Imagine carrying a load of laundry down the garden path in 1670 and having your uterus fall out. Such a thing happened to a 46-year-old peasant named Faith Haworth, who, exasperated by this frequent inconvenience, grabbed the organ, yanked it out, and cut it free with a knife. Faith thereby performed the first recorded successful vaginal hysterectomy.(6)
Or imagine seeking care for pelvic pain or vaginal bleeding in an era when the direct discussion of sexuality and reproduction was considered indecorous.(5)
Then imagine a common fate that was even worse than death in childbirth — a leaking stench resulting from traumatized vaginal tissues that prevented you from ever interacting in society again. (5)
Prior to the mid-nineteenth century, women who went underwent pelvic surgery or gynecological care were subjected to doctors’ lack of anatomical knowledge, an absence of accepted germ theory — neither hand washing nor sterilized instruments — and the absence of anesthesia.
In the early modern period, roughly 1400 to 1800, childbirth included a morality screening, when midwives who helped with births were expected to go beyond their medical role and enforce the moral norms of their communities.
Once a woman entered into the throes of labor — and was presumably more disposed to tell the truth — her midwife was required to ask her to name the father of the child, thereby exposing any adulterous hanky panky.(7)
For centuries, a sense of “appropriateness” continued to keep doctors from adequately treating women for reproductive problems. Doctors were further impeded by the lack electrical lighting (you can’t treat what you can’t see) and inadequate instruments.(5)
Dr. Anthony Tizzano, OB/GYN and historical consultant for the PBS series “Mercy Street,” explained that military misfortunes such as the Civil War Period, and the field surgery techniques learned as a result, did much to move expertise in abdominal surgery forward. This benefitted the field of gynecology, a primarily surgical field at its inception.
As obstetric and gynecological care became medicalized, maternal death in childbirth decreased, and women’s quality of life increased exponentially.(5)
The Most Dreaded Complication of Childbirth
In the 19th century, Dr. Marion Sims described a common side effect of childbirth as “one of the most loathsome maladies that can possibly befall poor human nature.”(9) The condition known as vesicovaginal fistula resulted from the crushing pressure on the vaginal canal during childbirth.
Vaginal fistula occurs when a hole develops between a woman’s bladder and vagina. A doctor in 1857 described the consequences of the condition, “The urine passing into the vagina as soon as it is secreted . . . It trickles constantly down her thighs, irritates the integument with its acrid qualities, keeps her clothing constantly soaked, and exhales without cessation its peculiar odour...”(8)
Vesicovaginal fistula, given the odor resulting from the constant trickle of urine, rendered a woman a social pariah.
“It was difficult finding a way to fix that, and a way that actually worked, until they had the proper instruments, and primarily the proper suture material, that didn’t encourage infection in the wound,” said Tizzano.
In the mid-1800s, Dr. Marion Sims performed the first successful surgical repair of a vesicovaginal fistula, thus rendering the debilitating condition to the annals of history and saving women from one of the terrors of childbirth.
Sims is also credited with the adoption of the “knee-chest position.” This kneeling, head-down position, along with the advent of electrical lighting pulled back the curtain, so to speak, on female reproductive health.(5) Doctors who could now see the intimate terrain of women’s bodies were better able to diagnose and treat them.
In addition, Sims popularized the use of silver suture monofilament, revolutionizing surgical care.
“Previously, doctors used braided sutures which wicked bacteria from the vagina and into the womb you are trying to repair, causing it to become infected,” Tizzano explained.
Sims’ success remains controversial, as he performed experimental surgery on African American slave women. These women, as Durrenda Ojanuga pointed out, couldn’t truly consent as they were “totally without any claims to decision making about their bodies or any other aspect of their lives.” (8)
Tizzano, who prefers to steer clear of the social side of gynecological history, nevertheless has a pragmatic view of the Sims controversy.
“I think weighing and measuring advances in history can be done fairly and we need to do our best to do that. There is certainly something that I am doing today that in another fifty years people will be saying, ‘I can’t believe they used to do this.’ As doctors we have to be humble.”
Timeline of Gynecological History
1500 B.C. -
Ebers Papyrus portrayed the uterus as a wandering animal — usually a newt, tortoise or crocodile — moving about within a woman’s body.(1)
460-370 B.C.
Hippocrates, the Father of Medicine, wrote that the female uterus went wild when deprived of semen.(1) He also used a pomegranate as a pessary, inserting it in the vagina to correct a collapsed uterus, a condition called uterine prolapse.
50 B.C.
First recorded reference to a hysterectomy by Themison of Athens.(6)
98-138 A.D.
Soranus of Ephesus was the first to describe the uterus based on human dissection.
12th century
The Doctrine of the 7 Chamber Uterus arises.
1237
“Furen Daquan Liangfang” (“The Complete Book of Efficacious Prescriptions for Women”), a voluminous Chinese treatise on gynecology and obstetrics was produced by Chen Ziming. It became an important reference work for later periods. (6)
1452-1519
Leonardo da Vinci provided the first anatomically correct illustration of a fetus in utero.(9)
1500
The first successful caesarian section was performed.
1812
The first vaginal hysterectomy was an accident! Palletta of Milan was planning to remove his patient’s cervix for suspected cancer, when he inadvertently removed the entire uterus. The patient died three days later of sepsis.(4)
1843
The first abdominal hysterectomy was performed in England by Charles Clay.(4)
1838
Dr. Marion J. Sims performs the first successful operation to correct a vesicovaginal fistula.(9)
1890s
The first series of successful C-sections were performed. (12)
1900
Spinal anesthesia was first used in labor.(12)
1941
The first screening test for cervical cancer was introduced.(12)
1950s
Using adaptations from the ultrasounds used to detect submarines during World War II, British physician Ian Donald collaborated with engineer Tom Brown to create medical ultrasound which would be used to track the fetal development.(3)
1981
Elizabeth Jordan Carr, the first IVF baby, was born.(11)
1981
The first successful fetal surgery on a baby in utero was performed at the University of California, San Francisco. (10)
2014
The first successful birth after a womb transplant took place.(13)
The Future of Gynecological Health
I asked Tizzano what future milestones he foresees in the field of women’s health care. Tizzano said he anticipates a future in gynecology and obstetrics in which the pendulum swings away from surgery to less invasive OB/GYN care.
Gynecology has been almost exclusively surgical since its earliest beginnings. Currently, hysterectomy is the number one surgery performed on women that is not pregnancy-related, with approximately 600,000 performed each year.(3)
Tizzano also noted the need to progress even further beyond the vestiges of “appropriateness” that still plague the doctor/patient relationship.
“Sixty percent of ObGyns do not use the word ‘vagina’ during a woman’s annual exam. They say, ‘Now we’re going to do ‘the pelvic exam,’ not ‘your vaginal exam’ distancing themselves.”
He is concerned about this lingering sense of appropriateness preventing women from getting access to the most current and effective contraceptive care. For example, 7 - 8 percent of women will become pregnant on the pill during a year of typical use.(5)
Tizzano believes that more effective contraceptive is underused because physicians are reluctant to discuss sexuality and reproduction in the office.(5)
”We have at our fingertips long acting, reversible contraceptives that work virtually as well as sterilization that should be far more widely used to give women control over their reproductive health in the form of the vaginal ring,” Tizzano said.
“Being able to comfortably discuss sexuality in the office is a huge issue,” Tizzano concluded. “Everybody thinks about it, everybody talks about it in their separate silos, but we don’t talk about it collectively.”
Vaginal fistulas continue to plague women in developing countries. To learn more, visit, The World’s Modern-Day Lepers: Women With Fistulas.”
.
Reviewed April 13, 2016
by Michele Blacksberg RN
Edited by Jody Smith