In the 1890s, when Thomas Cullen (1868-1953) was a medical student in Toronto, he recalled that “… there were anteversions, anteflexions, retroversions, and retroflexions and that some of the displacements might be relieved by appropriate pessaries.” Abdominal gynecologic operations, Cullen continued, “… were limited almost entirely to the removal of large ovarian cysts. An occasional myomatous uterus was removed, but the fatality in this class of cases was so high that the operation was rarely attempted.” Cullen also said that he did hear of cancers of the uterus in his student days, but only cauterization or curettage was performed. Entire removal of the uterus was not yet being done.
By the turn of the 20th century, the leadership of gynecology in this country had clearly moved to the new Johns Hopkins Hospital, where Howard A. Kelly (1858-1943) (Fig. 1.7) began to train a series of young men who put gynecology on a strong academic footing in the next two generations. Kelly received both his bachelor's and medical degrees from the University of Pennsylvania. After his medical graduation in 1882, Kelly spent some time in Germany learning the latest surgical and pathologic techniques.
Like President Theodore Roosevelt, who, for similar reasons, journeyed to the North Dakota Badlands to invigorate himself and to regain his health, he journeyed west to Colorado and worked as a ranch hand and cowboy on the OZ Ranch in Elbert County.
While at the ranch, he had an intense religious experience and life-defining moment, one that his medical and surgical colleagues could not understand, which he later described in A Scientific Man and the Bible:
“In the midst of the cold and lonely winter far out in the plains, I had a never-to-be-forgotten experience one day during one of Colorado's three-day blizzards, while I was bedfast with snow blindness from glare of the sun on the snow striking unprotected eyes.
There came, as I sat propped up in my bed, an overwhelming sense of a great light in the room and the certainty of the near presence of God, lasting perhaps a few minutes and then fading away, leaving a realization and a conviction never afterwards to be questioned in all the vicissitudes of life, whatever they might be, a certainty above and beyond the process of human reason” (Fig. 1.8).
P.11 FIGURE 1.7 Howard A. Kelly (1858-1943). (From Davis AW. Dr. Kelly of Hopkins. Baltimore, MD: The Johns Hopkins Press, 1959.)
P.12 FIGURE 1.8 Dr. Howard A. Kelly and other ranch hands at OZ Ranch in Elbert County, CO, 1880. (From Allen P, Setze T. Howard Atwood Kelly, M.D. (1858-1943): his life and his enduring legacy. South Med J 1991:84;361.) After a year in Colorado, his health restored, Kelly returned to Philadelphia to complete his medical studies. He was awarded the Doctor of Medicine degree on March 15, 1882. He took his internship in the Episcopal Hospital in Kensington, a working-class district of Philadelphia, and subsequently established his practice there. He founded the Women's Hospital of Philadelphia there in Kensington. It was during this period that he first attracted the attention of Sir William Osler. When a woman in the medical ward died of nephritis, Kelly, being doubtful of obtaining permission for autopsy, stealthily went to the morgue and extracted the kidneys through the vaginal vault. Osler, himself a pathologic anatomist in Montreal, heard about the method and thereafter followed with interest the career of the young surgeon.
By this time, Dr. William Osler had moved from Montreal and accepted a position at the University of
Pennsylvania in Philadelphia, providing an opportunity for closer observation of Kelly. Osler often visited the Kensington Hospital to watch Kelly operate, and he is said to have remarked that he had never seen a more skillful surgeon. When the position of assistant professor of obstetrics and gynecology came open at the University of Pennsylvania, Osler recommended Kelly and at that time dubbed him the “Kensington colt”
because he was only 31 years old and was a “dark horse” to obtain the appointment. The trustees did accept Osler's recommendation and give Kelly the position, but he was there only about a year before events led him elsewhere.
Meanwhile, plans were being made in Baltimore to use the millions left by a wealthy philanthropist, Johns
Hopkins, to establish a university and hospital. In 1884, Dr. William Welch was called from Bellevue in New York to take the chair of pathology. At his urging, Dr. William Osler was brought down from Philadelphia to head the department of medicine, and Dr. William Halsted was appointed to the chair of general surgery. Again, Dr. Osler used his influence with the trustees of the new institution to insist that Kelly be offered the position of professor of obstetrics and gynecology. Kelly was enthusiastic about working with those renowned physicians and starting his own department, but he had misgivings about a department of obstetrics and gynecology. Kelly did not like the practice or teaching of obstetrics, and his goal was to divide the chair so that he would become professor of gynecology.
In 1886, Kelly made the first of many trips to Europe to study under the great physicians there. In Leipzig, Max Saenger demonstrated the practicability of palpating female ureters in their lower pelvic portions. In 1888, Kelly dissected cadavers under the direction of Dr. Rudolf Virchow in Berlin to study the anatomic relations of the ureters and to attempt to determine the most efficacious method of ureteral catheterization.
At age 31, the youthful-appearing Kelly, who many patients thought was still a student or resident, initiated a residency program in gynecology with a strong link to the pathology department. Even more than half a century later, the leading texts in the field—Eastman's (Williams') Obstetrics, Te Linde's Operative Gynecology, and Novak's Gynecologic and Obstetric Pathology—were written by professors in Baltimore who had received their training at Hopkins with Kelly and his assistants.
Kelly soon found that his interests and skills were in gynecologic surgery; therefore, he turned the obstetric service over to J. Whitridge Williams (1866-1931), who became a leader in that field and the author of the most widely used textbook of the time. Kelly had a great interest in the female urinary system, realizing that the
symptomatology of urinary tract disease is often intertwined with that of the reproductive organs. He invented the air cystoscope and devised ureteral
catheters. He was the first to plicate the vesical sphincter for stress incontinence of urine. Physicians from all over the world came to Baltimore to watch him operate (Figs. 1.9 and 1.10).
FIGURE 1.9 Dr. Howard A. Kelly's operating room at the Johns Hopkins Hospital. To the left is the door to the corridor. In the center is the door to the ether room. The rubber pad was used for drainage during irrigation of the abdomen. A similar pad was developed by Dr. Kelly for drainage of blood and amniotic fluid during and after a vaginal delivery.
Kelly's legendary operative skill was well described by Cullen, who later became one of Kelly's outstanding residents and successors to the chair at Hopkins. Kelly and Hunter Robb, his earlier resident, went to the Toronto General Hospital not long after Kelly became chief at Hopkins. Cullen was an intern in Toronto at the time and handled the instruments during an operation that Kelly and Robb had agreed to perform. Cullen's description speaks for itself:
I turned around to thread a needle and when I turned back found to my amazement that the operator had the abdomen open. Operators in the General often took ten minutes to get that far. After cutting through the skin, fat and fascia they were apt to get lost in the muscles. Kelly and Robb working together used dissecting forceps as I had never seen them used. One man pulling each way, the cleavage between the muscles was seen at once and the opening in the abdomen could be completed without difficulty. I watched, fascinated, while Kelly went ahead and finished that operation and did the second, working with clock-like precision and at a speed I had not imagined possible. By the time he had finished, the course of my professional life was decided. Up to that afternoon I had intended to be a physician. From that afternoon I knew I had to be a surgeon.
P.13 FIGURE 1.10 Howard Kelly operates. Grouped about the operating table, left to right, are Emma Beckwith, head nurse, Jay Durkee (seated), Thomas S. Cullen, Max Brödel (center), Elisabeth Hurdon, J. E. Stokes, and John G. Clark. (From Davis AW. Dr. Kelly of Hopkins. Baltimore, MD: The Johns Hopkins Press, 1959.)
Chance often determines the course of one's life, so it was fortunate for Cullen that he had to wait 6 months for his residency with Kelly to start. He used this time to begin the study of pathology with William H. Welch at Hopkins, and it was the close alliance of gynecology and pathology, begun by Kelly and continued by Cullen, that shaped the careers
of many future gynecologists at Hopkins and elsewhere and determined the course of the field itself.
In 1898, Kelly published a two-volume textbook called Operative Gynecology, certainly the direct ancestor of the volume you have in your hands. Kelly wrote in the preface, “My aim in writing this book has been to place in the hands of the many friends who have from time to time visited me and followed my work, a convenient summary of the various gynecological operations I have found best in my own practice.”
Although gynecology at the end of the last century was still a very young science, in Kelly's words, change was at hand: “Although I have spent several years in the preparation of my book, so rapid have been the changes in the gynecological field that I have found it necessary to rewrite some of the chapters two and even three times.”
A little more than a dozen years later, in the preface to his text entitled Medical Gynecology, Kelly reiterated the pace of the changes: “What a transformation two generations have witnessed in the field of gynecology! From modest beginnings, as a sort of minor specialty coupled with diseases of children and often professed by general practitioners with no special training, it has grown to the dignity of a major surgical specialty, so extensive that many gynecologists of today (1912) claim the entire field of abdominal surgery as their proper domain by right of discovery and conquest.” This was also a time when radical or complete removal of tumors and repair of hernias became increasingly common. Kelly and his residents were pioneers in radical hysterectomy when Hugh Young of Hopkins introduced radical prostatectomy.
Summarizing Kelly's surgical innovations, Audrey Davis wrote:
“In the first place, he developed a combined vaginal and abdominal method of examination, perfected and carried out with unusual expertness the common plastic
repairs, and successfully operated through the abdomen. His suspension of the retroflexed
uterus was a signal innovation of the day and of this period of his development in surgical methods. Second, he early turned his attention to the urinary tract and began what he later considered his most important contributions to his specialty.”
When Kelly heard about the discovery of radium by the Curies in Paris in 1898, he associated this with the problem of malignancy, and he determined to obtain some of the material for the treatment of cancer. In 1904, he bought a small tube containing a few milligrams of radium and began to use it in the treatment of small external lesions. He continued to experiment with the treatment and determined to acquire more radium. In 1913, he went to Colorado to study methods of extracting radium from carnotite deposits there.
His rapid acceptance of the new treatment brought him much criticism, and he was called a quack not only by the lay public but also by some of his medical colleagues. In 1913, his friend Dr. William Mayo defended him in a letter:
“Don't you fret about what they are saying about you and radium. Your friends know what you are trying to accomplish and with your energy, persistence, and great intelligence you will succeed. But no man has tried to do something that is different from that of the
average man without being subjected to abuse and criticism. It is a curious phase of human nature to attack what it does not understand. So do not think about it again.”
From 1917 on, the Howard A. Kelly Hospital on Eutaw Street in Baltimore had 5 1/2 g of radium, said to be the largest amount available at that time in any clinic in the world. That hospital was the first to use radium in packs at appreciable skin distances, the first to use a teleradium apparatus, the first to establish a large radon plant, and the first in Baltimore and one of the first in America to install an apparatus for deep x-ray therapy. For years, the Kelly Hospital administered all of the radiation for patients at Johns Hopkins and did most of the radiation work in Baltimore and the state of Maryland.
Remembering the dry lectures of his medical school days, Kelly determined to teach by demonstration and by allowing his residents the widest possible latitude in caring for their patients under his supervision. According to Harvey:
“Kelly's postgraduate discipline by means of this long-term residency was an entirely new concept in surgical training at that time. Each year the assistant residents were given increasing responsibilities in the care of patients and in procedures in the operating room.
Surgery upon the ward patients was done almost exclusively by the resident and his assistants, subject to consultation and help when necessary by the senior staff. … Judging by the quality of his many residents, one may wonder whether this was not his greatest contribution to his specialty” (Fig. 1.10).
Dr. William T. Howard, Jr., one of Kelly's residents, described his method of instruction in the operating room:
“In the new B operating room, while assistants looked after anesthetizing and otherwise preparing the patient for operation, Kelly gave the history of the patient's illness, the results of the physical examination and laboratory tests, the diagnosis, and proposed procedure. When all was in readiness, operator and assistants in position, Kelly, glancing at the large wall clock, announced the time and began. Throughout operation, in a running talk, he described each procedure, and in abdominal cases what he found, and what he intended doing at each step and why. Whenever practicable, he let the students and
P.14 visitors view each step. The operation completed, Kelly again glanced at the clock and
announced the time. Often after operation, he would go to the blackboard and using both hands rapidly sketch and describe just what he had found and what he had done.”
Because he did so much medical writing, Kelly saw the need for photographs to illustrate the procedures he wanted to teach. In Baltimore, he found an excellent photographer, Anthony Murray, who filled a large folio with some 1,500 photographs of operations. Kelly then devised what he termed the “stereogram,” a photograph of each step in an operation with the written text describing it. He and his photographers then took great pains to make the stereograms as complete and as perfect as possible. He traveled to Europe to photograph the procedures of the great surgeons there. Often, it was necessary to wait for years for a particular operation. He published the stereograms in book form starting in 1908 and titled them The Stereo Clinic.
At times, however, the nature of the subject demanded a drawing rather than a photograph. Kelly had had a facility for sketching since childhood, and he always used his own drawings for teaching his students. When he saw the need for more elaborate illustrations for his publications, Kelly determined to obtain a medical artist for Hopkins. He heard about an artist, Max Brödel, then working in Germany. After a campaign of several years' duration, he succeeded in 1894 in bringing Brödel to Baltimore and installing him as a resident at the Johns Hopkins Hospital (Fig. 1.11).
The spectacular results of the collaboration between Kelly and Brödel are described by Davis: Four years after Brödel began work at Hopkins, Kelly's two-volume work Operative Gynecology (1898) appeared. Not only did these volumes proclaim to the world Dr. Kelly's leadership in gynecology, but they introduced to medical circles the illustrations that revolutionized medical illustration.
Some years later, the Department of Art as Applied to Medicine was established in the Johns Hopkins University School
of Medicine. It was the first department of its kind in the world and continues to the present.
FIGURE 1.11 Max Brödel. (From Robinson J. Tom Cullen of Baltimore. New York: Oxford University Press, 1949, with permission.)
At a testimonial dinner on Kelly's 75th birthday, Brödel described Kelly's method of teaching the illustrators:
“A clear and vivid mental picture always must precede the actual picture on paper. The planning of the picture therefore is the allimportant thing, not the execution. This is where we learned from Dr. Kelly. He had a way of making little modest outline sketches when he explained his operative procedure to his illustrators…. He invented diagrams to show variations of form and relationship, motion, pressure, tension, rupture, the development of a pathological process, the sequence of operative steps, the placing of ligatures, sutures, etc.; in short, every clinical phenomenon, every operative procedure flowed in simple, eloquent lines from the end of his pencil. … Dr. Kelly always permitted the artists to make original investigation to clear up the obscure point. … Without his sympathetic attitude we could not have learned our trade as we did.”
Kelly's brilliant 30-year career as the head of gynecology at Hopkins was equaled by his prominence in other fields of endeavor. He became a civic leader in Baltimore, at one time running for public office. His special crusades were against alcohol, tobacco, prostitution, and political corruption. He was a devout Christian and Bible scholar, reading the Bible in the original Greek and Hebrew. He never lost his early interest in natural history, and he became an authority on herpetology, mycology, and lichenology. He was ahead of his time as an environmentalist and bought wilderness land in Florida and Canada for preservation. He gave the land in Florida to the state, and it is now Kelly Park in Orange County.
As long ago as 1900, in his classic text, Cancer of the Uterus, Thomas Cullen, student of and successor to Kelly (Fig. 1.12), wrote that “The number of cases of cancer of the genital tract coming too late for operation is so appalling that the surgeon is ever seeking to devise ways and means by which the dread malady may be more generally detected at the earliest possible moment—at a time when complete removal of the malignant tissue is still possible. … But since it is the general practitioner who, as a rule, is the first consulted, upon him largely falls the responsibility of arriving at a timely diagnosis.”
FIGURE 1.12 Thomas S. Cullen (1868-1953). (From Robinson J. Tom Cullen of Baltimore. New York: Oxford University Press, 1949, with permission.)
P.15 One of the greatest advances in gynecology in this century has been the improvement in the early detection and cure rate of cancer of the uterine cervix that has resulted from the development of cytology and the recognition of carcinoma in situ. In 1943, George N. Papanicolaou (1883-1962) and Herbert Traut (1894-1963) published their seminal monograph entitled Diagnosis of Uterine Cancer by the Vaginal Smear. Papanicolaou had worked on this technique since the 1920s, but, like many other innovations in medicine, it took years to find widespread acceptance. Further publications by Papanicolaou and others, notably Ruth Graham, demonstrated beyond a doubt that cytologic studies could almost infallibly detect cervical cancer.
Cancer in situ was recognized early in the century by Cullen and in 1912 by J. Schottlander and F. Kermauner, but its relation to invasive cancer was not well understood. This relation was more clearly described in 1944 by G. A. Galvin and Te Linde in several reports. Since then, the relation has been amply confirmed, and early cervical cancer has become a detectable and curable disease. Since its inception by Hans Hinselmann in Germany in the 1920s, colposcopy has given a new dimension to the assessment of cervical carcinoma, making blind, random cervical biopsies unnecessary and providing more accuracy in finding and treating localized lesions.
By the early 1970s, the editor of a new journal, Gynecologic Oncology, pointed out that “… the scientific
importance of gynecologic oncology may be gained from the observation that the tumors that we study and treat are prototypes for cancer in other areas of the body, for the histogenesis of the two principal uterine cancers is probably understood better than that of any other tumor in the body.”
The immediate post-World War II years were a period of truly astounding medical developments and saw the explosive growth of medical research funding and new hospital construction. After 1945, penicillin became available for civilian use, and this was soon followed by other antibiotics. Hormone replacement became increasingly possible, and in 1946, the year that Richard Te Linde published the first edition of this textbook, Congress passed the Hill-Burton Act, making federal funds available to localities for the construction of new hospitals. These and other developments of the time greatly changed and expanded the work of medicine.