Chapter 1: History of Radical and Reconstructive Surgery for Gynecologic Cancer

EXTIRPATIVE PROCEDURES

Radical Hysterectomy

The evolution of the radical hysterectomy encompasses nearly 2500 years and is among the most fascinating stories in surgical oncology. Some writings on cervical cancer have survived from antiquity. Hippocrates of Cos (460–370 BC) attempted trachelectomy but noted that nothing he did could eradicate the disease.¹ In the mid-fifth century, Byzantine physician Aëtius of Amida used vaginal irrigation with herbal compounds to relieve pain caused by cervical cancer.¹ Ambroise Paré recommended cervical amputation, which was performed in 1652 by Tulpius.¹ Father of American gynecology J. Marion Sims (1813–1883) used galvanocaustic loops to amputate and cauterize a cervical cancer.²

John Hunter (1728–1793), founder of the Royal College of Surgeons of England, was 19 years of age when he traveled from Glasgow to London to study and subsequently work with his brother William Hunter, a graduate of Edinburgh University.¹ Although J. Hunter had no formal medical training, he became the leading anatomist and one of the country’s finest surgeons through self-education and training. Among his many prosected specimens are specimens of advanced cervical cancer demonstrating the natural history and route of spread locally within the pelvis.

The spectacular rise of the Johns Hopkins Hospital and School of Medicine began in the late 1890s with the recruitment of 40-year-old William Osler (1849–1919; later Sir William) and 31-year-old Howard Atwood Kelly (1858–1943), both members of the University of Pennsylvania faculty. They joined famous surgeon William Halstead (aged 37 years) and distinguished pathologist William H. Welch (1850–1934; aged 38 years) to form the nucleus that spearheaded the development of Johns Hopkins into the world class institution it is today.

John Goodrich Clark (1867–1927) completed his training at the University of Pennsylvania and interned at a local Philadelphia hospital for 2 years before coming to Johns Hopkins.³ Originally he had been granted a residency position with Osler; however, upon arriving in Baltimore, Maryland, he was told that position had been committed to another physician. Osler sent him to Kelly who had an opening in gynecology. Thus, but a quirk of fate, Clark became a gynecologist rather than an internist.

Kelly assigned Clark to develop a more radical surgical approach for the treatment of cervical cancer. At a pathologic examination of 20 cases of cervical cancer treated by hysterectomy, Clark found that the disease had extended beyond the margins of resection in 15 cases.³ Influenced by the surgical doctrines of Halsted, he began considering an en bloc radical hysterectomy for cervical cancer. Clark was familiar with the combined operation described in 1894 by the German surgeon A. Mackenrodt who extensively used actual cautery to destroy the local growth at its primary site before dissecting free the upper vagina and suturing it over the cervix.⁴ He credited Mackenrodt’s procedure as the first step toward wider extirpation of the pelvic tissues along ...