“[H]ow did societal perceptions of the female role influence diagnosis and treatment?” Roy, (1992).

There is still a great divide between journal articles, government studies, and the actual care that women receive at their local gynecologist's office. If you add disparities involving race, class, and other socio-economic and immigration issues, it will be found that though some women may be receiving gender specific interdisciplinary holistic care, others are receiving treatments thought to be abandoned during the Victorian era.

Gynecology has a long history, much of which is obscure, at times bizarre, and even brutal. Where does the history of women's medical care, as we define it, begin? Where is it headed? And what role do we, as women, have in that evolution? Are we business statistics for a health care firm, obedient or loyal patients, health-care consumers, patient participants, victims of experiments? The need to treat that which ails the intimate areas which define a woman has been existent since the beginning of time. Each age feels they are the most advanced; each era has its own procedures, and also social mores, including in their medical practices. Gynecology has been documented in the most ancient of cultures; however few women will find the application of leeches to the cervix to be the most preferred method of treatment, or being hidden beneath layers of sheets for the entirety of exam the most effective way to assess an ailment. In a few hundred years, our present day care may seem equally as strange or ineffective.

Female anatomy has been a point of fascination and reflection since the beginning of time. The ability to accurately depict a woman's anatomy has been a challenge to artists, a controversy within most societies, and a necessary way for medical care to evolve. The documented origin of gynecology begins with the advancement of medical iconography and texts.  In Mesopotamia clay tablets dating back to 2100 BCE show the cause of illness as spirits sent from the Gods, as opposed to virus or bacteria. The Ebers Papyrus, which dates back to 1550 BCE, regarded the uterus as an “independent animal capable of moving within the host”. Aretarus the Cappadocian, a 2 nd Century Greek Physician wrote in his Causes and Indications of Acute and Chronic Diseases , “In the middle of the flanks of a women lies the womb, a female viscus, closely resembling an animal, for it is moved of itself hither and thither…” Hippocrates had commented six centuries earlier, “The uterus often went wild when not fed with male semen” (Spreet, 1994, p. 9). ‘Hysteria' in Ancient Greece was attributed to “traveling womb”, as though the uterus was an animal which moved about independent of the rest of a woman's anatomy to the detriment of her mental facilities (Apple/Roy, 1992, p. 173). Female reproductive anatomy was considered to be beyond reasonable medical explanation despite efforts to care for gynecological problems. One of the main reasons was that no one knew what was actually inside of a woman; part of her anatomy was tucked inside and hidden from view.

  It was not until the Middle Ages that the female form began to be explored with a focus on specific detail. In 1543 Andreas Vesalius and Jan Kalkar created De humani corporis fabrica . It was the first medical text to “introduce female internal genatalia”, and is considered the foundation of modern anatomy (Spreet, 1994, .p 3). Vesalius did suffer greatly for his contributions. In 1564, by order of the Inquisition, he received a death sentence for his work with dissection and anatomical illustration (Channel 4 Television Corporation, 2005). Within a couple of years, a contemporary of Vesalius, Charles Etienne, published his own independent anatomy text entitled , De dissectione partium corporis humani. Both of these works were, and are, considered critical to the foundation of medical knowledge.

  In 1547, Johann Dryander, a German anatomist and mathematician, created “Arzneispiegel”. Adapted from an anatomical woodcut by Berengario da Cappi made twenty five years prior, a woman is depicted sitting in a chair with her feet to the floor, legs spread. Her midriff is cut open exposing a light bulb shaped reproductive system. This image was the basis for educational instruction for many years.

  It would be almost a century before advancements were made in recording the interior of a woman situated correctly within her body. An iconography entitled , Placenti tabulae anatomicae, was created in Venice in 1627 by Julius Casserius. It is quoted as showing the female abdominal and pelvic viscera as “portrayed with beauty and accuracy” (Spreet, 1994, p. 6).  The perfection of Casserius' work did not have any competition until 1681 when Francois Mauriecauis created a perfected anatomic illustration, called a ‘plate', of the pelvic organs. Entitled, Trait des malaides des femmes grosses, et all celles qui sont accouchees , the plates were an essential addition to the creation of the field of gynecology.

Part of the difficulty in understanding female anatomy was accessing it. The bodies of male prisoners and vagrants were common, but societal mores restricted access to deceased women on whom autopsies could be performed; few female cadavers presented themselves through acceptable means for purpose of dissection and iconography. Also, until the 20 th century male anatomy was considered the “proper” anatomy in the medical sciences, and only male anatomy was represented in educational forums.

16 th century Europe through the mid 19 th century was a time of great advancement in the understanding of anatomy. In 1775 the Imperial Regio Museo di Fisica e Storia Naturale (later known as 'La Specola', or the observatory) opened, combining life sciences and art. At the end of the 18th century, 'La Specola' was considered one of the most unique possible collections. Though segregated, the exhibitions were open to both upper and lower classes, who gathered daily to view the wax molds showing all aspects of the human body. These molds are properly defined as anatomical ceroplastics, and to this day, they are on display in Italy at, what is now called, Museo La Specola Florence .

This evolution from woodcut or copperplate was essential to the progression of medicine, but it still did not detail the female organs. Govert Bidloo created the Anatomia humani corporis in Amsterdam in 1865. Dissections of reproductive systems were made into perfect illustrations, revealing the complete composition of the female anatomy as dissection for the first time. Obstetrics and gynecology evolved into formal medical fields as a direct result of increased knowledge of the female reproductive system.

This era generated so many diverse fields of medicine previously unrecognized that the era has become a field of study onto itself. Foucault describes the phenomenon of rapid growth, the need for the creation of medical epistemology, the divide between the “gaze” of medical practitioners and the needs of patients, along with transdiscursive archeology and genealogy in Birth of the Clinic (Foucault, 1963). “With the increase in medicalization of women's bodies, and the birth of medical discourse based on the pathology of the female sexual/reproductive system, came an increase in new technologies to treat and diagnose these very pathologies; Foucault notes that modern western medicine arose with the visualization of pathology” (Bittiker, 2005, p. 1).

  Then defined as the diagnosis and attempted treatment of women's conditions, gynecology remained, in recent civilization, primarily non-surgical until the 19 th century. Ancient Greco-Roman civilization is documented as having performed over one hundred general surgical procedures related to men and women, and also as having near complete gynecologic care (Bliquez, 2005). Though some surgical attempts were made during the 17 th and 18 th centuries in Europe, it was unclear how to cut into a woman via her abdomen to access her reproductive organs without harm to her life. Surgery, which advanced quickly in the 19 th and 20 th centuries, became the defining point in modern gynecologic care. There were three categories of surgical procedure at the onset of the 20 th century:

1. Diagnostic: Identifying an illness or condition, such as with uterine curette (scraping of the uterine cells / lining with a sharp device.)

2. Extirpative: The total removal of a diseased organ or removal of the root of illness, such as with oophorectomy (removal of ovaries) or hysterectomy (removal of ovaries, fallopian tubes and womb).

3. Reparative: Resolution of conditions such as hernias or fistulas (which were common due to multiple childbirths under less than optimum conditions).

In the mid 19 th century, though established and reviewed, actual surgery was rare. However, a few pioneering American doctors did experiment with procedures. An example of such innovation was the work of surgeon Ephraim McDowell of Danville, Kentucky. In 1809 he successfully removed a 22lb ovarian cyst from a suffering woman. He performed three other ovariotomies, one of them fatal (Apple/Roy, 1992, p. 173).

 Institutional practice of procedures was slow in its accepting these developments. Between 1848 -1851 no gynecological operations were performed at New York Hospital, a leader in women's care (Spreet, 1994, p.455). However, at the end of the 19 th century, entering into the 20 th century, medical professionals would refer to the era as “the dark ages of operative furor” (Spreet, 1994). Few held the ideals of Dr. Kate Hurd Mead, who practiced from the 1880s - 1920s. Mead was a strong campaigner for legislation to fund programs supporting “maternal and child welfare services”. She felt strongly that “gynecology stood for the special relationship between women physicians and women patients rather than surgical cures for female complaints”. Dr. Mary Putnam Jacobi, another female physician of the era, supported humane treatment of women through surgical advances, while Dr. Elizabeth Blackwell felt strongly that “surgery mutilated women who were victims of male medical society” (Apple/Roy, 1992, P. 186). Overall, experimentation and class status seemed the norm in the new, male concentrated field of gynecology. Women, outside of midwifery, were not as common as men in gynecology, or any other area of medicine. The only reference to female-controlled women's health care was at the New England Hospital for Women, which performed gynecologic operations regularly during the last twenty five years of the 19 th century.

After 1870, as techniques in anesthesia and antisepsis were furthered surgery went from a controversial subject to the predominant form of accepted female care. However, the quality of this care is questionable. Author Lawrence D. Longo located a quote by Professor Eli Van de Warken from an American Medical Association (AMA) meeting in 1881 which said, “… that in 66 of 109 medical colleges gynecology either was taught by an ill-trained obstetrician or not at all” (Apple/Roy, 1992, p. 182). Also, with interest in vaginal and abdominal surgery, there were, of course, abuses. One such situation took place in England in the 1860s when ‘clitoridectomy' (the removal of the clitoris) became a popular trend, and in the 1880's in the United States where ‘oophorectomy' was an acceptable experiment for quite a few years.

Improvements were offered later in the 1920s, and especially in the 1930s, as a result of antibiotics and other pharmaceutical methods of treatment such as sulfa drugs. Until the advent of sulfa drugs, salphiongectomy (removal of fallopian tubes) and/or hysterectomy were the only cures for advanced forms of venereal diseases which led to reproductive decay. In 1883 and 1894, 50% of women admitted to Mt. Sinai Hospital Gynecologic Service suffered from pelvic infections which went untreated due to lack of knowledge of disease prevention and control. (Apple/Roy, 1992, p.192). The most common ailments in the United States at the beginning of the 20 th century were perineal lacerations (tear in the body region between the scrotum or urethral opening and the anus), prolapsed uteri (when the muscles and tissue supporting the uterus deteriorate and it collapses or falls within the body, at times leaving the cervix hanging out of the vagina), pelvic infections (acute pelvic inflammatory disease; PID), and incontinence. The most common recorded surgical procedures were attempts to reposition the uterus. Besides prolapse of the uteri, the most apparent reasons for gynecologic surgery was to relieve chronic pelvic pain (often caused by misunderstood and undiagnosed venereal disease such as gonorrhea), painful menstruation, spontaneous or heavy bleeding during periods, and sterility.

In his 1945 work entitled One Hundred Years of Gynecology; James Ricci noted that the increased interest in gynecology was connected to “improvement in the status of women during the 19 th century. The rise in status led to an increased concern with female health problems, and thus to a growing market for medical services.” He also commented that the high rate of surgery performed during the 1870s and 1880s was an era of “pelvic surgery gone wild” (Apple/Roy, 1992, P. 195). The evolution from “uterus gone wild” to “surgery on uterus gone wild” took thousands of years.

Were women in Ancient Greece, though mysterious in their anatomy, viewed with higher regard than American women in the Victorian era? Were their bodies treated with more dignity? Did doctors in Pompeii offer more spiritual and holistic forms of medical care than England during the Industrial Age? Beyond theoretical contemplation, it is not possible to answer those questions, since exact records do not exist from most civilizations. Some specific, documented history has been salvaged from the ruins.

  Non-surgical practices and hygiene methods have been recorded since the Hippocratic Era of Ancient Greece. Discoveries have included graduating dilators, speculums, uterine drainage tubes and douches which were used for intravaginal fumigation, medicine, and pessaries (soluble devices inserted into the vagina for hygiene or as medicine; an oval stone used to support the uterus.) The most common complaints throughout recorded Greco-Roman history were ovarian cysts/tumors, along with uterine and cervical prolapse.

According to the Historical Collections & Services of the Health Sciences Library, University of Virginia, gynecologic instruments of the Roman Empire were not only utilized in medical practice, but the few have even stood the test of time have greatly added to modern society's understanding of ancient medical care: " The extant comments of medical writers from antiquity--including Oribasius, Galen, Soranus, Aetius, and the Hippocratic corpus--have provided scholars with some clues about the use of some instruments. Some instruments, such as mixing instruments and tweezers, probably had other household [use] such as the application of cosmetics and paints".

 

One of the most spectacular, if fearsome looking, Roman medical instruments is the vaginal dilator or speculum (dioptra). It comprises a priapiscus with 2 (or sometimes 3 or 4) dovetailing valves which are opened and closed by a handle with a screw mechanism, an arrangement that was still to be found in the specula of 18th-century Europe. Soranus is the first author who makes mention of the speculum specially made for the vagina. Graeco-Roman writers on gynecology and obstetrics frequently recommend its use in the diagnosis and treatment of vaginal and uterine disorders, yet it is one of the rarest surviving medical instruments. Specula are large and readily recognizable and should not have suffered the same degree of destruction as thin instruments, such as probes, scalpels and needles. As a source of bronze, however, they may have been more subject to recycling than the smaller instruments.

 

Though Pompeii was destroyed in AD 79 by an eruption at Mt. Vesuvius, deep within the petrified ash, contemporary archeologists and scientists in Naples have found and archived gynecologic instruments and other surgical devices amidst the ruins. In his article Gynecology in Pompeii , Lawrence J. Bliquez discusses excavation of sites in Pompeii between the 18 th and 19 th centuries. Two of the medical sites discovered were considered to be where “female problems” were treated in Pompeii. The ruins of the ‘Casa Del Medico Nuevo' and the ‘House of the Medicus at Pomponius Magonianus' revealed vaginal speculum, birthing hooks, forated clysters (enemas), and trivalve uterine speculums (Bliquez, 1995).

The 16 th and 17 th centuries in Europe produced procedures for cervical amputation after prolapse. Cervical prolapse is when the cervix, literally, falls through the vagina, creating a “tail” between the legs. Vaginal speculums are archived as used to attach leeches to the cervix in an attempt to relieve genital inflammation.

Even as treatment of problems became more acceptable, finding the “organic root” of illnesses remained elusive. Social mores and etiquette made communication between a female patient and her doctor restrictive and ambiguous, and there were class barriers in receiving health care in many areas of American and Europe.

Complete abdominal hysterectomy was successfully achieved in June 1853 by Walter Burnham of Lowell, Massachusetts (Spreet, 1994, 482). Wilhelm Alexander Freund performed the first complete abdominal hysterectomy for uterine cancer in 1878. This was a major advancement from the groundbreaking European research conducted by Joseph Cavallini when he successfully “excised the uteri of pregnant dogs and sheep” (Spreet, 1994, 455). America, despite its moral overtone, became the world leader in gynecologic advancement, with gynecology defined primarily as surgery.

James Marion Sims is considered the “Father of American Gynecology” (Spreet, 1994, p.456; Apple/Roy, 1992, p.242), and is accredited as having “created the science of gynecology, invented the duck-billed speculum and other instruments to properly examine female organs, and was the first to use silver wire instead of silk sutures in surgical cases” (Healthcare Alabama Hall of Fame, p. 1. 2005).

A graduate of Charlestown Medical School in 1833, and Jefferson Medical College in Philadelphia in1835, he practiced as a physician in Lancaster, South Carolina before moving to Alabama. Upon his death the Journal of the American Medical Association (JAMA) stated in memoriam, “His memory the whole profession loves to honor, for by his genius and devotion to medical science he advanced it in its resources to relieve human suffering as much, if not more, than any man who has lived within [19 th century]” (Mendehlson, 1982, p. 33).

Not everyone felt such praise. In a recent article, commentary included: J. Marion Sims, an antebellum southern doctor, invented the speculum and thus became known as the Father of Modern Gynecology. Sims first came involved with “women's problems” in his general practice. Although it wasn't his specialty, and he particularly disdained “women's problems”, he nevertheless became involved in gynecology through the many black slave women who were brought to him for treatment because of their impaired reproductive systems. Sims experimented on these women using different surgical techniques that he invented on his own, practicing them on these women repeatedly without the use of anaesthetic. Having difficulty accessing the vagina and cervix, Sims arrived at the idea for his speculum (Bittiker, 2005, p.2).

 

In 1846 he started a private gynecologic clinic in Montgomery, AL. It is documented that he began experiments on female slaves with vesicovaginal fistulae (tear between the vagina and the bladder/anus) from difficult childbirths and surgically implied injuries. “Plantation owners were happy to turn their incontinent, damaged female slaves over to Sims for experimentation. They were of little use to their masters in their present condition.” (Brinker, 2005, p. 6) Over a period of a less than five years, a select group of female slaves underwent nearly forty failed surgical attempts before the process of vesicovaginal repair was perfected. These surgeries were done without anesthetic.

Sims subscribed to a commonly held belief that Africans had a specific physiological tolerance for pain, unknown by whites. He never felt the need to anesthetize his black patients in Montgomery” (Brinker, 2005, p. 6). Anarcha, the slave on whom the procedure was perfected, had originally been injured by Simms during childbirth when an instrument slipped, creating her fistula (Mendelsohn, 1982). “Two enslaved women in addition to Anarcha - Betsey and Lucy - were also young women who contracted fistulas giving birth for the first time. Together, these three women endured repeated operations and were patients of Sims for the duration of the hospital's existence (Brinker, 2005, p. 6). 

Dr. Sims also determined the “most correct” position for gynecologic examination as being the reclined, sitting position with the legs bent and spread in stirrups. The lithotomy position is otherwise known as the “lateral Sims position”. Other credits include the invention of the curved speculum, use of silver sutures, and use of silver catheters (Who Named It? 2005).

In 1852 Sim's fistula technique was considered a new, national standard. In 1853 he moved to Manhattan where he founded (along with Thomas Addis Emmet, E.R. Peaslee, and T. Gaillard Thomas) the Woman's Hospital of the State of New York. The primary functions of the hospital were fistula repair, vaginal plastic operations, research and experiments for the advancement of surgical procedure. In 1861, Sims traveled to Europe to demonstrate his famed procedure in Edinburgh, London, Paris, Brussels, and Dublin. He won many awards. Over the years he traveled abroad, studying in European hospitals, and returning to the States where Sims contributed to the betterment of American hospitals, and women's care in general. He was an active surgeon until his death in 1883 (Who Named It? 2005).

Two other pioneers in gynecologic science are the European's Freidrich Schauta and Ernt Werheim. Both presented procedures which are still studied by contemporary American gynecological students. Schauta was an Austrian surgeon who became specifically interested in gynecology, as opposed to general medicine. Between 1876 -1881 he worked in Vienna, where, in 1884, he became a full professor. Schauta contributed to research in radiology, bacteriology, histology, serology, and gynecologic surgery. He perfected vaginal radical extirpation (hysterectomy) for the treatment of uterine, cervical, and endometrial cancer. Werheim, an Austrian professor, performed radical abdominal hysterectomy in 1899 to cure a patient with carcinoma of the cervix. These doctors received funding in 1886 to begin essential training of students with hands on experience in obstetrics (Gruber/Huber, 1999).

There has been much progress in the diagnosis, treatment, and care of women since the start of the American Gynecological Society in 1876, but it was only at the very end of the 20 th century that the implications of hormones became completely clear. Though the basis of endocrinology study was established at the end of the 19 th century and beginning of the 20 th century, most of the research between 1937 and 1987 was on estrogen in the form of contraception and hormone replacement therapy (HRT) for menopause aged women. The study of hormones for therapeutic use simply did not have the same financial possibilities as the two other areas of research and marketing. In the early 1990s a wave of new information and interest, and, therefore, funding fueled renewed interest in the study of hormones and the human body. Gynecologic Endocrinology, a relatively new branch of medicine, advanced understanding of the relationship between not only the reproductive system (primarily ovaries and menstruation) and hormones, but women's over all health and their reproductive hormones. Though treatment of menopause is the most commonly discussed topic of the field, it is now being recognized that ovarian steroids influence neurological (cognitive and affective function), dermatologic, and metabolic disease in women of all ages; though how exactly the endocrine system works is still being explored.

Osama Tanizawa wrote in his 1988 article, Method of evaluation of hormone assays in practical obstetrics and gynecology, “…humans are controlled by neural and endocrine functions. The neural system controls organs through various neurotransmitters, while the endocrine system controls organs by hormones that flow through the circulatory system in the blood” (Tanizawa, 1988). Hormones are not just about birth control and menopause, they are essential to all healthful life functions.

Gynecologic medicine has entered the new millennium. To some that means the “dawning” of gender specific medicine and research, with equal research and care methods for both men and women; for others it means less dependency on invasive surgical procedure and the integration on multi-disciplinary and more holistic means of care, treatment, and maintenance. Though a certain appreciation of women's health care has been in existence for centuries, quality gender specific medicine which concentrates on body, mind, and spirit of women's health is actually considered something special and new.

  The Department of Gynecology and Obstetrics Division of Gynecological Endocrinology and Reproductive Medicine in Vienna, Austria comment that demands by the public for more specialized and holistic treatment have assisted in generating research. “The new qualifications for gynecologists will be measured by their capacity to prevent surgery” (Gruber & Huber, 1999. p.1). With increased knowledge on how the female endocrine systems affect numerous aspects of bodily functions, “Gynecologists should be more than specialists in genital matters. Instead, they should offer holistic advice and assistance to women with regard to all problems that are gender-specific and due to the different hormonal regulation of the female body” (Gruber & Huber, 1999, p. 005). Further, “… the discipline of gynecology will be called upon increase not only diagnostic, but also its therapeutic range services in an interdisciplinary manner” (Gruber & Huber, 1999, p. 005). The era of pelvic surgery gone wild is, seemingly, nearing an end.

There is still a great divide between journal articles, government studies, and the actual care that women receive at their local gynecologist's office. If you add disparities involving race, class, and other socio-economic and immigration issues, it will be found that though some women may be receiving gender specific interdisciplinary holistic care, others are receiving treatments thought to be abandoned during the Victorian era.

Women have the right to the enjoyment of the highest attainable standard of physical and mental health. The enjoyment of this right is vital to their life and well-being and their ability to participate in all areas of public and private life. Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Women's health involves their emotional, social and physical well-being and is determined by the social, political and economic context of their lives, as well as by biology. However, health and well-being elude the majority of women. A major barrier for women to the achievement of the highest attainable standard of health is inequality, both between men and women and among women in different geographical regions, social classes and indigenous and ethnic groups. In national and international forums, women have emphasized that to attain optimal health throughout the life cycle, equality [is necessary]” (FWCW Platform for Action Women and Health, 1995).

 

Footnotes and References available upon request.