The History of Hysterectomy

Abstract

Vaginal hysterectomy dates back to ancient times. The procedure was probably first performed by Themison of Athens 20 years before the birth of Christ and definitely performed and described by Soranus of Ephesus in 120 AD. There are many reports of its use in the middle ages and, although some can be substantiated most were for the extirpation of an inverted uterus post-partum and the patients rarely survived.

Up until the beginning of the nineteenth Century it was considered certain death to open the peritoneal cavity by a surgical incision so the only realistic way to remove a uterus for cancer was by the vaginal approach and there are well documented successful vaginal hysterectomies by German surgeons such as Ossiander and Langenbeck who both came from Gottingen.

The first laparotomy deliberately performed to remove a massive ovarian tumour was by Ephraim McDowell on Christmas Day 1809 and was not in a famous University Hospital but in the small American frontier town of Danville in Kentucky when he operated on Jane Todd Crawford on his kitchen table without anaesthetic.

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 on the 15th day and it was not until 1853 that Walter Burnham from Lowell, Massachusetts achieved the first successful abdominal hysterectomy although again the diagnosis was wrong.

Later that year Gilman Kimball who was also from Lowell had the honour of achieving the first survivor of abdominal hysterectomy in the world when he removed a large fibroid correctly diagnosed before the operation.

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 sero-sanguineous 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 Pfannenstiel in 1900, there was little advance in hysterectomy techniques until the advent of endoscopic surgery and the performance of the first total laparoscopic hysterectomy by Harry Reich in Kingston, Pennsylvania in 1988.

Since general surgeons introduced laparoscopy to remove the gall bladder industry has risen to the challenge and new instrumentation of increasing sophistication including the use of robotics continues to refine hysterectomy leading to increasing safety for the patient and less fatigue for the surgeon.