All right, so welcome to the Augs FPMRS webinar series. I'm Casey Roberts, the moderator for today's webinar. Today's webinar is Medical History of OBGYN presented by Dr. Tony Tizano. Dr. Tizano will present for 45 minutes. The last 15 minutes of the webinar will be dedicated to Q&A. A little bit about Dr. Tizano. Dr. Anthony Tizano is Director of Student and Learner Health at the Cleveland Clinic. He is a clinical professor of surgery at Case Western Reserve University and Cleveland Clinic's Lerner College of Medicine and a former medical director at Cleveland Clinic's Family Health and Surgery Center in Worcester, Ohio. He serves as president of the Cleveland Medical Library Association, advisor to ACOG's Jacobs Library for the History of Obstetrics and Gynecology in America, and honorary curator of the Dietrich Medical History Museum. Dr. Tizano has lectured widely and authored articles and book chapters on contraception and history of obstetrics, gynecology, and pelvic surgery. An avid collector, he holds one of the most unique private collections of medical artifacts and medical books in the country. His extensive museum, while privately situated, makes a worthy contribution to the study of women's health history. So before we begin, I'd like to review some housekeeping items. First of all, this webinar is being recorded and live streamed. Please remember to use the Q&A feature of the Zoom webinar to ask any of the speakers questions. And please use the chat feature if you have any technical issues. All staff will be monitoring the chat and can assist. And so without further ado, Dr. Tizano, if you'd like to take it away. Well, Casey, thank you very much. It's really a privilege. You know, this is kind of my hobby. I don't want anyone to think that I'm an academic around the history of obstetrics and gynecology, but I'm a collector who, with kind of the support of Mickey Karam, Mark Walters, have kind of urged me to take a little more of an academic approach. So I'd like to share with you some of my interests, and you'll see why I have the world's most tolerant wife, as all of this material, about 3,000 artifacts, resides in the downstairs of our home. To get started, I'd like to just review a few of the objectives. I really would like to try to convey an appreciation for the surgical challenges that were faced by 19th century providers, with all the lack of modern technology that they were saddled with, to identify the requisites for consistently successful surgery. There were plenty of procedures done, but whether they were successful or not, was the question, and we'll talk about that. We also want to look at some of the fundamental gynecologic surgeries that were performed about the mid-19th century, when we began to finally have some successes that were worth discussing, and become equated with some of the incredible instruments, which, to me, are almost like artwork in a way, and which kind of drives me and my passion to collect these items. So, you have to keep in mind that when we look at education in obstetrics and gynecology, it was really midwifery and obstetrics to begin with, and when we look at the early part of the 19th century, there were very, very few lectures. In fact, the first more had to do with jurisprudence than it had with any kind of medical skill set. First references were made at Harvard of instruction in 1830, and before that, there were nothing more than really apprenticeships to create teaching opportunities. They didn't work on patients. Instead, they had these beautiful models from Italy and from France, that many of which were created in Florence, and these are just beautiful, wonderfully anatomically correct. You can see here's an abdominal pregnancy, something I've never gotten to see, and these are life-size models that have kind of fallen into disrepair, so come to the market from time to time. By the time you're at mid-century, there were 50 obstetric lectures given at the Harvard Medical School, but clinical experience was lacking, and in fact, if you wanted any clinical experience, you had to pay for them at about $2 each, which mid-19th century was a lot of money. So what did it look like? Well, we were almost an exclusively medical discipline. There was really no successful surgery well into the century. We were typically teaching along with diseases of women and children, so pediatrics was a big piece of it. By the time we look at mid-century and you look at New York at some of the larger hospitals, there were no gynecologic cases in the mid to third quarter of the 19th century, and it really wasn't until Sims and Emmett at New York's Women's Hospital began to perform procedures that they picked up in any kind of volume, and things really began to get rolling. Still, by again, third quarter of the 19th century in an address before the American Medical Association, they looked at something as simple as myomectomy as so dangerous and difficult an operation that desperate conditions must exist to even consider it. So what did we need to have successful surgery? Well, we needed education to begin with, and at the outset and certainly prior to the revolution, we kind of followed what was done in London and Leiden where you got an apprenticeship, and you paid for the privilege of doing that and really received no money, and you were kind of a housekeeper and maybe got to do a little bit of medicine, waiting for something more structured to occur. There are plenty of illustrations of early anatomical dissections. This is one that actually is in the town where I live is Worcester, Ohio, and the medical school actually did their dissections outside of the main city because it drew so much attention. It was nice to have anesthesia for no other reason that the patient wasn't moving despite and also, of course, not feeling pain, but imagine what it would be like to do any of these procedures, and many of them were done in the absence of any real anesthesia. Antisepsis was an afterthought. It didn't come until the third quarter of the century, but certainly was an important step into having successful surgery. Hemostasis, something we take for granted. We have great suture material. We have the bovie. We have clamps that work very nicely, but none of these existed with any kind of real trustworthy results, and so there was question marks around them all the time. And finally, something we really take for granted, you need to be able to see, to have retractors that work, but more than anything, you needed light, and it used to be operated in the morning in an east-facing window so you'd have sufficient light to be able to operate. Teaching obstetrics was strapped with all kinds of issues. It was almost entirely didactic because it wasn't proper to be able to see a woman without clothes. It was part of social custom. And Victorian morality really reigned and kind of saddled us with all kinds of issues. So all of you are familiar with Ridge Williams, and he received the University of Maryland's OBE Prize and was a leading figure in American obstetrics, but he participated in only two births during his training before he arrived at Hopkins and then, you know, became chairman there. We need to have good educational materials, and it's our literature today, and we have rapid access to all of it on the internet. But in the beginning, it was few and far between, and most of what we had were books, and books were always outdated by the time you got the information. There was only a meager medical literature in terms of journals, and most of that was in Europe. So if you had money to go there, you were okay. So the first catalog in 1723 at Harvard only had 58 medical volumes. Later, we would have the medical repository in the end of the 18th century, and then finally the eclectic repository reported on McDowell's oophorectomy in 1817, which was the first successful abdominal surgery. By the mid-19th century, about 250 journals had been published, and by the early 20th century of the world's 1,600-plus journals, more than half were published in America. So we look at the explosion of information, and today, doubling time is about 120 days. In 120 days, the entire medical literature doubles in size. Anesthesia was certainly welcomed in this country in 1846 at the Ether Dome in Mass General, and it really was nothing more than having a dropper bottle and a mask with some gauze over it, which you would use chloroform or you could use ether. Both of them worked very well. The flammability, of course, was an issue, but at least we had patients who could come in and out of anesthesia relatively safely. Antisepsis was a long road. It wasn't just a matter of developing it. You had to believe it, and it was an entire generation of physicians that came and went before what was actually being worked with was believed. So in the third quarter of the 19th century, to probe operative sites with unwashed fingers and reused sponges was the norm. In fact, it was such a problem that even when you would see pus, you thought it was a good thing because these were bad humors that were able to escape the body. That infection internally wasn't considered. It was leaving through separation of a wound that was being considered. So Joseph Lister in 1865 came up with these antiseptic techniques that he used around a fracture and began to see that there was less separation and patients had better survival. And to reduce germs in the atmosphere, he developed a carbolic acid spraying device. So now you've got carbolic acid being sprayed over the operating table and you're working in the abdomen. So of course, you couldn't tell what the patient was feeling, but you could tell that your hands weren't feeling so hot. And so one of his assistants actually needed to wear gloves and began to all of a sudden discover that, gee, I'm not having the pain, but they also began to have less infection. So some of these things happened by happy coincidence, others by design. Sterilization had a number of issues in front of it. Number one, you couldn't boil instruments because they would rust. And of course, the carbolic acid that was being sprayed about the room was also problematic. But once, in about the 1870s, they began to develop good nickel plating, you could all of a sudden have resistance to corrosion. And then finally, in the beginning of the 20th century, you had stainless steel and now you could boil instruments. This is an obstetrical sterilization tray, and it's dated 1876, which is just after we began to have nickel plating. We take hemostasis for granted, we have so many things we could do, but imagine that what they used to do was simply use a cautery iron that was heated in a fire and burn the wound. Still in the 17th century, Perret, who was a military surgeon in France, had the idea of a ligature. So this worked great. The problem was the suture didn't last. And so it would break down before the vessel could be totally occluded and you'd have late hemorrhage. So there was early hemorrhage and late hemorrhage. And late hemorrhage was usually due to the failure of the suture material. Still, it was considered barbaric to use cautery. And of course, this is well before anesthesia. And so over time, we finally developed suture that was more applicable to what we were doing. Once again, it's Lister. And Lister, by using his carbolic acid, was able to treat silk so it didn't break down from the bacteria around it. And then chromic catgut, which, of course, we still may use from time to time, which is sheep intestine treated with chromic acid, which not only killed the bacteria, but it also increased the longevity of the surgery so that it would last after surgery had been over several days. But perhaps most important, particularly in urogynecology, was the development of a silver suture. So this was the first monofilament, an aggravation to use for sure, but not wicking bacteria from the vagina through the wound or from the rectum into the wound was important. We talked about exposure. And of all the things I collect, probably the most intriguing part of the collection is the 170 or so different speculums going all the way back into the 16th century, and there is so much diversity in these instruments because we didn't exchange information. So when you look at an early 16th century speculum, and this one's from about 1515, this is all iron. It doesn't even have hinges. So where this would pivot right here, you have a handle to crank, you've got it threaded, and you just splay these blades very slowly. And as barbaric as this looks, it probably was easier to use and more comfortable than the great speculum that we use today at the outset. At the outset, as I always say when I get contacted wanting to look at speculum design, it's the need to work with the person using the speculum, probably more than the speculum itself. When going to look for fistulas, they had speculums that had a fenestration. So you had an obturator, you had a glass sleeve, and then an opening, you could pull this back, remove the glass sleeve and be able to see the fistula's opening. This is a presentation instrument, which is very lavishly signed by the maker, Maugh, and it has the obturator, which comes apart to give you a sponge holder, and then a caustic holder as well. So you had some sort of material like silver nitrate that you could use to stop small points of bleeding. The same type of instruments were made from ivory on top and the lower one of horn. The one on the bottom is by Woker, a Cincinnati maker. The top is a French. Now, they used materials that would not conduct heat like horn and ivory so that you could use cautery irons inside these to stop bleeding and not burn the vaginal mucosa. Of course, you've got to have an obstetrical table or you have to have some kind of exam table or operating table. And this is what would exist in a doctor's office. And this is one of my favorite gadgets because this isn't an actual chair, but this is a model that is only about 12 inches high, but it's fully functional. It was a salesman sample that would be taken around so doctors could have a look at what they might be able to purchase. And lastly, you needed illumination, but of course, they didn't have electricity, so you didn't have light. And if you're going to get anything focused, it had to be with a candle. And in this case, we've got a candle holder that has an aperture that you can't see and a small reflector. So you've got a flame right next to the bulb and you're trying to use your instruments and still see. So you can imagine the difficulty with that. Occasionally, if you were operating in the morning, you'd have people with parabolic mirrors and concave mirrors to be able to direct light into the vagina. So once we had all these ideas in place, there were various individuals. And when I say individuals, one person can make a big difference. And this is Reichard's set of instruments. He treated venereal diseases. In fact, he headed up a hospital where that's about all they did were treat venereal diseases. And you can see that among his instruments, there are ivory speculum, a gold-plated speculum, a bunch of cautery irons, retractors. Again, with ivory so they could use cautery. And they treated syphilitic lesions and gonorrheal lesions. But the chancre, Reichard's lesion on the cervix, was initially treated with cautery. So in the first half of the 19th century, things began to occur. We had oophorectomy by McDowell in 1809, repair of vesicle vaginal fistula by Matur in 1838, myomectomy, 1844, by Atlee, and hysterectomy, Birney, in 53. So looking at oophorectomy, which are some of the more intriguing instruments, again, there are so many different kinds of clamps because people weren't communicating. So this is a group of instruments that Tate would use for oophorectomy, and here are some illustrations of what would happen. These were always massive cysts because they weren't cancerous. To get a tumor this large, you certainly didn't have a malignancy, but they had to be able to tell what was going on, and when McDowell did his first surgery, they thought the woman was pregnant in the beginning, and it took a long time before that it was all sorted out. So once they've shown the cyst, they puncture it with a cannula that has an attachment that you can evacuate the fluid, and once you've shrunk it down, with your bare hand, you're in the abdomen, shelling it out, trying to bring the pedicle up to the surface. So once you have the pedicle, you have to decide, what am I going to do with it? Are you going to go ahead and constrict it with a clamp that is held outside the abdominal cavity? Are you going to go ahead and ligate it, and then hold it up at the surface of the abdomen with pins or sutures? Are you going to transfix it with double sutures and let it go back into the abdomen with hopes that nothing will break down and that bleeding won't occur? And with an ovary that you've already enucleated, that probably was a reasonable thing. Or the tumor may be enucleated entirely if no pedicle exists, and of course you have to deal with the spot bleeding with cautery and with various kinds of medications that would just stop bleeding. Or you could use a temporary clamp and then sever the pedicle with cautery, which was probably the thing that was most commonly done. Then finally, closing up the abdomen with a layer of deep and superficial sutures. And here are the clamps that you would use for the pedicle. And notice in both of these cases, you have an ivory scale on the side of the clamp that would go against the abdominal viscera so that when you use the cautery iron, you have a thermal break. And these are large clamps. Either one of these, you could pound and nail into a two by four width. And this is an entire set of instruments. This case is probably about 24 inches wide and about 12 inches from here to here with a whole assortment of instruments, all pre-suture to address the removal of ovaries. So Emmett, when he commented on vesicovaginal fistula repair, suggested that although Sims was certainly not the first, she definitely was able to popularize the idea that fistulas could be repaired. And of course, we could have a socio-political conversation about this all day long. But the fact that he popularized, it meant that other people were willing to try it. And so we began to slowly but surely have more and more success in fistula repair. So what did he do? Well, he would look for the fistulas opening and then he would pair the edges. He would pass all these silver sutures and then using specific instruments, bring them all together and trim them. So these are his retractors so that he could see through them. There were just copper loops malleable so he could change the position. And he used many of these fine little hooks to grab the edge, hold it so he could put a suture in place. And we don't use this sort of thing now. We would use a pair of pickups instead, but even the pickups they used had great variation. All of these are fistula pickups or tweezers, forceps. And each of them generally either has a lock to keep them closed or they're cross-acting so that when you let them go, they remain closed. So they could almost be relaxed and not have to continue to hold pressure to keep the tissue in place. One of my favorite instruments are the rotating knives that Sims devised. And you can see here, there's a little cog like a gear. And by turning the knob at the very end, you can go ahead and release that and you can put the blade into any position you want. And by simply turning this thumb wheel, you can lock it into place to get whatever angle you need in whatever situation you're presented with. Of course, there are all kinds of curved scissors and some of them doubly curved, which we really don't see much anymore, but these held together very nicely and would produce very, very clean excisions. To be able to get a knot down, and particularly when you were using silver, you had to have some sort of pulley or fork. And so this instrument was used to go down the knot, push it to the point where it was re-approximating the wound and oftentimes in front of that, you had two pieces of lead shot to act as a bolster so that the suture would not pull through the tissue. And then you'd have to twist it. And the twisting was accomplished by another instrument that had either two openings like this or here. And then you just spun this between the thumb and forefinger to make a long twist. And then finally finish up by cutting it with an instrument that has a little envelope at the end and to trim the suture so that you didn't have it eroding into other tissue and so forth. A lot of times the end of the suture was also bent back towards the incision to avoid harming surrounding tissues. Lastly, you put a catheter in place. Of course they didn't have a balloon catheter so they used one of the sigmoid curves so it would stay in place. The portion that was in the bladder had an area that had a shallow opening on it so that if it were up against tissue, it would still be able to drain. And of course you needed to have sponge holders and plenty of them because you didn't have suction. And so there would be a number of these in any kit that was being used. Now working with fistulas was not unlike working with the soft palate and palate defects. And so some of these instruments had a dual purpose and this was a bit of an automated device where you actually crossed over the fistulas opening then push this little lever forward and it took the suture off so that you were left with a double arm suture going from one side of the fistula to the other and you didn't have to pass the needles over and over again. And again, when you look at the time that this was made, this was done in 1830. So, you know, these ideas were there, it was popularizing and that was the problem. Bozeman was a contemporary of Sims and the two were added all the time and Bozeman kind of lost out. Sims became much more popular but Bozeman wouldn't adopt any of Sims' instruments. Instead, he made variations or Sims took his instruments and made variations. Who's to say which came first? And I'm very fortunate to have a group that's entirely devoted to his designs that was made by a New York manufacturer. In addition to all the instruments, he has these ivory bolsters and here's the lead shot and lead buttons that we were talking about. And temporarily, they might even use like miniature clothespins called seraphins to re-approximate a wound while they were putting sutures in place. A small, compact, vesicle-vaginal fistula set. A French set, also Sims' instruments and much more extensive. You can see the rotating knife, all the ones that are just angled for sponge holders, a bunch of hooks and blunt probes and a variety of different scissors and forceps. And then the thing that we all look for as an instrument collector are exhibition sets. So this is a set that's made of ivory and silver with some bold embellishments and bluing of the steel that a manufacturer would have, for example, a world's exhibition to just show the virtuosity of their instrument makers. And these were probably not used at all. And in fact, when you look at these instruments, they're like the day they were produced. This is a French set made by Cherrier which was the largest of the Parisian makers. And this is a set I would love. If someone wants to do homework with me, this is an Italian set by Lalini that is probably later than all the rest, but there are instruments in here the purpose of which I really can't pin down. Why do you have a scalpel that has a sigmoid curve in the blade? And then instruments with little forked protrusions. They have a needle holder that has silver suture inside a spool, inside the handle. They have a variety of probes that open up to expand the inside of the uterus and also that rotating knife holder. And then a very unusual speculum with two different sets of blades that attach to it. And I can't find an instrument maker's catalog to identify these. And I can't find it in the literature as well. So getting away from fistula and just looking at something as simple as procedentia, Sims kind of like along the lines of a Laforte thought, well, if we just take a V-shaped area of the mucosa between the cervix and the urethra and denude them and re-approximate them, we can hold the uterus back. Of course, this took a lot more technique and pessaries were probably much more common to be used, but they were very robust instruments. So this is a porcelain pessary made in 1848 that would be utilized with this corset-type girdle that you could wear and a device to hold it up into the vagina. Or even more difficult, a simple glass sphere. Now these were sold in a local pharmacy in Worcester and there was a whole box of them. And I was fortunate enough for them to give me one of them. I can see how you get it in, but I can try to imagine trying to get it back out. And I'm sure it presented all kinds of problems. When you have lesions inside the vagina or protruding through the cervix from inside the uterus, they used a necrosaur, which was a chain attached to a linkage that by spinning this part of the instrument, it would draw the noose closed and tight. Well, this wasn't just polyps that they would take off with this, but they would even amputate a cancerous cervix and they would do it over a long period of time. So between hours, they would crank the device, tighten it up a little more and the tissue would hopefully necrose. You can only imagine the kind of discomfort as the tissue became ischemic and so forth in functioning this way. Scissors and knives designed for trapelectomy were common. Very often they had teeth so that the tissue wouldn't slide out from the scissor or the knife had a blade in both directions so you didn't have to pivot your hand. Of course, you had to be careful of surrounding tissue, but that was an afterthought perhaps. We use LEAP procedures, loop electrosurgical excision procedures now for taking off cervical lesions, vaginal lesions. And they were doing this in the mid-19th century as well, attached to a battery and with a titanium or a tungsten wire and then isolated by ivory portions so that they could get a nice hot, and this was not just electrical energy, but this was heat energy to be able to carve away at lesions. And of all my favorites, in terms of a single instrument, this hysterectome to do trachelectomy has to rank up there. This is a presentation instrument. It's ivory, gold, silver, and polished steel. So look at this and you see a tenaculum. You pull back on this portion here and the tenaculum opens. And then you release this lever, which is a spring-loaded blade, and it rotates by spinning this portion of the device around the central axis of the tenaculum. So you perform a perfect cervical conization while you're pulling at the same time. And of course, the problem was bleeding and followed by cautery. But the idea here was to create an instrument that for someone who didn't have the facile hands to do a nice conization and have it come out appropriately, they could do this mechanically. Trachelectomy sets, again, with lots of cautery instruments. And notice the scissors and so forth with wooden handles because the blades would be heated for hemostasis. And each one of these, just to give a different angle to approach a lesion that you were having difficulty with. A hysterectomy was an entirely different affair. And in cases of procedentia, it's hard to believe that they would literally simply take suture over a total procedentia and slowly ratchet down, perhaps with a neck pursuer, such as this, over a period of time without doing much dissection in the hopes of having something along the lines of a supracervical hysterectomy. You can only imagine the problems you got into with bladder and ureters and so on and so forth. And that's why when I say, you know, we did procedures, but did we do them successfully? Lots of ideas, lots of techniques, but in practice, many of the... Looking at vaginal hysterectomy, a lot of this looks familiar. Notice though, that you're not using any clamps. You're simply taking a large curvilinear needle and you're going along the vasculature because number one, they didn't trust the clamp. And this was simply the way it was done. And again, you had to have a fair amount of prolapse to be able to do this successfully. These sorts of instruments are tourniquets that were actually used for an abdominal approach. So once you had the uterus and the... Whoops, I'm sorry, I didn't mean to go back. You would place this around the base of the cervix inside the abdomen. This pin would keep it from sliding off. And then you would transect the cervix doing a supracervical hysterectomy. And then you had to bring the entire stump up to the abdominal wall. So here you see them cutting it free. And now they take these transfixion pins, put them through the stump. Again, they're not trusting clamps. They put metal plates in the abdomen so that the abdomen doesn't heal shut. And they have to leave it there for a few days to make sure that bleeding didn't occur. Well, you can imagine the host of issues that occurred by doing it this way. So we get towards the end of the 19th century and we have Hopkins. We have Williams there for obstetrics. You've got Kelly. You've got Brodel doing all kinds of wonderful illustrations. They're a whole group of very important physicians that came out of Hopkins that really influenced them. So vaginal hysterectomy was the operation most frequently performed for cancer of the cervix. But Kelly had it in his mind that if I did this abdominally, I'd have a better chance of getting disease that was outside of the uterus. And of course, that was certainly a worthwhile approach to take, but wasn't quick to be popularized. Still vaginal hysterectomy prevailed and this is the way he performed it. So he would put spacers in so he'd have something for traction. We're still not wearing gloves of any kind. And of course, in this situation, everything is gonna be exposed well enough that you can at least see. Making the same kind of incision we do today, he gets down to the cervix and begins to slowly dissect it away with a finger and then enter anteriorly and posteriorly. Notice again, no clamps, placing the suture, and then just making the cut with a pair of scissors while irrigating with water. Once they get up to the broad ligament, if you can pass a finger all the way over the top, you can then go ahead, sever the one side, bring it all the way out, and then go from top down on the remaining part of the round ligament, utero-ovarian ligament and broad ligament on the opposite side. You can only imagine the kind of bleeding they encountered. They never show any of that in any of these illustrations, but make certain that it was there. And at the end, he simply fixed the peritoneum from top to bottom, and then the cuff was left open and the vagina packed with aodiform gauze. So there were all kinds of clamps that were made, and the early clamps didn't have a catch because they didn't trust the way the catch worked. I mean, they had to be made very specifically so they'd stay closed. So instead, they would tie a piece of suture through the finger openings to be able to hold the clamp closed. When they first began to use clamps, they put the clamp on, then they would take the stitch and make the stitch between the clamp and the organ. And then they would take the scissor and cut even more proximally towards the offending organ, towards the uterus, so that you had the clamp behind the stitch, which of course damaged tissue, and you could have problems occurring there. And they said, well, this is not working well, so let's use a massive clamp that has tremendous crushing power. So they put this in, they tightened it down, it would have a mechanical advantage often to even put more force, and then they would put the suture through the crushed portion of the pedicle, and then reflect it medially. So then what happened? The tissue broke down, and again, it failed. It took almost 50 years to say, wait a minute, let's go ahead and put the clamp on, put the suture behind the clamp in healthy tissue, and cut on the medial side of the clamp. So, you know, sometimes we just don't learn as quickly as we would like to, but we get there nonetheless. So what about mortality from procedures such as hysterectomy? Well, you can look at the innovations. So in the beginning of the 19th century, everyone died. We weren't washing our hands, we were moving what we're trying to operate, you can only imagine what it was like. Anesthesia in 1846, and all of a sudden, we began to take a little bit of a different slope. Antisepsis comes along, improves things a little bit more, and then names that you all recognize, Wertheim, Mayer, Richardson, Haney, and we're getting better and better with our technique. We're beginning, in this period of time, we're using aseptic instruments, so mortality is falling very quickly. But way over here in 1842, I'm sorry, 1942, we finally have antibiotics. Well, we were doing pretty darn good even before antibiotics, but of course, with antibiotics, we did much better, and we were getting, you know, very, very little mortality with surgery. And this is kind of a project that Mark Walters did for me in one of the chapters that we wrote, and did an excellent job. He was very curious about what were the outcomes actually like. So, what was left was you were having apprenticeships, you were learning by word of mouth, there was very little formal training, and this was taking, getting a lot of notice by the American Medical Association. In 1910, the Flexner Report came out that looked at the deplorable state of medical training. And so, Williams got the idea, let's think of a residency type program, where there is progressive, administrative, and clinical responsibility. And this really set a new standard for scholarship in the beginning of the 20th century. And of course, his first edition of his book was from 1903. And the effect of Hopkins, and Williams and Kelly in particular, was profound. And for almost three decades, three quarters of the chairs across the country were protégés of Hopkins. Then, end of the first quarter of the 20th century, Frank Litsch said, you know, we need to go further. We need to expand these residency programs so there are one year of medicine, three years of OBGYN clinicals. So, you'd have 1,500 to 2,000 obstetrical cases, and 150 major gynecologic surgeries. And you'd have some form of continuity of care clinic, things that we still regard today. Then finally, the Accreditation Council for Graduate Medical Education, and the Residency Review Committees established in 1981, where we began to have in-house attendings. This was my last year of residency. Before this, we didn't have in-house attendings. And if we were going to do a needle suspension of the bladder neck, a stamy at that time was a popular procedure. Nikki Karam was over at Good Samaritan Hospital. I was at Bethesda Hospital, myself and a third-year resident would do the vaginal hysterectomy. We would dissect all the way up to the bottom of the abdominal wall. And then we'd call over to Good Sam for Dr. Karam to come over and help us pass needles. I mean, that was the level of supervision. At night, there were not attendings in-house. And I'm embarrassed to say that I look back on this, and by my second year of residency, I was licensed in Pennsylvania, Kentucky, and Ohio, and was moonlighting when I wasn't in residence. And that was just the way we did it. Hard to believe, but we did. 2003, duty hour maximums came into place, which of course we all know is a good thing, where you get into private practice in a small town and you're out of the frying pan and into the fire again. So at the end of the day, you look at all that came before us. You look at the many difficult challenges that were met without the advent of anesthesia, but elimination of hand-washing and sterilization. And I think Newton perhaps sums it up better than anyone. If I've seen farther, it is by standing on the shoulders of giants. And it continues today. There are individuals who just take us in sometimes small steps, but steps in the right direction, occasionally a backstep, but we make progress. And then I also like Kelly's observation that no group should ever neglect to honor the forebearers upon whom their contributions are based. Great is the loss to anyone who neglects to study of the lives of those he follows. And with that, I'd like to thank you for your kind attention, and I'd like to address any questions you might have. And I hope you have some. I hope there are a few collectors out there too. Great. Thank you so much, Dr. Dezano. So just as a reminder, we have about 15-20 minutes for questions. So just put your questions in the Q&A box down at the bottom. I had a quick question, Dr. Dezano. It seems like there was a lot of French instruments and maybe some Italian instruments. Do you happen to know how scholars kind of interacted with each other early on? Did they just write letters or did they actually have, were they like kind of going to each other's amphitheaters? Or how did that, it seems like there was instruments that were similar between different cultures. They must have been communicating somehow. Well, I think, you know, the evolution of instruments is really an interesting topic. And I think to a large extent, you had a purpose in mind, and the instruments naturally involved in a direction that kind of looks similar. You look at vaginal speculums, and that's where you probably see the most diversity. But, you know, a knife was a knife, a scissor was a scissor. And they might put curves, but there wasn't a lot of communication. In fact, that's one of the reasons you have so much diversity, because no one was communicating. I would go to a instrument maker, and, you know, in the early 19th century, France, some of the most beautiful instruments were coming out of France. And so there were three major makers. Charriere was the largest. It was affiliated with the medical school at the Sabon. And so doctors would go and say, this is what I need. I need something like this. Now tweak it a little bit this way and that way. And so they also, I think, wanted to gain prominence, and at times weren't real excited about sharing information. And you see that in American physicians as well. And in fact, the ones who were wealthy enough to travel abroad and go to Europe would come back, and there would be textbooks that they would write. And in them, they would illustrate instruments that were invented a decade or two before on the continent or in the UK and called their own. And you see this in surgical instrument catalogs in America with some frequency and with some physicians more than others. But it's pretty obvious. All of the instruments that I identify are from surgical instrument makers catalogs. And when I can, if I can get a physician's book where he describes the development of an instrument, those are the kinds of books I like to buy. So it's really collecting the instruments that kind of drives me. So I'm afraid there wasn't a lot of communication until later. And now, of course, every time we devise something that goes to a manufacturer who markets it, but it wasn't always that way. Okay, yeah, it made me make sense way back in the day, people didn't have the ability to communicate like we do now. Someone was commenting on here, basically, just obviously an avid history medical buff like yourself, and commented saying that I think the next chapter should be the introduction of laparoscopy mesh and other instruments, instruments in pelvic surgery, just amazing. And then asked for your personal collection, where do you get your instruments from? How do you collect them? What are your sources? So prior to eBay, there were medical instrument dealers. Many of them were in Europe, but there were several and there are still are several in the United States that had built the beginning of my collection. But when eBay came around, all of a sudden, things that I thought were relatively uncommon became common. And the prices went considerably down. But the other thing that happened is sometimes extraordinary rare instruments would come onto the market. And everyone had a shot at and collecting gynecology compared to collecting amputation sets or neurosurgical sets, which I have some of those, but I really focused on gynecology instruments into a certain degree of skeptical instruments. And they were just not as popular, it was easier for me to afford. And after doing it for about 30 years, I began to discover it's like, it's hard for me to find an instrument I don't have. And as I look through catalogs, I always have my eyes out, we have all these keywords. Every morning, the moment I get up, the first thing I'm doing is looking at my phone to see what might have come up across the pond that that I might be able to purchase. But now after doing it for so long, also, people contact me. So I don't have to look much anymore, it kind of comes my way. And I, I'm not sure if you mentioned this during the lecture, but one of the one of the instruments that you showed us that I found really interesting was that ivory ligature, I think it's basically and they kind of cauterized in between. And you said they had the ivory buffer on the outside. So how did that work? Did they they heated it kind of off stage? Oh, no, I'm, yeah, I'm sorry. So that, yeah, in that particular instrument, what you have is you have a very robust clamp, looks like a big hemorrhoid clamp. On one side, there's ivory, the other side is metal. So you put the clamp on, so that the metal side is towards the ovary. And then the tissue you're trying to preserve has the ivory side. And then you cut it off, and then you take a cautery iron against the metal. Okay, so it's actually holding it sealed while you cauterize the cut edge, and the ivory is there simply so that you have a thermal break, so you don't transmit the heat to surrounding bowel or other organs that you're trying to preserve. Okay, that makes sense. I just misunderstood. That makes some sense. Yeah, I should have been more clear about that. No, yeah, that's great. Doesn't look like we have any more questions at the moment. So just in the end, go ahead. I just might add that, you know, all most of the slides you see in this are actually, if you were to Google Tosano Museum, I had some students who worked on a project at the College of Worcester, and they put about half my collection online. And so you can look at a variety of these instruments. And they'll look just like these slides. And what I'm ultimately going to do at the clinic is to put these into a format that physicians, students, residents can access them for free and use them for like a historical perspective or introduction to a program. And it's also the way I inventory my collection, because the god awful task is going to come on the day that I leave this earth and my poor family, you know, I couldn't be a coin collector and have just a bag of things. But, you know, I've got this room that's filled. And by the way, anyone who is so interested that they feel they have to come down to Worcester and visit, you'd be more than welcome. I get curators from European museums and some of the US museums. I've also helped museums catalog their OBGYN collections, because the gynecology material is very often misidentified. It just, it's a little more complicated and you to know how to do the surgeries helps you identify some of these instruments. And the only other specialty that even begins to approach what gynecology has in terms of diversity is urology. And there's some extraordinary urologic instruments, which we could do at another time for retrieval of stones, and so on and so forth. Stricture release and what have you, they're just a plethora of very fine instruments. And all of them had to be used blindly, like many of our instruments. You couldn't see what you were doing inside the uterus and how they got that chain around the base of a polyp from the outside is difficult to imagine. So it's your collection, it's all types of medicine and surgery. It's not just exclusively gynecology. Right, I collect microscopes and I collect some apothecary things, but I lean everything I can towards OBGYN. It's just when you finally have kind of finished one area, you know, it's kind of have this bug. And much to my wife's chagrin, you know, it just continues to grow. I couldn't collect paintings or something like that. And the kids, the kids get a big kick out of it. They like to show people because they think some of it's outlandish. When you looked at the one wax model, I had the full body wax model. That was something that I had purchased. And when my family saw it, they said, what are you going to do with that? And I go, well, it's going to be in the room. You know, it's the room is closed up. No one goes in there. And my wife is like, there is no way. So, you know, you pick your battles. Happy wife, happy wife. I said, that's fine. I don't need to have that thing. And there's more to the story, but we'll leave it at that. So a good friend of mine has it. Well, you're enthusiastic. So that's, I think that's what matters. It's a lot of fun. Yeah, it sounds like it. So, so yeah, so no further questions, it appears. So Dr. Zano, any last words? No, I encourage any of you who are interested, if you want to touch base with me, I think it's getting easier and easier to find some of these items. And there's lots of things around bloodletting and this and that, that, you know, an elderly pediatrician got me started. And I'm just glad she got me started at the very end of residency, because had I discovered all this during residency, I think I would have been distracted and Lord only knows. So you can have fun with it. Just don't get obsessed with it. I really appreciate the opportunity to speak with fellows in residence. I don't know if my email is anywhere there, but I think you have my contact information. Anyone is more than welcome to give me a call or if there's information they want to work on a project together. I always enjoy doing that. Wonderful. So, yeah, thank you. So on behalf of the AUGS, I'd like to thank Dr. Zano and everyone for joining us today. Our next fellows webinar will be held on November 16th at 8pm Eastern time. Please visit the AUGS website to sign up and have a good night, everyone. Thank you, Dr. Zano again. Oh, you're so welcome. Thank you, everyone.

Dr. Tony Tizano

webinar

medical history

obstetrics and gynecology

19th century challenges

surgical techniques

medical training

medical artifacts

women's health