks later, so there was no one to testify that the procedure had in fact taken place, and the patient was demented and thus an unreliable witness and died of senility 26 years later. Only then was it shown at post-mortem examination that he had performed the operation. During that 26 years he was ridiculed and subjected to the jibes of his colleagues and no one gave him credit at the time for this spectacular achievement.

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Figure 7. Conrad Langenbeck, surgeon general to the Hannoverian army, who performed one of the first vaginal hysterectomies for carcinoma.

Further developments in technique Further developments took place in the latter years of the last century and the technique for abdominal hysterectomy was refined and standardized by Freund. Czerny, following Langenbeck's original description, achieved the same for vaginal hysterectomy (Ricci, 1945). The first planned hysterectomy performed on a gravid uterus took place in 1876 by Porto of Milan (Speert, 1980).

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Radical hysterectomy for cervical cancer was introduced by the German surgeon Schuchardt and later refined and popularized by Ernst Wertheim, a Viennese surgeon after whom the operation is now named. The end of the 19th century and the early part of the 20th century witnessed the introduction of specially modified instrumentation, anaesthesia and antisepsis. The mortality rate for vaginal hysterectomy decreased significantly: by 1886, approximately 15%; by 1890, 10%; and by 1910, 2.5%. Abdominal hysterectomy lagged far behind and at one time it was formally condemned by the Academy of Medicine of Paris, when they met in 1872. Even 8 years after that, T.G. Thomas reported on 365 collected cases with a mortality of 70%. It is extraordinary that, despite this high mortality, women agreed to the procedure. There was a time that it was advocated for hysteria and menstrual melancholia, the modern equivalent of which is the pre-menstrual syndrome. In spite of these disastrous results, progress in abdominal hysterectomy was being made. Mikulicz abandoned the serre-noeud after using it for 15 years and instead placed triple ligatures on the broad ligaments and tied each one of them separately. In 1878, Freund introduced techniques for packing off the intestines, ligating the major blood vessels and coveting the cervical stump with peritoneum which, in the same year, had been practised independently by both Schroeder and Wells. In 1889, Lewis Stimpson advocated the systematic ligation of the main ovarian and uterine vessels instead of tying off the entire broad ligament and 3 years later, Bare of Philadelphia, the father of the modern subtotal hysterectomy, tied the uterine vessels 'outside of, but close to, the cervix'. He was also the first to advocate ' c a r e . . . to avoid the ureter'! This technique was further refined in 1896 by Howard Kelly, who described an immaculate technique for subtotal hysterectomy little different from that employed today. Thus, in the space of a decade, exterior fixation of the uterus by the serre-noeud or a cervical clamp, such as that designed by Wells, had been replaced by intraperitoneal treatment of the cervical stump, which itself was modified and became extraperitoneal again, by covering the stump with pelvic peritoneum. These new techniques are reflected in the statistics from the London teaching hospitals in 1896 and 1906 (Table 3), showing an impressive drop Table 3. A summary o f t h e a b d o m i n a l hysterectomies performed for fibroids in London, (1896 and 1906). 1896 Hospital

1906

Cases

Deaths

Cases

Deaths

St Bartholomew's St George's St Thomas' Middlesex University College Soho Hospital for Women St Mary's (Samaritan) Chelsea

7 1 5 6 3 1 17 9

3 0 2 1 0 0 4 1

26 8 40 50 21 60 37 80

4 0 2 0 1 1 2 1

Total

49

11 (22%)

322

11 (3.4%)

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in mortality from 22 to 3.4%, allowing one of my distant relatives John Bland Sutton to write in 1904: 'The removal of the uterus is followed less frequently by unpleasant sequelae than any other major operation in surgery. Hysterectomy has a wonderful future, and this is a great thing to say of an operation which 40 years ago had no more reality than "Jack the Giant Killer".'

Development of hysterectomy in the 20th century Up until the end of the Second World War, the universal approach to hysterectomy was the subtotal procedure, with the reduced chance of pelvic infection and ureteric injury, but mainly in the pre-antibiotic era, to reduce the chance of ascending infection and peritonitis, which was almost invariably fatal. Once the problem of ascending infection and peritonitis had been eradicated by the development of antibiotics, hysterectomy almost invariably included removal of the cervix. The first total hysterectomy was performed by E.H. Richardson of the USA in 1929 (Richardson, 1929). His main concern in moving away from the traditional subtotal procedure, was to prevent the occurrence of cervical stump carcinoma, yet even in the days before cervical screening was available, the actual incidence of neoplastic change in retained cervical stumps was only 0.4% in 6600 cases in the USA (Cutler and Zolenger, 1949) and 0.1% in Finland (Kilkku et al, 1985). As Lyons of the USA (1993) pointed out, this is similar to the rate of vaginal cancer following total abdominal hysterectomy and yet no one has seriously recommended the removal of the vagina at hysterectomy as prophylaxis against this. Apart from the change from subtotal to total hysterectomy during the 20th century, the only change in the abdominal procedure was the almost universal adoption of the less disfiguring transverse incision introduced by Johannes Pfannenstiel of Breslau, in 1900. Unfortunately this great surgeon died at the young age of 47, following a needle-stick injury in much the way as his Viennese colleague Semmelweiss, who taught the world the value of antisepsis in the prevention of puerperal fever, had done before him. Apart from the obvious cosmetic attraction of the transverse incision, it had a much higher tensile strength and was less prone to wound dehiscence and subsequent incisional hernia. Nevertheless, it took many years to be universally accepted and my predecessors in Guildford were still employing large vertical incisions even in the 1980s. Increased surgical skill and prowess from an apprenticeship type of training has ensured that the operation now is extremely safe with an incidence of ureteric injury of 0.2 to 0.5% and a mortality of 0.12% (Amirikiah and Evans, 1979; Daly and Higgins, 1988). The advent of prophylactic anticoagulants and antibiotics has further increased the safety of this procedure. Dicker et al (1982) showed the superiority of vaginal hysterectomy (morbidity, 24.5%) compared with abdominal hysterectomy (morbidity, 42.8%). These figures are an eloquent testimony to the efficacy of prophylactic antibiotics, since those who had a vaginal hysterectomy had the benefit of these drugs, whereas those who had an abdominal hysterectomy did not.

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Almost inevitably the increased safety of the operation led to an explosive increase in the number of hysterectomies performed, so that it is now the second most common operation undertaken in the USA with over 650 000 being performed annually at a cost of approximately three billion dollars. With this increasing safety the indications for the procedure had become more wide, such that up to 50% of American women at the end of the past decade underwent hysterectomy. Not only had the procedure become open to a certain amount of abuse, but technological advances, apart from endometrial ablation, had largely by-passed hysterectomy and during the mid part of this century, gynaecological surgery was in the doldrums.

Development of laparoscopic surgery Laparoscopy was introduced into continental Europe in the 1940s by the pioneering surgery of Hans Frangenheim of Konstanz and Raoul Palmer of Paris. It was largely ignored in the UK and North America until Patrick Steptoe, working in a small district hospital in Oldham, Lancashire, published the first book in the English language (Steptoe, 1967) which allowed wide dissemination of this new technique in the English speaking world. Laparoscopy became an enormously important diagnostic tool in gynaecology and even allowed the performance of relatively minor procedures, such as female sterilization, ventrosuspension and puncture or fenestration of ovarian cysts. In the early years it was necessary to operate directly down the laparoscope in an uncomfortable position, which certainly contributed to my own prolapsed intervertebral disc and I suspect many of my colleagues also developed occupational injury to their backs. The catalyst needed to catapult this new surgical approach from fantasy to reality was the development of small silicone chip cameras, enabling the entire operating team to participate in the surgery by way of a television monitor and superior optics. The rod lens system and external cold light source were developed by Professor Harold Hopkins, of Reading University. Gradually, gynaecological surgery became more sophisticated owing much to the pioneering work of Professor Kurt Semm of Kiel University, Germany, and Professor Maurice Bruhat and his team of Clermont-Ferrand, France. Minimally invasive surgery had become a reality, and for a long time gynaecologists struggled with primitive surgical equipment and relied on advances in laser technology and electrosurgical devices to achieve cutting and coagulation. Our general surgical colleagues took an astonishingly long time to wake up from their slumbers before realizing that the procedure par excellence suited for endoscopic surgery was the removal of the gall bladder. Even then, it took a gynaecologist (Philippe Mouret) from Lyon, France, to show them how it was done. The advantages of endoscopic surgery encouraged instrument manufacturers to produce a new generation of surgical equipment; scissors that cut and devices that could quickly and effectively secure vascular pedicles with clips, sutures or linear arrays of titanium staples.

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In a remarkably short time, these techniques were adopted intemationally so that, at the time of writing, at least 80% of gynaecological operations are performed using endoscopy with several small access ports for the surgical instruments. This has resulted in shorter hospitalization and a rapid return to work.

Laparoscopic hysterectomy Harry Reich performed the world's first laparoscopic hysterectomy in 1988, at Pennsylvania's William Nesbitt Memorial Hospital. He published his article the following year (Reich et al, 1989). Subsequently he demonstrated this technique worldwide. Critics claimed that it took too long and would not be suitable for the busy operating schedules of most countries, where the average gynaecologist performs only one or two procedures a week (Sutton, 1994a,b). The reason for the long operating time was that he performed the entire procedure laparoscopically, including dissecting out part of the ureter and individually ligating and tying off the uterine artery and vein with extracorporeal sutures. He also performed the colpotomy incision and repaired it laparoscopically. Other surgeons found this too time consuming and soon the procedure of laparoscopically-assisted vaginal hysterectomy became established, where the upper pedicles were ligated and, electrocoagulated or stapled whilst the remaining part of the operation was performed as a routine vaginal hysterectomy. Although this procedure was designed to replace an abdominal, not a vaginal hysterectomy, many cases were performed which clearly could have been completed entirely by the vaginal approach. Equally, it soon became evident that none of the laparoscopic part of the operation did anything to make the vaginal approach easier and because there is no descent until the uterosacral and cardinal ligaments are transected, and most surgeons found that with the limited access involved, the procedure became a very difficult vaginal hysterectomy. Cynics pointed out that this was in fact a complicated way of performing a vaginal hysterectomy, but it certainly had the advantage of honing vaginal surgical skills andallowed dissection of bowel adhesions laparoscopically, as well as the treatment of endometriosis and the easier removal of ovaries. It also had the advantage that the internal wound could be inspected at the completion of the procedure and any residual bleeding vessels could be sealed by bipolar diathermy ensuring that at the end of the procedure the field was absolutely dry. This did not however prevent secondary haemorrhages occurring a few days later or prevent subsequent haematoma formation. These various criticisms led some laparoscopic surgeons to develop a purer approach to the operation reverting to supracervical hysterectomy with removal of the transformation zone, either by coring it out with a serrated edge reamer (Semm, 1993; Ewen and Sutton, 1994), simply removing the transformation zone with an electrosurgical loop from below (Donnez and Nisolle, 1994), or coagulating it with the Nd:YAG artificial sapphire contact probe laparoscopically (Lyons, 1993). In this instance, the possibility of cervical carcinoma should theoretically be reduced to zero,

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although all authors recommend annual cervical cytological surveillance. It also avoids a vaginal incision, and the fundus and adnexae can be removed by morcellation. Additionally it has the advantage of avoiding any surgery in the danger zone around the ureter, is less likely to be associated with infection and abscess formation, maintains the integrity of the pelvic floor and is less prone to post-hysterectomy urinary dysfunction, since there is little bladder dissection and, arguably, it does not interfere with a patients sexual arousal and orgasm (Kilkku, 1983). Although this procedure enjoyed a good safety record, could be performed relatively quickly and the patients discharged 2 or 3 days postoperatively with return to full activity in 3 weeks (Ewen and Sutton, 1994), a number of patients have suffered persistent pain and bleeding and eventually had to have the cervical stump removed. A clinical audit (Haddad, 1995) found that this was only in patients whose indication for hysterectomy was endometriosis; if this group was excluded, then it was a very satisfactory operation. Other authors (Schwarz, 1993) have had a similar experience and we have found that since endometriosis is the main indication for hysterectomy in our department, its role has become somewhat limited. SUMMARY

Considering the time man has inhabited this planet, the history of hysterectomy is comparatively short and we have undoubtedly come a long way. Our pioneering forefathers had to contend with a horrendous mortality rate and very high morbidity, but with technological advances made during this century, particularly with regard to antisepsis and antibiotic prophylaxis of infection, together with safe anaesthesia, intravenous fluids and blood transfusion, the procedure is now very safe with a mortality rate of approximately 12 per 10 000 (Bachmann, 1990) and is increasingly performed to improve quality of life, rather than to save life. It is always difficult to predict the future, but almost certainly alternatives to hysterectomy will continue to evolve and, as with general surgery, many operations will be replaced by medical treatment. A clearer understanding of the aetiology of endometriosis creating a basis for rational treatment would considerably decrease the number of procedures performed. The widespread introduction of cervical screening has reduced the incidence of cervical cancer in the western world and, in the future, more effective screening for endometrial cancer could allow medical treatment in selected patients, although ovarian cancer will probably still require surgical treatment. Endometrial ablation with electroresection or the Nd:YAG laser has been successful in the treatment of menorrhagia, although some have suggested that the initial 1 year 87% success rate, which is widely reported, decreases rapidly and merely delays the need for hysterectomy for a time. This has not been the experience in our department (A. Pooley, personal communication) and we have found that even at the end of 5 and 6 years, 75%

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of the patients are still satisfied with the treatment and this has avoided a large number of hysterectomies. Increasingly the use of gonadotrophin-releasing hormone analogues and early detection by sophisticated ultrasound scanning will allow many fibroids to be treated by submucous resection via a hysteroscope, or myolysis (Goldfarb, 1995; Phillips, 1995) or embolization of the blood supply by the interventional radiologists. Newer methods of endometrial ablation that are already being developed, such as thermal balloons (VestaBlate; Valley Laboratory, Colorado) and new microwave systems, will be expected to provide much more uniform destruction of the endometrium and once perfected will probably result in complete amenorrhoea in most cases. With the development of less toxic photosensitizers, another means of treating the endometrium will be from photodynamic therapy, and almost certainly photobiological mechanisms triggered by lasers of a certain wavelength will target endometriosis, adenomyosis and even possibly ovarian cancer and will, almost certainly, render the way we use lasers now as something that our colleagues in the next century wilt regard as laughable. REFERENCES Amirikiah M & Evans TN (1979) Ten year review of hysterectomies: trends indications and risks. American Journal of Obstetrics and Gynecology 124: 431-437. * Bachmann G (1990) Hysterectomy. A critical review. 35(9): 839-862. * Benrubi GI (1988) History of hysterectomy. Journal of the Florida Medical Association. 75: 533-542. Clay C. (1863) Observations on ovariotomy. Statistical and practical. Transactions of the Obstetrics Society of London 5: 58-74. Cutler EC & Zolenger RM (1949) Atlas of Surgical Operations. New York: McMillan & Co. Daly JW & Higgins KA (1988) Injury to the ureter during gynaecological procedures. Surgical Gynaecology and Obstetrics 167: 19-21. *Dicker RC, Greenspan JR, Strauss LT et al (1982) Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. The collaborative review of sterilisation. American Journal of Obstetrics and Gynecology 144: 841-848. Donnez J & Nisolle M (1994) LASH: laparoscopic supra cervical (subtotal) hysterectomy. In Donnez J & Nisolle M (eds) An Atlas of Laser Operative Laparoscopy and Hysteroscopy. pp 195-202. Carnforth, UK: Parthenon. Ewen SP & Sutton CJG (1994) Initial experience with supracervical laparoscopic hysterectomy and removal of the cervical transformation zone. British Journal of Obstetrics and Gynaecology 101: 225-228. Goldfarb HA (1995) Bipolar laparoscopic needles for myoma coagulation. Journal of the American Association of Gynecological Laparoscopists 2: 175-179. Graham H ( 1951) Eternal Eve: The History of Gynecology and Obstetrics. New York: Doubleday. Haddad C (1995) Audit of the outcome of supracervical laparoscopic versus total abdominal hysterectomy. 11-40. Royal Surrey County Hospital Clinical Audit Department. (Annual Report) Royal Surrey Hospitals Trust, Guildford. *Kilkku P, Gronroos M & Rauramo L (1985) Supravaginal uterine amputation with pre-operative electro coagulation of endocervical mucosa. Acta Obstetrica et Gynaecologica Scandinavica 64: 175-177. * Kilkku P, Gronroos M, Hirvonen T & Rauramo L (1983) Supravaginal uterine amputation VS hysterectomy. Effects on libido and orgasm. Acta Obstetrica et Gynaecologica Scandinavica 62: 147-152. Kimball G (1855) Successful case of extirpation of the uterus. Boston Medical Surgical Joul~al 52: 249-255.

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Lameras K (1975) Galen and Hippocrates. Athens: Papyrus. * Leonardo R-A. (1944) History of Gynaecology New York: Foben Press. Lyons TL (1993) Laparoscopic supracervical hysterectomy using the contact Nd:YAG laser. Gynecological Endoscopy 2:79-81. Morton LT (1965) Garrison and Morton's Medical Bibliography, pp 527-537. London: Andr6 Deutsch. Phillips DR (1995) Laparoscopic lyomyoma, coagulation (myolysis) Gynecologic Endoscopy 4: 5-12. * Reich H, De Caprio J & McGlynn F (1989) Laparoscopic hysterectomy. Journal of Gynecological Surgery 5(2): 213-215. * Ricci JV (1945) One Hundred Years of Gynaecology. Philadelphia: Blakiston. Richardson EH (1929) A simplified technique for abdominal panhysterectomy. Surgical Gynaecology and Obstetrics 48: 248-251. Semm K (1993) Hysterectomy by pelviscopy: an alternative approach without colpotomy (CASH) In Garry R & Reich H (eds) Laparoscopic hysterectomy, pp 118-132, Oxford: Blackwell Scientific publications. * Speert H (1980) Obstetrics and Gynecology in America: A History. Baltimore: Waverly Press. Steptoe PC (1967) Laparoscopy in Gynaecology. London: Churchill Livingstone. Sutton CJG (1994a) Whither hysterectomy? Current Opinion in Obstetrics and Gynaecology 6: 203-205. *Sutton CJG (1994b) RCOG Historical Lecture 1993. 150 years of hysterectomy: from Charles Clay to laparoscopic hysterectomy. The Year Book of the Royal College of Obstetricians & Gynaecologists. London: RCOG Press. Schwarz RO (1993) Complications of laparoscopic hysterectomy. Journal of Obstetrics and Gynaecology 81: 1022-1024.