J Obs Gyn Brit Emp 1951 V-58

THE EVOLUTION OF THE GYNAECOLOGIST" BY A. LEYLANDROBINSON, M.D., F.R.C.S., F.R.C.O.G. Emeritus Professor of Obstetrics and Gynaecology, University of Liverpool THE Oxford English Dictionary defines man had some knowledge of surgery, there gynaecology as " that department of is no such unequivocal evidence of his medical science that treats of the functions attainments in gynaecology and we must and diseases peculiar to women " and thus look to more esoteric sources for informa- declares that obstetrics is an essential part tion on this stage of his development. We of the work of the gynaecologist. If may derive some help from the study of the this be so, "The Royal College of sex behaviour of modern savages who, Gynaecologists " would be a fitting descrip- according to the best ethnographical tion of our foundation, but the founders opinion, have never come under the had good reason for perpetuating in our influence of civilization and who for this polysyllabic and sonorous title a time reason must be placed farther back in the honoured name and a duality of purpose evolutionary scale than the earliest that is of great historical interest. It is the civilized communities of which we have fortunes of the gynaecologist in this dual any record. Among aborigines of this role that we are now to consider. type, man is lord and master and a firm His evolution may be said to have begun believer in a system that relieves him of in the garden of Eden and although uncongenial occupation while the women priority may be claimed by the thoracic do the work and look after the family. surgeon, or by the anaesthetist, for we read Under this system the women are the mid- that Adam was put to sleep, the wives and also the supervisors of many gynaecologist can afford to be generous for ceremonies relating to puberty and the operation upon Adam was never marriage. Among certain tribes they carry repeated, whereas the gynaecological out the operation of circumcision and also activities of Eve have continued to exert a the procedure known as fibulation, which profound effect upon the welfare of man- involves the removal of not only the kind ever since. If, therefore, the clitoris and nymphae but also a portion of Aesculapian symbol has a somewhat the labia majora and the mons veneris-a obscure application to medicine in general, mutilating procedure which results in a there can be no doubt that the serpent is degree of vaginal occlusion so complete as an emblem of peculiar significance to the to make coitus impossible until the vagina gynaecologist. has been re-opened by the operation of The earliest phases of his evolution are a defibulation. The tribal doctors or medicine matter of speculation, for although the con- men play little if any part in these operd- dition of neolithic skulls proves that ancient tions, either because they are excluded by a dominant matriarchal tradition or * William Meredith Fletcher Shaw Lecture because they consider such work beneath delivered at the Royal College of Obstetricians and the notice of those who are the friends of Gynaecologists on 29th September, 1950. the gods and the inasters of witchcraft. We 5"

history-of-obgyn.com THE EVOLUTION OF THE GYNAECOLOGIST 51 must not identify the sex behaviour of gods and to confuse the gods with men is modern uncivilized man too closely with beautifully illustrated in Greek mythology the customs of his unknown pre-civilized in the legends of Apollo and Aesculapius. ancestors, but it is reasonable to infer that Apollo, the twin brother of Artemis, is of in prehistoric times midwifery was in the special interest to the gynaecologist, for at sole charge of women and that the pre- Delphi there may still be seen a monument historic physician played no part in either as old as the pyramids-the Omphalos-a midwifery or gynaecology. stone placed there to commemorate the separation of the umbilical cord of the I.itfluence of the Early Civilizations young god and to establish for all time the importance of this physiological, if fabu- It is a far cry from neolithic man to the lous, event. After Apollo as a prodigious Greek physician but during this long neonate had slain the monster which transition the progress of gynaecology can ravaged Pamassus, he founded the cult for be faintly discerned through the cuneiform which Delphi became famous, and it was inscriptions of the earliest writing and the here that Aesculapius is alleged to have papyri and the mummified remains of the practised the art of healing. Unhappily he ancient Egyptians. We learn that the was all too successful and his career was Sumerians in 4,000 B.C. were interested in cattle breeding and thus had the rudiments brought to an end with a thunderbolt after Pluto, the God of the underworld, com- of genetics, and that the Babylonians 2,000 years later had an organized medical plained to Zeus that Aesculapius was profession with penalties for malpraxis. depriving his dominions of subjects by Medical literature made its appearance raising the dead to life. It may be that and some of it related to gynaecology Aeskulapius was not a purely mythical including the fragmentary Kahun papyrus character, for he has been identified with a priest who lived and practised the cult of (850 B.c.), which deals with uterine disorders and one of the Berlin papyri Apollo at Delphi in 1250 B.c., but whether mythical or mortal he became the God of (I ,450 B.c.), which consists of incantations for the protection of mothers and babies, Health and temples in his honour were built in various parts of Greece and the whilst the Ebers papyrus of 1,500 B.C. describes a test for pregancy that adum- Ionian islands, including the island of Cos, brates the principle of Aschheim and where Hippocrates was born in 460 B.C. Zondek. The conception of health as distinct from disease also took shape with InfEuence of the Hippocratic School Thoth as the God of Health and the lion- It was formerly believed that Hippo- headed Sekhet as the deity of childbirth. It crates was a son of a priest-physician of became traditional to associate the lives of the Aesculapian order, but this view is no great men with the art of healing and the longer tenable as it is now known that the celebrated Imhotep who was the Grand cult had not been established at Cos at the Vizier. of Egypt and the architect of the time of his birth. It is certain, however, Great Pyramid of Sakkarah, the oldest that he visited several of these temples, stone building in the world, was that he was steeped in their tradition and worshipped after death as the God of Heal- literature and fully conversant with their ing, although nothing is known of his methods and practice. After much work medical activities during his lifetime. This and wandering he settled in Thessaly and tendency to identify medicine with the spent the rest of his life in the vicinity of

history-of-obgyn.com JOURNAL OF OBSTETRICS AND GYNAECOLOGY 52 Delphi practising medicine and gynae- last resort for dead or dying patients. The cology in the towns and villages that may Hippocratic Oath makes a direct reference still be seen in that neighbourhood. It was to the gynaecologist in the following words here during the first worId war that your -"I will not give a pessary to a woman memorialist may humbly claim to have to procure abortion "-and perhaps an established a link between the Father of indirect one where it says--" I will not cut Medicine and this College, when after visit- persons labouring in stone, but will leave ing the oracle at Delphi he performed an this to be done by men who are practi- operation for excision of the vulva in the tioners of this work". It may be that village of Suvalla on the foothills of Parnas- Hippocrates disapproved of procuring sus, and on another occasion met a Greek abortion on purely ethical grounds, a view physician in consultation over a gynaecolo- which is in keeping with the moral tone of gical case in the town of Lahrissa, which the rest of the oath, but in conjunction with Hippocrates frequently visited and where his reference to lithotrity the words would he eventually died. This link may be seem to imply that such a dangerous regarded as somewhat tenuous, but at least operation as procuring abortion should we may be sure that given the opportunity only be performed by those who in the Hippocrates would have lent his support to words applied to the lithotritist " are prac- the foundation of this College. In his day titioners of this work ". It is evident that gynaecology had lost much of its crudity Hippocrates recognized the importance of and had become an accepted part of medi- technical training and that, although he cine. The range of the subject was consider- would not accord to the specialist the able and in some ways surprising. For the full status of the physician, he regarded investigation of sterility attention was paid him as a necessary and acceptable member to the regularity of menstruation, the size of the profession. The Greek system of the 0s uteri and the position of the uterus, whereby physicians were responsible for and some cases were treated by the insuffla- medicine, most of the surgery and the diffi- tion of aromatic fumes conveyed to the cult midwifery, specialists cut for stone and uterus through a hollow tube inserted into sometimes operated for cataract and other the cervix. Dilatation of the cervix was conditions, and women were in sole charge carried out by means of wooden or leaden of normal midwifery, persisted right pipes. Astringents were recommended for through the ages until the Renaissance leucorrhoea and medicated tampons for of learning in the 16th Century. Among the treatment of ulcers of the cervix. the many universities and schools of medi- Accessible tumours and polyp were excised cine which flourished during this period, and a type of vaginal hysterectomy one is of particular interest to our subject occasionally undertaken for prolapse or -namely the school at Salerno, which was inversion of the uterus. In addition to his founded in the 9th century and ranked for knowledge of gynaecology, the Greek 400 years as one of the great universities physician had developed an interest in mid- of Europe. Students could not enter at wifery for, although midwives were still in Salerno until they were 21 years of age and charge, the Hippocratic system recognized had studied logic for three years. The that difficult or preternatural cases came course lasted five years and was completed into the province of the physician and by an additional year of post-graduate should be treated bv cephalic version or study under an older practitioner, after "I craniotomy, with Caesarean section as a which the student was entitled to call him-

history-of-obgyn.com THE EVOLUTION OF THE GYNAECOLOGIST 53 self doctor. Associated with this School on his mind. Confronted with the treat- were “ thc Ladies of Salerno ” whose quali- ment of five desperately wounded men fications remain obscure but who cannot after the battle of Turin in 1537, he was have been fully qualified medical women asked by an old sergeant of the regiment because the terms of entry obviously pre- whether he could cure them. When Par6 clude the admission of women students- said “no”, the sergeant quietly and, as nevertheless they were the recognized Par6 himself records, “ with no ill will ” teachers of midwifery, and one of them, cut the throats of all five as the quickest Trotula by name, is the reputed author of and least painful method of treatment. a Text Book on Midwifery written in 1050. This deplorable if humane action gave an Trotula and her colleagues were not of impetus to a life work which touched every course the first women to become famous branch of medicine, and when Par6 sub- as midwives, for Smellie mentions that stituted podalic version for craniotomy and Cleopatra was an Egyptian teacher of con- the use of traction hooks, Smellie claims siderable renown and that the writings of that he was the first to improve upon the Aspasia were known and quoted by Aetius treatment of the ancients. Park’s work was in the fourth or fifth century A.D. Itis followed up by other Frenchmen, including clear that, whatever the status of these Mauriceau and Gregoire, who founded the ladies may have been, they must havc French School which did so much to pro- enjoyed a reputation and a prestige far mote the advancement of midwifery and above that of the untrained women of the training of the man-midwife during the primitive times. The first teachers of mid- 17th century. This innovation naturally wifery were in fact women and the training aroused the ire of the women midwives, of midwives began long before that of and these doughty matriarchs entered with medical students, and there can be little zest into a fray that was candid, personal doubt that at the Renaissance the com- and often libellous. The cause of the men petent midwives were better obstetricians received welcome if unexpected support than the untrained and inexperienced from the French Court when, in 1663, physicians. It is therefore not surprising Louis XIV called in Dr. Clement for the that such women should resent the intrusion confinement of Louise de la Vallihre-ap- of the man-midwife into their traditional parently because he wished to conceal the field of work. condition of this lady and he was not sure that the court midwife could keep a secret. The rise of the Man-Midwife It was not however the work of the French This intrusion began with the work of School, great as it was, and certainly not Ambroise Par6, who was born in 1510 and the appointment of a Royal Accoucheur, died in 1590. He was a Barber Surgeon that finally settled the controversy, but and as such not quite acceptable to his rather the introduction of an instrument academic brethren “ of the long robe ” and which afforded a rapid and comparatively anathema to the physicians who could not safe method of delivery for normal as well forgive the use of the vernacular instead of as abnormal cases-namely the Forceps Latin (of which he had none), but neverthe- invented by Peter Chamberlen at the begin- less he became the greatest medical figure ning of the 17th century, but retained as a of the Renaissance and the foremost sur- family secret for upwards of IOO years. geon of his age. His first experience of war During this time the Chamberlens were surgery made an ineffaceable impression exploiting the instrument for their own

history-of-obgyn.com 54 JOURNAL OF OBSTETRICS AND GYNAECOLOGY benefit, and with great success for three effect upon the development of midwifery. generations enjoyed the patronage of During his residence in London he gave Royalty, but they made no effort to further organized courses of instruction to no less the interests of their professional brethren, than 900 students and, having no hospital and indeed one member of the family, beds, his practical work was conducted at Peter the Younger, actually espoused the the bedside of his patients in their own opposite side, for he was accused of homes. In this way he established an “ Out “ actively and impudently advocating the Door District” where the poor received cause of the midwives”. But however the same attention as the rich and the much we may deplore this extraordinary doctor and the midwife met on common conduct, which undoubtedly delayed the ground, and this must be regarded as one development of midwifery in this country, of his greatest achievements. Smellie repre- it can hardly be denied that the unique sented a new type, altogether different position of the Chamberlens in society and from the fashionable physician or surgeon at Court, their large practice and unques- with a flair for obstetrics, for he and his tioned skill, and even their suppression of contemporaries and successors-Douglas, the family secret, must have aroused con- William Hunter, Fielding Ould and siderable interest in midwifery and specula- others-were professional obstetricians and tion as to its future, long before the details students as well as teachers of their subject. of the forceps were published by Chapman But, although Smellie himself had no in 1733, access to beds , such beds were in fact avail- This resurgence of interest had been able to some Obstetricians at that time, for already manifested by the establishment of Sir Richard Manningham had instituted a Chair of Midwifery at Edinburgh in the Lying-in-Wards in 1739, the very year year 1726. This was the first chair to be Smellie came to London, and his example founded in Europe, but it is significant to was soon followed by others. In Dublin note that it was endowed by the City Dr. Moss founded the Rotunda in 1745. In Fathers and provided for the instruction of London the Middlesex began to admit midwives only: at its inception it did not maternity patients in 1747,and the London rank as a University Chair, and it was not Maternity Hospital was established three until 30 years later that medical students years later. The first of the provincial were admitted to its classes. The year 1756 hospitals, St. Mary’s at Manchester, was is therefore an important year in the evolu- founded in 1790 by Charles White, F.R.S., tionary calendar, for it marks the appear- who, together with his son Thomas and ance of the man-midwife or Physician his friends Edward and Richard Hall, Accoucheur as a Professor of midwifery resigned their posts at the Manchester and the beginning of the organized teaching Royal Infirmary in consequence of a af medical students. difference of opinion with the board of management. Charles White, who was the The Rase of the Teacher and the author of a treatise on the Management of Special Hosfiital Pregnant and Lying-in-Women and the Smellie, that great man of Lanark, set- forerunner of Wendell Holmes and Sem- tled in London six years after the publica- melweiss in the attack on puerperal sepsis, tion of the forceps and in the course of the had been Surgeon at the Royal Infirmary next 20 years established a reputation for 38 years and was in fact one of its which has exercised a lasting and potent founders, and one is tempted to suggest

history-of-obgyn.com THE EVOLUTION OF THE GYNAECOLOGIST 55 that the difference of opinion may have medicine : but an appointment to the staff concerned the admission of the man-mid- of a general hospital in London or the pro- wife to the staff of that institution. What- vinces was a very different niatter and in ever the reason may have been, he and his many instances attempts to make such colleagues took a private house in Old appointments aroused a great deal of Bridge Street, Manchester, and there estab- opposition. lished the Manchester Lying-in-Hospital and Charity. The work was carried out The Physiciaiz Accoucheur artd the chiefly on the district, but accommodation General Hospital was also provided for the reception of In- Some of this opposition was not un- Patients, as the records show that in the reasonable for beds were few, skilled year 17g3-g4,749women were delivered in obstetricians were rare, and in many their own homes and 203 women were general hospitals sepsis was rampant, but delivered in hospital, whilst 70 were treated nevertheless, as soon as the need for instruc- for “disease” as Out Patients and so tion in midwifery was recognized, the formed the neucleus of a Gyiiaecological teaching hospitals were morally bound to Department. St. Mary’s had a flourishing provide facilities for teaching although they Ladies Auxiliary Society which did much were not disposed to attach much clinical to promote harmony between the doctors importance to such lectureships. Amongst and the midwives. In 1816 fifteen mid- the earliest of these appointments was that wives were attached to the hospital and the made at Guy’s in 1789, when John Haigh- report for the year that states : “ Mr. Wood ton (1755-1823) was made Lecturer in continues to give instructions to practising Physiology and Midwifery and Physician midwives and female pupils ” . In addition Accoucheur to Guy’s and St. Thomas’s to these special maternity hospitals many (which at that time were next door to each smaller institutions, known variously as other). Haighton is described as a skilful Ladies’ Charities, Lying-in-Dispensaries, surgeon, and a good lecturer, but he was and the like, were set up throughout the an irritable and argumentative man and country and staffed by the local practi- although he obtained an M.D. degree he tioners. retained his original title and was never .4t the outset most of these dispensaries appointed to a full physiciancy. He had were concerned with midwifery only, the use of some beds for there are records but many like St. Mary’s evinced an of his operations, but it was not until 1830 early interest in the treatment of the that William Blundell, his nephew and diseases of women, and later on as gynae- successor, obtained a ward of his own. cology developed they were ready to pro- Blundell, like his uncle, was a general sur- vide in-patient accommodation for such geon, but he was also an enterprising cases under the same roof or in a separate gynaecologist and removed the uterus for gynaecological or women’s hospital. Staff cancer on at least three occasions. appointments to such institutions were of The progress of the Physician Ac- little interest to the general physicians and coucheur is taken a stage further by the surgeons of that time who were apt to sequence of events at St. Bartholomew’s regard the obstetrician with pity if no Hospital. Here the first Lecturer in Mid- longer with contempt, and his work with wifery was Andrew Thynne in 1812. He its long vigils and night watches as the had no beds. The Lecturer in Midwifery most arduous and least interesting part of taught gynaecology as well, but only in a

history-of-obgyn.com 56 JOURNAL OF OBSTETRICS AND GYNAECOLOGY very restricted sense, and in 1861 Charles rarely justified the appalling sufferings West resigned because he was dissatisfied inflicted upon the patient-that saw the with the conditions of service. His suc- birth of abdominal surgery when Ephraim cessor Greenhalgh was styled Physician McDowell performed the first successful Accoucheur in addition to Lecturer, but ovariotomy. Houston of Glasgow had like Matthews Duncan who came next he tackled an enormous cyst over IOO years was allowed to perform vaginal operations previously (in 1701) but, although he only. Matthews Duncan died in 1890 and opened the abdomen, for otherwise he Champneys who followed him was re- would hardly have dressed the wound, as stricted in the same way. Champneys he says, “ with a large napkin dipped in retired in 1912, and his successor Griffiths warm French brandy ” , he merely tapped was the first to be allowed to perform the tumour and made no attempt to deal abdominal operations, but in fairness to with the pedicle, and McDowell is justly the hospital it must be pointed out that entitled to the honour of priority. He was Griffiths was the first holder of this appoint- born in 1771 in America of Scottish ment to take the F.R.C.S. The Physician parentage and , like a good Scott, studied for Accoucheur thus gained admission to the a year in Edinburgh, where he came under general hospitals as a teacher, but was not the influence of Bell, a bold and resource- at first accorded the status of a full member ful operator and the leading surgeon of of the staff. As a gynaecologist he was that time (1793). McDowell returned to his permitted to teach the subject and to native country with an enthusiasm for sur- perform vaginal operations, but as soon as gery and a determination to pursue that ovariotomy and other abdomino-pelvic branch of medicine. He settled in the procedures became practicable he found West, and there at the small village of himself opposed by the general surgeons, Danville in Kentucky in the year 1809 he and we must now go back and consider the performed the operation which was to fom et origo of the situation which then immortalize him and his patient Mrs. developed. Crawford. To face the ordeal this heroic woman travelled 60 miles on horseback The Origin of AbdomirtaE Surgery In the early part of the 19th century with the tumour wedged so tightly against surgery as we know it to-day did not exist. the pommel of her saddle that the abdomi- There was indeed little to choose, in its nal wall was found to be extravasated with rationale and result, between the terrible act blood when the incision was made the of the French sergeant at Turin and many following day. During the operation of the operations that were performed by McDowell’s house was surrounded by an the surgeons of the pre-anaesthetic era. angry mob accusing him of butchering a Picture Syme, for example, carrying out woman, but happily the remarkable an excision of the lower jaw, so distorted recovery of the patient-who was up and by sarcoma as to enlarge the patient’s about in four days and lived to the age of mouth to a circumference of 15 inches , and 78-relieved McDoti.ell of any further imagine the feelings of the young man who accusations of this sort, and subsequently sat up in a chair and submitted to this pro- he did 13 similar operations of which eight cedure for half an hour without any form were successful. The publication of of narcosis. Nevertheless it was this pre- McDowell’s initial success led to further anaesthetic era of crude, oblative and often attempts by different surgeons in America brutal treatment-for the after results and Europe, but relatively few women

history-of-obgyn.com THE EVOLUTION OF THE GYNAECOLOGIST 57 were willing to submit to an abdominal lines-with Simpson and Marion Sims operation prior to the advent of anaesthesia leading in vaginal surgery and Spencer and the heavy mortality amongst those Wells and Lawson Tait in the van of who did was not calculated to encourage abdominal work. other patients, or for that matter, other surgeons. The world was waiting for The Inflmnce of Simpson and Sinas Simpson and Lister, or rather for the sym- As a gynaecologist Simpson belonged to biosis of their work, because although the old school and he is remembered anaesthesia must always rank as a supreme chiefly by the sound which bears his name. discovery, its introduction had little im- This instrument resembles the forceps in mediate effect upon operative results except its capacity for misuse and, in the wrong paradoxically to increase the death rate. hands, is admittedly dangerous, but it was Previously great speed and dexterity had thc first instrument of precision to be used been demanded of the surgeon or he got no for the investigation of uterine disease and patients, and one may marvel at Liston it remains to-day an indispensable aid to amputating through the thigh in thirty the most advanced gynaecologist. But if seconds and yet understand the need for the sound is indispensable its use is condi- such celerity. By eliminating pain and tioned by visiblg access to the cervix uteri, shock, anaesthesia inevitably increased the and this type of approach was first made number of operations but also the number possible by the invention of the duckbill of slow and less skilful operators, with a speculum by Marion Sims. This instrument, corresponding increase in the mortality totally different in principle from its name- from post-operative sepsis, until the work sake, the speculum matricis of the of Pasteur and Lister solved the problem ancients, placed in the hands of the of infection. In 1877 for example, a date operator a new method of approach to the before Lister’s work had come to fruition, vaginal walls and the uterus, and opened the mortality rate for ovariotomy in the way for operations which had hitherto London, according to figures supplied by been impossible. Simpson and Sims be- Mr. McKim McCullagh, was as follows : tween them made a unique contribution to the development of those vaginal opera- tions which are euphemistically termed Mortality minor but which include such difficult pro- Cases per cent cedures as vaginal hysterectomy and the Three large general hospitals 61 60.65 radical repair of vaginal prolapse. Many Guy’s Hospital 82 52.43 other names have been associated with Soh0 Hospital 71 38.16 these developments, but none is more Samaritan Hospital 281 23.84 widely known in this country than that of Fothergill, in association with the Man- These figures reveal the relative safety of Chester operation. The matter of credit has the special as compared with the general been much debated, but the situation was hospitals of that time and also the remark- pithily summed up by a Liverpool student able influence of Sir Spencer Wells at the in a Final Examination at which Sir Samaritan. But, in spite of the inevitable William Fletcher Shaw was present on sepsis, the introduction of anaesthesia gave behalf of the General Medical Council. The an impetus to the development of surgery, candidate, who was quite unaware of the and gynaecology proceeded to advance identity of the gentleman sitting at the side along two separate and slightly divergent of the examiner, when asked to describe

history-of-obgyn.com 58 JOURNAL OF OBSTETRICS AND GYNAECOLOGY the Manchester operation replied-‘ ‘ this opinion after studying the reaction of the procedure was begun by Professor Donald, peritoneum to gunshot wounds of the modified by Professor Fothergill and per- abdomen. Three years later he carried out fected by Sir William Fletcher Shaw ”. his first ovariotomy, but the operation was a complete failure and Wells was again The influence of Spencer Wells, Lawson inclined to the belief that tapping and Tait and the Ovariotomists incision were alone justifiable and the Whilst these vaginal operations were more so because at this time only one suc- being worked out, Spencer Wells and cessful case had been reported in London Lawson Tait were following up the pioneer (by Hawkin of St. George’s Hospital in work of Ephraim McDowell and his suc- 1846). On reflection, however, Wells cessors. Lizars of Edinburgh was the first decided to persevere with his mission and, to perform a successful ovariotomy in being an honest as well as a fearless man, Scotland, but his success was limited to he determined to record all his results one operation performed in 1825, and regardless of the consequences to himself Claye of Manchester, who has clear priority or his reputation. This pledge he scrupu- in England, made a much greater contribu- lously kept and at the time of his retire- tion to the problem. Born near Stockport ment from the Samaritan Hospital, in the in 1801, after studying in Manchester and year 1877, he had reported 408 cases with Edinburgh, he settled in practice (in 99 deaths-a mortality of 24 per cent. 1823) at Ashton-under-Lyne where, like Ephraim McDowell, he combined a good Lawson Tait deal of surgery with his other work. In Tait came later than Wells but went 1839, he removed an ovarian tumour further. Born in 1845, he left Edinburgh weighing 36 pounds, the operation taking, in 1867, with a determination that he would it is said, only ten minutes, and by 1848, never deliberately open the abdomen. He i.e. before Wells had done his first case, he said “ the results I have seen in Edinburgh had 33 to his credit and, by 1865, no less were truly awful, some thirty cases and than 113 cases of whom 77 recovered. not a recovery ”. After acting as house This was a great achievement but neverthe- surgeon in Yorkshire, he settled in Birm- less it is to Spencer Wells (1818-97) and ingham, giving as his reasons for the choice to Lawson Tait that we owe most for the of this city that he was the first pupil of development of abdominal gynaecology . Simpson to go there and that Birmingham Spencer Wells was born in 1818, and was about the centre of England and there- after joining the Navy as a surgeon spent fore most easily accessible to patients who six years in Malta. By training and by might desire to see him from all parts of inclination he was a general surgeon, and the country. Like Spencer Wells he was a he admitted afterwards that, when he was general surgeon rather than a specialist, appointed to the Samaritan Hospital in for although he founded the Birmingham 1846, gynaecology “was a subject of Hospital for Women as a special hospital, which I knew less of than of any other he did not restrict himself to gynaecology special division of our profession.” A year and in the course of his career carried out earlier he had agreed with Dr. Waters of 4,000 abdominal sections including the first Chester, whom he met in Paris, that successful cholecystectomy in this country, ovariotomy was an unjustifiable opera- and the first operations for cystic ovary, tion, but he went to the Crimea in 1854 as pyosalphinx and hydrosalphinx. He was a an army surgeon and here he revised his fine operator and, although he did not

history-of-obgyn.com THE EVOLUTION OF THE GYNAECOLOGIST 59 accept Lister's work on antisepsis or con- with the exception of Lawson Tait, and sciously apply his principles, he got better indeed it was darkly hinted that Spencer results than his great rival Spencer Wells, Wells had hiniself supplied the funds for who believed in both, but it must be the prosecution. The medical evidence remembered that Spencer Wells did a great given in this case tended to bring gynae- deal of his work before the principles of cology into disrepute with the general antisepsis were established, and that he got public, and it had an unfortunate effect far better results than his own contempora- upon the profession by suggesting that ries. Tait held that, if organisms existed Tait was as unorthodox as Imlack, that at all, they could only live on dead matter, specialists were potentially dangerous, and and in the belief that organisms could not that the new gynaecology might best be survive in a healthy wound, he took infinite left in the hands of the general surgeon. care to keep his wounds healthy. He had With this Iatter view, curiously enough, been greatly influenced by the work of Tait was in agreement for he was never an Syme, who unlike most of his colleagues, obstetrician and had very little sympathy observed the most scrupulous cleanliness, with the physician accoucheur. In 1884, and Tait developed these principles to such two years before the Imlack case, Tait had an extent that he finally evolved a method assisted to found the British Gynaecologi- that was practically identical with the cal Society for the benefit of those who modern aseptic technique. He was a man were eager to advance the study of the dis- of great originality of mind and above all eases of women, as opposed to the mem- an individualist, always ready and willing bers of the Obstetrical Society who were to maintain his own views and to sustain supposedly interested in purely obstetrical his own reputation against all comers-and problems. In his book, written in 1889, particularly against Sir Spencer Wells, with Tait animadverts as follows-" The old- whom he was frequently in conflict. He fashioned mechanical school, the teaching was certainly the most original and possibly of the speculum, the sound, the caustic the best abdominal surgeon of his day and stick and the pessary has been practically as such he made a fundamental contribu- killed . . . the day has gone by when the tion to gynaecology, for which his capacity treatment of pelvic and abdominal may be judged by the fact that he actually diseases . . . is to be regarded as a mere performed a series of 136 consecutive appendix to the work of the accoucheur ovariotomies without a single death. But . . . Gynaecology and Obstetrics are now if he made a great contribution to gynae- happily severed, and this division of labour cology, his contribution to the fortunes of has resulted in enormous advances for the gynaecologist was somewhat different. both ". His earliest operations on the cystic ovary led to the accusation that he was " spay- The Gynaecological Surgeon or the ing " his patients-a view that Wells did Obstetrician and Gynaecologist little to refute when he remarked '' I never This disruptive idea was short lived, but see such cases, perhaps they all go to it was responsible for the establishment of Birmingham ", and his reputation was not separate Chairs in Obstetrics and Gynae- enhanced by his support of Dr. Imlack, cology in some places, and for sharp the Liverpool surgeon, who was differences of opinion and practice in prosecuted for performing an operation others. In Vienna for example, there was, for appendage disease. Imlack received and possibly is, the Schauta or the Vaginal little if anv support from his colleames School and the Wertheim or Abdominal

history-of-obgyn.com 60 JOURNAL OF OBSTETRICS AND GYNAECOLOGY School-each almost wholly committed to students. This spirited riposte was too the one technique and almost wholly in- much for the surgeons and Rankin Lyle different to the other. These family differ- was given an appointment and teaching ences were good ammunition for the beds at the Infirmary, having fought, as surgeons in their attempt to restrict the Professor Farquhar Murray tells us, as a activities of the physician accoucheur and complete stranger for a proper status for to repel the invasion of the gynaecologist the gynaecologist-and all honour to him into the field of abdominal surgery. for his courage and altruism. Fortunately the attempt to separate gynae- cology from obstetrics was doomed to Fomdatiolz of a College failure, for all the modern advances in The special societies in London, Edin- medicine and surgery had shown the burgh and elsewhere did much to fuse the biological unity of the two subjects, whilst two elements of their branch of medicine the mcetings of the various Obstetrical and and to promote the welfare of the obstetri- Gynaecological Societies, with their trans- cian and gynaecologist, but they did not, actions and their journals, afforded abun- and indeed could not, constitute a central dant proof of the common interests of the authority to which all might look for guid- obstetricians and the gynaecologists. ance and control. Their fellows and mem- Nevertheless long after this internecine bers owed allegiance to one or other of the warfarc had been settled, the cold war be- Royal Colleges, and in some cases to both, tween the general surgeons and the gynae- but neither college had a comprehensive cologists lingered on in those parts of the knowledge of obstetrics and gynaecology country outside the influence of teaching nor a special interest in the obstetrician or centres where trained specialists were not gynaecologist . easily available and the general surgeons In the course of the 50 years which pre- had come to regard gynaecology as an ceeded the foundation of our College only interesting and remunerative part of their four obstetricians-Dr. Galabin 1898, Sir own work. In such places the gynaecolo- John Williams 1900, Sir Henry Champ- gist, like his predecessor the phj’sician neys 1902, and Dr. Herbert Spencer 1918, accoucheur, gained admission to the were elected to the Council of the Royal genera: hospital as a teacher, but not College of Physicians, whilst in the Royal always without a struggle, of which one College of Surgeons during the same may perhaps be permitted to quote one period, if we exclude Sir William Fergu- example. In Newcastle, the late Professor son, Sir Spencer Wells and Sir John Bland Rankin Lyle, when Assistant Master at the Sutton, who were Presidents and general Rotunda, was appointed Lecturer in Mid- surgeons, only one gynaecologist was wifery at the Medical School. The appoint- elected to the Council, namely, Mr. Victor ment carried beds at the Maternity Bonney in 1926. The situation became the Hospital but none for the teaching of more pressing with the trend of events- gynaecology, and Rankin Lyle was the progressive work of the Ministry of refused admission to the Staff of the Royal Health, the Central Midwives Board and Victoria Infirmary when he applied for the Municipal Hospital System with iis un- access to that institution. He thereupon limited number of beds-developments bought a house at the very gate of the which made for disunity in the control of Infirmary, equipped it as a Women’s midwifery, and thereby made the need for Hospital with an Out Patient Department, an independent and authoritative body yet Wards and Theatre, and there taught his more urgent.

history-of-obgyn.com 'THE EVOLUTION OF THE GYNAECOLOGIST 61 The call for action was answered at a longer an age of gradual transition along meeting of the Gynaecological Visiting the lines laid down by Lamarck and Dar- Society-a society of teachers which owed win, but one in which sudden and incal- its inception to the imagination and culable changes take place by a process as enthusiasm of the late Professor Blair mysterious and uncontrollable as the Bell, who resembled Lawson Tait in the mutations described by de Vries and the fertility of his thought, his boundless geneticists. Chemotherapy for example energy, and in his burning interest in has revolutionised the outlook in puerperal gynaecology. He shared too his love of sepsis and the sulphonamides and peni- polemics and his passionate aspiration cillin have rendered operative delivery so towards priority of purpose and achieve- safe that most of the vaginal methods of ment, and li'ke Tait he was the outstanding dealing with difficult cases are now gynaecologist of his generation. It was at obsolete. By this dramatic stroke obstet- one of these gatherings that Sir William, rics has been reduced to the simple formula then Professor Fletcher Shaw, first brought of vaginal delivery with episiotomy and forward the project that eventuated in the low forceps for normal cases and Caesa- foundation of a College that was British rean section for all the rest, a formula from,birth and has since become Royal by strangely reminiscent of the Greek system gracious permission and by illustrious in which the natural cases belonged to the fellowship. By this unique foundation- midwife and the preternatural to the for our College was the first of its kind- physician. But mutation is not always Obstetrics and Gynaecology were pre- sudden and spectacular, and none has been sented to the world not as a dual specialty, more interesting and far reaching in its but as the interwoven and indivisible benefits to mankind than the emancipation elements of a basic branch of medicine, of women, a long and arduous movement, and its Fellows and Members were called the consumination of which by a curious if upon to emulate the status and the respon- unrelated coincidence marked the prelude sibilities of the physicians and surgeons. to a global war which has waged ever since. This bold claim was a challenge to all those We recognize to-day how happily this sur- who founded the College and it remains a render of the ancient rights of man has challenge to us to-day-and especially to affected the destiny of this College, as we the younger men who are called upon to reflect that twenty long centuries inter- take up the gage. We have received help vened between the birth of Hippocrates and encouragement from all parts of the and the appearance of the first woman world, and none has been more gratifying doctor, and only twenty short years be- than the advice and co-operation of the tween the foundation of this College and older Colleges, who have given us a royal the election of the first woman President. welcome and fully acknowledged our posi- The ultimate effects of these and other tion as a junior member of the family. It changes are unpredictable, for no man can remains for us to show that this Cinderella tell how the lives and work of the fellows of ours is worthy of her older sisters. and members of this College may be affected by the social strife of a world in Mutation and the Future which atomic energy may at any moment And here we must leave the evolution of be unloosed. But as we cannot foretell the the gynaecologist to the care of the College luture we must face it with courage and and to the discipline of the future and its resolution, or, better still, in the spirit of fortunes, bearing in mind that ours is no Osler's words, " Banish the future, live for

history-of-obgyn.com 62 JOURNAL OF OBSTETRICS AND GYNAECOLOGY the hour and its appointed task ”. And it 1948-M.R.C.O.G. required as an additional is with the firm hope and belief that we qualification. shall do our duty and strive to emulate the MY. Frederick W.Roques spirit of those young men whose supreme sacrifice for their country we commemo- GUY’S HOSPITAL rate to-day that we recall in honour and 1789-John Haighton appointed Lecturer in in lasting gratitude the name of William Physiology and Midwifery to Guy’s and St. Meredith Fletcher Shaw. Thomas’s with title of Obstetric Physician. 1831-Obstetric ward opened under care of William APPENDIX Blundell, nephew and successor of John Haighton. It is my duty to acknowledge the help received Mr. G. F. Gibberd from the Fellows and Members of the College in the preparation of this lecture-and to offer them ST. THOMAS’S my sincere thanks for answering questions ahout the hospitals to which they are attached, and thus 178g-John Haighton appointed Lecturer in placing at my disposal much information of his- Physiology and Midwifery to St. Thomas’s and torical interest which would otherwise have been and Guy’s Hospital. unobtainable. 1887-Dr. Gervis resigned and the Governors had For the sake of simplicity this information has some difficulty in filling the appointment- been tabulated under the various types of hospital possibly because the ovariotomies were done by which have been directly concerned with the the surgeons only. The Medical Board were evolution of the gynaecologist, and maternity obliged to look for a distinguished obstetrician hospitals have been excluded because they have outside London and finally they recommended always been conceded to the specialist and have Dr. Cullingworth of Manchester, explaining that thus escaped most of the problems and controver- ‘‘ The two or three London men whom we first sies which have beset his path. Moreover, the approached having given the question very ample hospitals cited are dealt with from the evolution- consideration, for various but sufficient reasons, ary point of view only and no attempt has been declined to come forward ” ! Cullingworth, who made to indicate their present position or import- was Physician to St. Mary’s, Manchester, and ance-and necessarily the list is incomplete. In Professor of Obstetrics and Gynaecology to effect the data here presented are a sketch of the Owen’s College, got the appointment-and from historical background but not a complete picture this time onwards the Obstetric Physician was of the development of the gynaecologist and his allowed to perform all gynaecological operations. work. MY. James Wyatt The hospital facilities now available to the obstetrician and gynaecologist are In fact much ST. BARTHOLOMEW’SHOSPITAL greater than might appear from any summary of 1812-Andrew Thynne appointed Lecturer in Mid- the past and, in order to prevent misunderstanding wifery: but the original appointment carried no on this point, the situation at Glasgow has been beds. included at the end of this appendix as a typical 1861-Charles West, who was Lecturer in Gynaeco- example of the modern resources of a great city logy as well as Midwifery and had a ward of 13 and teaching centre. beds, resigned because he was dissatisfied with GENERAL HOSPITALS IN LONDON the conditions of service. THE MIDDLESEXHOSPITAL 186z--Greenhalgh, West’s successor, was styled 1747-Physician Accoucheur appointed with use Physician Accoucheur as well as Lecturer. of beds. 1890-Champneys succeeded Matthews Duncan r91z-Title changed to Gynaeco!ogical Surgeon. who died in 1890, but he, like his predecessor, F.R.C.S.(Eng.) made an essential for Staff was restricted to the vaginal field of surgical appointment. work.

history-of-obgyn.com THE EVOLUTION OF THE GYNAECOLOGIST 63 1912-Champneys retired, and Griffiths was Kent was a matter of national importance appointed-the first holder to be allowed to per- because the child if it survived was destined to form abdominal operations and the first to hold succeed to the throne. The Duchess was safely F.R.C.S. Diploma. Apparently the Physician delivered by Dr. Daniel Davis of a female child Accoucheurs were required to be members or who in due course became Queen Victoria, and fellows of the Royal College of Physicians. there can be no doubt that this happy result did 1946-Title of Physician Accoucheur changed to much to restore the confidence of the public in Obstetrical and Gynaecological Surgeon. the obstetrician, and to promote the advance- MY. Wilfred Shaw ment of obstetrics. MY.Clifford Whzte [It is clear from the course of events at Bart’s Miss Joseph z rig Barw es that the Obstetricians were rated as Physicians (or perhaps Assistant Physickns) until well into the present century, and no doubt this assessment ST. GEORGE’SHOSPITAL was fairly general throughout the country. 1853-Dr. Lee, who was already the Lecturer in Moreover, there were few special hospitals that Midwifery to the School, appointed Obstetric required a higher surgical diploma its a condition Physician to the Hospital-and to hold office of appointment to their staff-and most of the only so long as he shall continue Lecturer in Mid- earlier specialists in obstetrics and gynaecology wifery. were content with an M.D. degree. There was 1898-The Obstetric Physician and Assistant in fact a good deal to be said for those general Obstetric Physician should be required to be surgeons who held that the new gynaecology was either Fellow of the R.C.S. of England or Gradu- a part of general surgery, and this attitude had ate in Surgery of the University of London. a very stimulating and salutary effect upon the Mr. C. M. Gwililn work and the training of the obstetrician.]

UNIVERSITYCOLLEGE HOSPITAL LIt should be noted that the first successful 1829-Dr. Daniel Davis appointed first Professor ovariotomy in London was performed by Dr. of Midwifery in University College, London, and Hawkin of St. George’s. Evidently the General Obstetric Physician to the North London Hos- Surgeon did most of the abdominal gynaeco!ogy- pital (Now U.C.H.). He was Physician to Queen until 1898, when the Obstetric Physician was Charlotte’s Hospital and Accoucheur to the required to be a surgeon.] Duchess of Kent at a time when the public confidence in obstetrics had been rudely shaken by the tragic events surrounding the confinement THE LONDONHOSPITAL of Princess Charlotte (daughter of Prince Regent 1854-Br. Kamsbotton was appointed first Obstet- and second in line of succession to the Throne). ric. Physician on 11th January, 1854. He had no Sir Richard Croft, an eminent physician but not fixed beds, but it was decided to “ set aside as a practical obstetrician, had been the Royal many beds as may be needful in certain allotted Accoucheur. His antenatal care consisted of portions of medical and surgical wards, as the severely restricting the diet of the patient, and case may be, until increased hospital accommo- frequent bleedings and forbidding all food during dation shall admit of a separate ward for obstetric labour, which unhappily was protracted for jO patients.” Originally the title was Obstetric hours and resulted in the birth of a stillborn Physician and applicants were required to be infant and the death of the mother soon after- members of the Royal College of Physicians. It wards. was not until Dr. (now Sir) Eardly Holland was The tragedy was deepened by the death of the appointed to the staff that the title was changed obstetrician, who committed suicide a few months Honorary Gynaecological Surgeon. later. 1851-Dr. Ramsbottom had “ obstetric beds ” but In 181Q-two years after the death of Princess apparently no ward of his own. Charlotte-the confineme7:t of the Duchess of 1876-Dr. G. G. Herman appointed Obstetric

history-of-obgyn.com 64 JOURNAL OF OBSTETRICS AND GYNAECOLOGY Physician and a ward oi 7 beds for gynaecology GENERAL HOSPITALS OUTSIDE LONDON and abnormal obstetric cases allocated to him. EDINBURGH: ROYAL INFIRMARY Sir Eardley Holland 185o-Sir James Simpson, Professor of Midwifery Mr. R. C. Perciual and Diseases of Women and Children, appointed to the Staff. ROYALNORTHERN HOSPITAL Piof, R. W. Johnstone I 857-Physician Accoucheur appointed. 1858-Title changed to Obstetric Physician- LIVERPOOL: ROYAL INFIRMARY Physicians shall possess a degree obtained by 1863-A Gynaecological Ward was endowed by Mr. examination at a British University or be Thornton at the Royal Infirmary but no members of the Royal College of Physicians. appointment was made until 10 years later when rg31-Title again changed to Gynaecological 1873-Professor Wallace joined the Staff. and Obstetrical Surgeons-Surgeons shall be A.R.L. F.R.C.S. LEEDS: GENERALINFIRMARY Mr. Lane Roberts 1885-Obstetric Physician appointed to Staff. WESTMINSTER HOSPITAL Professor Andrew Gluycyt. 1801-Dr. Frederick Bird was the first Obstetric Physician to be appointed to the Hospital-the GLASGOW: WESTERN INFIRMARY 1885-Appointment of Physician for Diseases of appointment “ being subject to all the laws and regulatims of the hospital relating to Physicians Women with use of beds and apparently no restriction was imposed upon the work of the and Surgeons I’ . . .“ he shall have the treatment of such patients as the Physicians and Surgeons gynaecologist . Professor R. A. Lennie may from time to time refer to him” . . . and presumably at first he had no ward of his own. BRISTOL: (a) ROYALINFIRMARY Mr. Arthur Be11 (b)GENERAL HOSPITAL 1887-Appointments (with use of beds) made CHARINCCROSS HOSPITAL (u) at the Royal Infirmary with the title of 1868-Dr. Edward Parson was the first Fhysician Obstetrician (1887); Accoucheur. (b) at the General Hospital with the title of 1877-Title changed to Obstetric Physician when Physician Accoucheur. Dr. T. Watt Black was appointed to the staff, Both hospitals took in obstetrical as well as and it has remained the same ever since. gynaecological cases. Dr. Arthur Gruji IgIo-Up to this year the specialist was not a!lowed to perform abdominal operations, but after this WEST LONDONHOSPITAL date, and in spite of opposition by the surgeons, 1868-Dr. (later Sir) William Priestly appointed the gynaecologists took the matter into their Consultant Physician Accoucheur ” but, as own hands. patients in advanced pregnancy were not 1g3g-After the amalgamation of the two hospitals admitted, he was in effect physician for the as the Bristol Royal Hospital, no further obstet- Six cots were diseases of women and children. rical cases were taken in. installed for his patients-suggesting that 1g5o-The present title is Obstetrician and Gynae- Priestly had a special interest in pediatrics. cologist. The prefix “ Honorary ” has been 1871-Dr. Willshire appointed Physician for dropped as a result of the New Health Service. Diseases of Women; Priestly retaining his Professor Drew Smythe original position and title. 1887-Record in the minutes to the effect that the GLASGOW: VICTORIA INFIRMARY Surgeons were not to operate upon the patients 1890-Physician for Diseases of Women appointed in hospital in charge of the Physician for with the use of 8 beds. No restrictions were im- Diseases of Women. posed although in the view of some surgeons 1gz4-Physiclan altered to Surgeon. “ no gynaecologist should open the abdomen.” Mr. Arnold Wulker Professor R. A. Lennie

history-of-obgyn.com THE EVOLUTION OF THE GYNAECOLOGIST 65 ABERDEEN: ROYAL INFIRMARY Member of the R.C.O.G. or Fellow of the R.C.S. 1898-Professor Wm. Stephenson appointed as of England or Edinburgh.

" Surgeon to the newly-opened ward for women." MY. R. MI. Watsoit Some doubts were expressed by the surgeons as

to the possible " economic repercussions " of this SPECIAL GYNAECOLOGICAL HOSPITALS appointment. The case for the Special Hospital was admirably Professor Dougald Baivd put by Dr. Protheroe Smith, the Founder of the CARDIFF: ROYALINFIRMARY Hospital for Women, Soho, London, when he 189GDr. John Williams appointed Honorary addressed the Provisional Committee on 1st Gynaecologist to the Royal Infirmary with use September, 1842. His address has been made 01 beds. available by the kindness of Mr. Leonard Philhps. The Honorary Gynaecologist was required to Dv. Protheroe Smith's Address to the Provisional limit his activities to his own subject. He was Coininittee of the Hospital for Diseases of Wowien. not allowed to engage in general practice or do general surgery. F.R.C.S. and M.R.C.O.G. now 1st September, 1842. an essential qualification for the appointment. GENTLEMEN-Having' long deplored the want of Pvofessor Gilbert Strachan suitable accommodation for treating patients labouring under the diseases peculiar to females, DUNDEE: ROYALINFIRMARY and having maturely considered the subject, I have 1899-Professor Kynock and Dr. R. C. Buist lately determined, with God's blessing, to appointed gynaecologists and obstetricians. endeavour to supply the desideratum, by proposing MY. A. Chisholm that a hospital should be founded for the Diseases NEWCASTLE: ROYAL VICTORIA INFIRMARY of Women. The knowledge of the great extent of 1906-Dr. Rankin Lyle appointed Gynaecologist to female suffering in this Metropolis, and of the the Infirmary on 6th December, 1906, with the limited means which at present obtain for acquir- use of beds. ing professional information on this interesting Professor Farquhar Murray department of practice, have induced me to suggest this measure. DERBY:ROYAL INFIRMARY. I have for some years enjoyed the privilege of 1907-First gynaecological appointment 15th July, being associated with Dr. Rigby, the Lecturer on 1907. Midwifery and the Diseases of Women, etc., at St. MY. N. L. Edwavds Bartholomew's Hospital, to whose friendship and co-operation in the investigation of the diseases of CAMBRIDGE: ADDENBROOKE'S HOSPITAL females I am indebted for much valuable informa- 19zo-First appointment of Hon. Surgeon Gynae- tion. But although I gratefully acknowledge the cological Department made In 1920. Previously advantages which I have thus had of examining and a small amount of gynaecology was done by classifying these peculiar and much neglected a general surgeon. maladies, and though I regard with pleasure the J. R. C. Canney MY. opportunity which has been thus afforded of NORTHAMPTON: GENERAL HOSPITAL ministering to their wants, I am equally reminded 1935-Appointment of the first Obstetric Surgeon that these benefits, valuable alike to the medical to the General Hospital-" Candidate must hold practitioner and his patients, have been much the Fellowship of the Royal College of Surgeons curtailed for lack of hospital accommodation. of England or Edinburgh, and the successful The question may arise, whether it would not candidate will have charge of the obstetrical and be more desirable to appropriate a few wards in gynaecological patients and must confine himself the large hospitals which already exist, to meet, the to his own specialty." exigencies of the case, or whether attendance 1946-Appointment of Consultant Obstetrician and could not be afforded to the suffering female poor Gynaecologist-applicant must be Fellow or at their own homes. In answer to such inquiries, E

history-of-obgyn.com 66 JOURNAL OF OBSTETRICS AN11 GYKAECOLOGY I would first observe, that there are but two hos- to advance the objects which I here advocate by pitals in this great city, which have severally set your personal interest and active co-operation, I apart a ward for this object. Other hospitals, as feel assured that the appeal will be responded to by is well known, find accommodation at present all who are interested in Woman, and sympathize inadequate to their extensive demands, and there in her sufferings. Coiifidently hoping that our appears no reason to expect that they will be able warmest expectations will speedily be realized, that to adopt such a plan, however they might approve the liberality of the public will be excited in so its expediency. In consequeiice of the delicacy of good a cause, and that England, famed alike for treatment to which the women of this country its charities and its high standard of female have always been accustomed, it is quite impractic- character, will no longer lie under the reproach of able, without outraging English modesty, for the neglecting to provide an asylum for its suffering physician or surgeons to give requisite attention to women such cases as may promiscuously occur in the I have the honsur to be, wards of our general hospitals, where he is usually Gentlemen, accompanied on his rounds by a large number of Your obedient, humble servant, pupils. In the next place, the possibility of carry- PROTHEROE SMITH ing out the objects of the proposed charity, by attending the poor at their own habitations, the HOSPITALS FOR WOMEN IN LONDON experience of past pears sufficiently disproves. SOHOSQUARE As a high degree of nervous sensibility is a rS4z-The first Special Hospital in the world to frequent attendant on female disorders, it is be established exclusively for the treatment of generally necessary to keep the patient free from diseases peculiar to women. all excitement; and the great majority of these Founded in 1842 by Dr. Protheroe Smith, who complaints require confinement to the horizontal was at first the only surgeon. posture as essential to their successful treatment; A Consulting Physician and a Physician com- but we are constantly driven to the painful pleted the original Staff. necessity of watching the slow but fataI progress 1887-Royal Charter granted. of disease, which might have been arrested in its 1895-Detailed clinical reports published for the commencement, had the patient enjoyed the quiet, first time. F .R.C.S. required (and by implication repose, and other advantages of a hospital. the M.R.C.O.G.). Such cases abound in the dark and crowded alleys MI,. Leoiaard Phillips of London, where the sufferer is often found to be a mother, upon whose constant exertions the S.4MARITAN HOSPITAL cleanliness and comfort of the family depend. 18~7-Founded by Dr. William Hones for reasons Whilst the one close room she occupies in common similar to those given in Dr. Protheroe Smith’s with her family-her careworn aspect-the filthy address. Provision was also made for a few and squalid appearance of her children-the im- maternity cases and sick children. Staff consisted pure atmosphere in which such misery is necessarily of operating surgeons, including Sir William bred-prove that no remedies can be effectually Fergusson and Sir Spencer Wells and also applied whilst so many causes are operating to physicians who were allowed to do vaginal opera- counteract them; and this is an instance of tions only-a distinction that was not eliminated innumerable cases which daily fall under the until 1902. observation of professional men. 1851-There were 8 in-patient beds and one for the A very important benefit will also be conferred matron. on society by the accomplishment of this proposal, 1855-Maternity cases no longer admitted. namely, the opportunity thereby afforded to the 1867-The first medical report was published. profession, of extending their knowledge in this 1875-Number of beds now 75. branch of practice, which, I trust, may Induce my 1889-Children no longer admitted. medical brethren generally to unite with me in 1907-F.R.C.S. Eng. a condition of appointment, carrying out this great undertaking. In urging you Sir Frederick Treves opening the new theatre

history-of-obgyn.com THE EVOLUTION OF THE GYNAECOLOGIST said-“ At the Loiidon Hospital (where Treves early clinics there grew up by a gradual and al- Lvas on the Staff) every surgeon was asking what most imperceptible process. The gynaecological the Samaritan was doing, so great was its work of the Rotunda and St. Mary’s Hospital

ienown. ” and many other gynaecological hospitals have 1911-In or about 1911the first Wertheini operation developed in the same way. We are not con- to be performed in Britain was carried out by cerned here with the origin and subsequent Cutlibert Lockyer at the Samaritan. history of those hospitals, of which many are 1934-Lord Moyniham opened a new wing and justly famous, which have always been exclu-

declared: ‘I there was not a woman in this or sively engaged in maternity work. any other civilized country who did not owe a Dr. John Bride debt to the work which had been done at the Samaritan, where lay one of the great shrines of LIVERPOOL: WOMEN’S HOSPITAL surgery.” 184I-Dispensary for the treatment of uterine MY.iMcKim McCidlugla diseases established in connexion with the Lying-in-Hospital CHELSEAHOSPITAL FOR WOMEN . 1871-Dr. James H. Aveling was the original 1855-A special ward was added for the treatment Founder of the Chelsea Hospital for Women. of diseases peculiar to women. Opened in April 1871 with 8 beds by H.R.H. the 1862-New joint hospital built for lying-hi woiiien Duchess of Albany. and the better accommodation of special cases (diseases of women). 1883-New hospital opened with 63 beds. “ One distinguishing feature of the new institution is 1881-The Committee resigned owing to the avowed that it will be the first building specially and intention (of one section) to abandon the treat- entirely designed as a Hospital for Women in ment of the special diseases of women. London. ’ ’ 1882-Movement started for the “ protection of 1g48-The Hospital in conjunction with Queen the special wards ”, but the Committee refused Charlotte’s designated under the National to allow the ‘I new movement ” to purchase the Health Service Act (1946) as Post-Graduate hospital in Myrtle Street. This building was sold Teaching Group under a Board of Governors. to the Cancer and Skin Hospital, and the This teaching group was amalgamated with the original Lying-in Hospital abandoned its “special Obstetrical and Gynaecological Department of wards ” and assumed the title of Liverpool the Post-Graduate Medical School to form the Maternity Hospital. Institute of Obstetrics and Gynaecology (Uni- 1883-The “ special wards and Dispensary ”, under versity of London). the direction of the new Committee, transferred 1950-A salient feature of the work of this hospital to 107 Shaw Street, which was opened in July has always been the teaching of Post-Graduates. with 30 beds as the Hospital for ,Women. 1g3z-The Hospital for women amalgamated with In 1948 the total number of Post-Graduates the Samaritan Hospital and a new building was was 248, derived from 17 different nationalities. opened with IOO beds-as the Liverpool Women’s SPECIAL HOSPITALS FOR WOMEN OUTSIDE HospitaJ. LONDON LEEDS: HOSPITALFOR WOMEK DUBLIK: ROTUNDAHOSPITAL, 1745 1853-Hospital established for women and and children. ~‘~LNCHESTER: ST. MARY’S,1790 1897-Special Maternity Department added with Both these hospitals were originally lying- 16 beds. Gynaecological wing continuing with in institutions, but almost from the outset (the 50 beds. precise date is uncertain) they made provision Igog-Children’s Surgical Department transferred for the treatment of those sequelae of child- to Leeds General Infirmary. bearing which at that time formed the chief part ~g~z-Children’s Medical Department transferred of the “diseases peculiar to women.’’ Out of these to Leeds General Infirmary.

history-of-obgyn.com 68 JOURNAL OF OBSTETRICS AND GYNAECOLOGY Igzo-Maternity work transferred to Maternity Pavilion of 150 beds in the grounds of the Royal Hospital. Infirmary-has always been an exclusively 1g334ynaecological work of the General Ii~rinary obstetrical hospital. handed over to the Hospital for Women. The bulk of the gynaecological work of Edin- F.R.C.S. and M.R.C.O.G. now essential quali- burgh and the surrounding parts of Scotland is fications for Staff. carried out in the wards or the Royal Infirmary, MY. Bryan Jeaff~eson where there are three units of 35 beds each. In addition there are both obstetrical and gynae- BIRILIIPU’CHAM: MIDLAND HOSPITAL FOR WOMEN cological beds in the Eastern General Hospital, 1871-Founded by Lawsoii Tait and Ross Jordon- the Western General Hospital and a few at Leith. with an in-patient and out-patient department, Dr. Ernest Fahmy and 8 beds. Exclusively gynaecological from its inception . GENERAL HOSPITALS FOR WOMEN 187z-Clinical Report first published. STAFFED BY WOMEN ONLY F.R.C.S. and M.R.C.O.G. now an essential quaiification for Staff. The establishment of the Elizabeth Garrett Anderson Hospital, the first hospital to be staffed NOTTINGHAM: HOSPITAL FOR WOMEN by women only, is of great historical interest in 18754astle Gate Hospital for Women (15 beds); so far as it commemorates the name of the first and Samaritan Hospital for Women (10 beds) woman doctor, and records one of the iirst attempts amalgamated in 1924 as Nottingham Hospital for to assert the professional equality of women. These Women. special hospitals-of which only z out of many are 1929-New joint hospital opened with 60 beds. cited-subserved a useful purpose in an age that 193g-New maternity block opened with 40 beds opened the medical register but closed the hospital for abnormal obstetric cases. Originally staffed staff to women graduates-but their usefulness has by general practitioners, the hospital now a limited range in a world that recognizes equal demands the M.R.C.O.G. as an essential rights for both sexes and it is unlikely that any new qualification for membership of the Staff. hospitals of this type will be set up. DI. M. Gha Bott LONDON: ELIZABETH GARRETT ANDERSON GLASGOW: ROYAL SAMARITAN HOSPITAL HOSPITAL 1886-Exclusively gynaecological from its founda- 1866-St. Mary’s Dispensary established in Sey- tion in 1886. mour Street. 1gz8--Clinical report first published. 1872-10 beds provided over the out-patient N.B.-The Glasgow Lying-in Hospital and department. Dispensary was founded in 1834 and its work has 1875-Hospital removed to Marylebone and re- always been exclusively obstetrical except for one named New Hospital for Women-a general period of 15 months in 1908-09, when gynaeco- hospital for women and children though mainly logical cases were admitted (see Glasgow General gynaecological. Hospitals). 1899-Removed to Euston Road-42 beds. DY. John Hewitt Ig)zg--New wing opened-Hospital now IOO beds. Dr. Beatrice E. Tuvner EDINBURGH A small hospital was founded by the late Dr. EDINBURGH: ELSIE INGLIS MEMORIAL HOSPITAL Haultain at the beginning of the century. I 878-Edinburgh Hospital Dispensary for Women Under the New Heath Service it continues as an and Children opened. exclusively gynaecological unit with 30 -beds, 1886-6 beds provided to form a cottage hospital and is the only special hospital for the diseases in Grove Street. of women in Edinburgh. The old Simpson ~gog-The Cottage Hospital transferred to Brunts- Memorial Hospital-now the Simpson Memorial field Lodge, with 20 beds.

history-of-obgyn.com THE EVOLUTION OF THE GYNAECOLOGIST 49 rgo3-The “ Hospice ” opened with 8 beds as Visiting Consultant-and effected other changes another small general hospital staffed by women. which brought their units into line with the require- 1910-Bruntsfield Lodge and the Hospice com- ments of the ColIege in regard to preparation for bined-the hospice becoming an exclusively the Membership Examination. As a result of these Maternity Department with 10 to 14 beds-and arrangements the status of the Junior (resident) Bruntsfield continuing as a general hospital. as well as the Senior (Visiting) appointment was greatly enhanced-and the field of training for the MUNICIPAL HOSPITALS young obstetrician and gynaecologist was corre- spondingly enlarged. The first appointments of this In regard to the development of Obstetrics and type were made at St. James’s Hospital, Balham, Gynaecology, the Municipal Authorities came late and at Dulwich Hospital. intg the field, because it was not until the Local Following upon the publication of the Post- Government Act of 1929 was passed that the Local 2. graduate Medical Education Committee’s Report Health Authorities and the Medical Officers of in 1930, the London County Council played an Health obtained effective control of the general essential part in the negotations which ensued hospitals working under the old Poor Law System. Nevertheless, it must be recorded with gratitude between the Government, the University and the that many Health Authorities, and above all the Hospital Service of London, and which culminated in 1934, in the establishment of the British Post- London County Council, provided valuable facilities for gynaecological work at a time when graduate School at the London County Council such facilities did not exist, or were not made Hammersmith Hospital-with Professor James available in many voluntary hospitals-and there Young of Edinburgh in charge of the Obstetrical can be no doubt that prior to the advent of the and Gynaecological Department. National Health Service the municipal hospitals Facilities for advanced post-graduate teaching in many parts of the country were making a notable and research had hitherto been almost non-existent contribution to the practice and teaching of in this country, and the provision of a hospital and obstetrics and gynaecology, and towards the train- financial assistance for this purpose was a major ing and welfare of the gynaecologist. contribution towards the solution of a difficult and important problem. THE LONDONCOUNTY COUNCIL 3. A final development was the federation for In 1930, the London County Council took over the purpose of post-graduate teaching, in 1948, of the hospitals of the Metropolitan Asylum Board and Professor Young’s Unit at Hammersmith with of the 25 Metropolitan Boards of Guardians, and Queen Charlotte’s Hospital and the Chelsea Hos- under the aegis of the new governing body these pital for Women as the Institute of Obstetrics and hospitals developed into the largest and most pro- Gynaecology with a Board of Management in gressive group of municipal hospitals in the world. affiliation with the British Post-Graduate Medical These developments included three of major Federation. The Institute with its fusion of the interest to the gynaecologist. best elements from the old voluntary and municipal I. Under the old regime the maternity work of systems has an important and responsible role to the public hospitals was camed out by whole time play in post-graduate medical education and it is resident medical officers with the help of a part time assured of the sympathy and support of every visiting consultant from the stafc’ of a voluntary gynaecologist. or teaching hospital, but the latter was “ on call ” only, and technically the treatment of the patients MUNICIPAL HOSPITALS OUTSIDE LONDON was the responsibility of the Medical Superinten- DUNDEE dent. In 1936, the London County Council, after 19z4-Dr. R. C. Buist was appointed Visiting discussion with the British College of Obstetricians Obstetrician and Gynaecologist by the Dundee and Gynaecologists, modified the terms of medical Parish Counc,il to the Eastern Hospital-now appointment by transferring full clinical respon- Maryfield Hospital. sibility from the Medicai Superintendent to the Dr. W.L. Burgess, M.O.H.

history-of-obgyn.com 70 JOURNAL OF OBSTETRICS AND GYNAECOLOGS BIRMINGHAM (Stobhill) and there:ifter rapid de\.e!opments xgzz-The post of Resident Obstetrician created at took place and inany new consultant appoint- Dudley Road Hospital-mod&ed z years later ments were made to the various maternity units as Resident Obstetrician and Gynaecologist. established by the Corporation; from the outset Mv. R. P. S. Kelnanii, F.R.C.S. these consultant obstetricians were given full clinical control of their beds. CAMBRIDGE Dr . Stir art La id lnzt~,.ti. 0 .H . rgz7-The Borough Council obtained the services of a Consultant for Puerperal Pyrexia cases in DERBY 1927 and for cases of difficult labour 2 years 1931-Consultant Obstetrician and Gynaecologist later-but without providing beds as these were first appointed with control of beds in March 1931. available at the voluntary hospitals (Adden- Dr. 1'. N. Lep-hon, M.O.H. brooke's). CARDIFF Uv.Cyril Eastwood, M.O.H. 193z-The Professor of Midwifery in the Welsh LEEDS National School of Medicine was appointed 1928-A Consultant obstetrician and Gynaecolo- Consultant Gynaecologist and Obstetrician to the gist was appointed to the Staff of St. James City Lodge Hospital. Hospital by the Leeds Board of Guardians. The DY.J. C. Gseoizuood Wzlsori. M.O.H. Consultant was not originally in full clinical control of beds but paid regular visits to the EDINBURGH hospital. At such times he was asked to give an rg32-Wheii the Local Government (Scotland) Act opinion on certain ases submitted to him. 1929 became operative, arrangements were made Dr. I. G. Davies, M.O.H. between the Corporation of Edinburgh and the University whereby the Corporation was enabled LIVERPOOL to have the expert advice of the professorial 1921-Visiting Obstetrician with clinical control staff of the University for work in the hospitals. of beds appointed by the select vestry to their The professors of Medicine, Surgery, Midwifery Brownlow Hill Hospital. and Child Life were appointed to act as Directors Gynaecology remained in the hands of the of the Municipal Units for their respective sub- visiting surgeon. jects with full clinical control of the beds placed igz7-Visiting Obstetrician and Gynaecologist in at their disposal. Tht-se appointments became full clinical charge of obstetric and gynaecologkal operative on zznd November, 1932. wards appointed to Walton Hospital. Dr. H. P. Tate, F.R.C.P.

MANCHESTER OXFORD 1929-Before Crunipsall Infirmary and Withington 1c~37-Prior to the igrg Act, the Oxford Council Hospital were transferred to the City Authority, did not appoint a Specialist in Obstetrics and each hospital had a part time Visiting Obstet- Gynaecology, but relied upon the expert and rician and Gynaecologist-with beds at their gratuitous advice of the local consultants. In disposal and clinical independence of action. 1937, however, the City, in association with the Dr. C. Metcnlf Brown, M.O.H. Oxford County Council, provided the equipment

for a " Flying Squad '' based on the voluntary GLASGOW Maternity Hospital and made arrangements to 1929-Prior to the Local Government Act, in pay the consultants for services to their own Glasgow as in London and elsewhere, public cases. assistance institutions had maternity and gynae- Dv. M,ayy Fisher, D.C.H. cological beds with a visiting consultant in clinical charge. As soon as the City took over BRISTOL these hospitals, a new maternity department was 1939--After a new maternity building had been created at the largest Municipal Hospital erec-ted at Southmead by the Local Health

history-of-obgyn.com THE EVOLUTION OF THE GYNAECOLOGIST 71 Authority the voluntary hospitals in Bristol medical oificer (who was in general practice in decided to give up internal and external mid- the town) to look after the cases. In 1929 this wifery work and to leave this to the Local lady became part-time Consultant Obstetrician. Authority. A comprehensive scheme was then The fust appointment under the new regime was drawn up by the Corporation and the University, made in 1938 when a member of the British and Southmead became the teaching hbspital. College of Obstetricians and Gynaecologists The Professor of Obstetrics at the University became part-time Consultant Obstetrician and took charge of the Obstetric Department, and Gynaecologist to the Corporation Hospitals. the Medical Superintendent of the Hospital was Dr. N. Gnbbi, M.O.H. recognized as a Specialist in Midwifery and a member of the team. Under this system the NOTTINGHAM Professor was responsible for teaching. the 1g40-A~Obstetrician and Gynaecological Surgeon Medical superintendent for administration, and was appointed by the City Council-with a de- the clinicians in charge of the three units, which partment in the City Hospital. together composed the Obstetric Department of There has never been a Gynaecological Depart- 160 beds, had full clinical responsibility for their ment at the General Hospital (former Voluntary ,own cases. Hospital) although the anomalous title of Lh. R. H. Parry, M.O.H. A4ssociate Gynaecological Surgeon was created to allow the City Obstetrician and Gynaecologist SUNDERLAND to come in for consultation-without, however, xgj8-A Consultant Obstetrician to the Sunderland giving him the control of beds or any routine County Borough. with beds at the Municipal out-patient or in-patient duties. Hospital, was appointed in 1938,the M.R.C.O.G. Mv. Hwold Malkiri being a necessary condition of appointment. DY.Williovn Dodd. M.O.H. Prior to the New Health Act, the Royal Infirmary had no Gynaecological Department although the title of Hoiiorary Associate Assistant Obstetri- HOSPITAL FACILITIES FOR THE TKEAT- ciaii was conferred upon the Municipal lWENT OF OBSTETRICAL AND GYNAECO- Consultant in order to enable him to perform LOGICAL CASES NOW AVAILABLE (1950) IN major obstetrical operations in its private THE CITY OF GLASGOW Lvards: he was not allowed, however, to do gynaecological work in the hospitd. I. There are three general hospitals which were MY. F. J. Bllr.ks formerly voluntary hospitals in which there is a Gynaecological Department but no Obstetrical NEWCASTLEON TYKE Department. These are known as the Royal 1938-.A full-time Maternity Child Welfare Officer Infirmary, Castle Street, Glasgow, C.4, the under the old conditions was appointed in 1920. Western Infirmary, Dumbarton Road, Glasgow, In 1938 a new appointment was created of W. I., the Victoria Infirmary, Langside, Glas- Obstetric Surgeon with charge of a 30-bedded gow, s.2. Maternity Unit at the General Municipal Hospital 2. There are Three general hospitals which were ahd supervision of the City’s obstetric and mid- formerly municipal hospitals in each of which wives’ services. This appointment was modified there is both an Obstetrical and Gynaecological in 1043 with the title of Obstetrician and Gynae- Department. They are known as Stobhill Lolo$& to the City’s Hospitals. Hospital, Govan, Glasgow, S.W.1; the Eastern Dr. W.S. Wnlto?~,M.O.H. District Hospital, Duke Street, Glasgow, E. I ; the Western District Hospital, Bairdsbrae, Glasgow , HULL c.4. sy38--Under the old regiine, the City took over in 3. There Is a small general hospital, formerly a 1015 a Maternity Hospital supervised by voluii- voluntary institution, staffed entirely by women t try auspices and appointed a part-time lady doctors and dealing exclusively with female

history-of-obgyn.com 72 JOURNAL OF OBSTETRICS AND GYNAECOLOGY patients, and having both obstetrical and gynae- 5. Robroyston Hospital, Millerston, Glasgow, cological beds. formerly a municipal tuberculosis hospital with It is known as Redlands Hospital for Women, two pavillions set apart for cases of puerperal Lancaster Crescent, Glasgow, W.Z. sepsis. These septic wards being no longer 4. There is Lennox Castle Institution, formerly a required have been converted into a maternity municipal hospital situated about 12 miles from unit. the centre of the city and built initially to 6. There are two special Hospitals, the Royal accommodate mentally defective children, but Maternity Hospital and the Royal Samaritan now containing both an obstetrical and gynae- Hospital. cological unit. Dr. John Hezvitt

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