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The 100th Anniversary of Tubal Sterilization*
FERTILITY AND STERILITY Copyright ' 1980 The American Fertility Society
Vol. 34. No.6. December 1980 Printed in U.S A.
THE looTH ANNIVERSARY OF TUBAL STERILIZATION*
ALVIN M. SIEGLER, M.D., D.Sc.t AMOS GRUNEBAUM, M.D. Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, Brooklyn, New York 11203
this precaution, therefore, as an improvement of the operation." In lecture XXVII, entitled "Means of Superseding the Cesarean Operation," Blunde1l 2 suggested a method for interval sterilization by laparotomy: "In my opinion, there is: for if a woman were in that condition, in which delivery could not take place by the natural passage, provided she distrusted the circumstances in which she was placed, I would advise an incision of an inch in length in the linea alba above the symphysis pubis; I would advise further, that the fallopian tube on either side should be drawn up to this aperture; and, lastly, I would advise, that a portion of the tube should be removed, an operation easily performed, when the woman would, forever afterward, be sterile; all this, after due consideration, circumstances not forbidding. But the abdominal incision-that is bad:-true; but the Cesarean incision, that is worse. Is not that true also?" Blundell's vivid description of a "minilaparotomy" is quite precise. He described this procedure as early as 1824. 3 It is difficult to imagine that he did not perform this operation, but in none of his voluminous contributions to the medical literature could any specific acknowledgment be found. Aware of the dangers of laparotomy, Froriep4 described a different method of tubal sterilization in 1849. Using the transcervical approach, he introduced silver nitrate into the uterine cavity to stricture the upper uterine angles (tubal ostia) by chemical cauterization. As surgical techniques improved and more women survived cesarean sections, physicians became concerned about the rising incidence of repeat cesarean section and the added maternal risks of reoperation. One of the accepted methods was to induce premature labor. Another approach was to remove the ovaries during cesarean section
Probably more significant changes in obstetric and gynecologic care were accomplished during the last half of the 19th century than in the previous 2000 years. Although more than 200 different techniques of sterilization by interruption of the luminal continuity of the fallopian tube have been described, tubal sterilization is a relatively new operation. Currently, sterilization procedures account for the most common method of contraception in women over the age of 35 years. The history of tubal sterilization describes, as does the history of medicine, some of the trials and failures of the early pioneers (Table 1). A recapitulation and awareness of their attempts add immeasurably to the fascination with this subject. In 1809, Haighton 1 reported a series of experiments on animal impregnation by dividing rabbit fallopian tubes. Dr. James Blunde1l2 (Fig. 1), in his Lectures on the Principles and Practice of Midwifery given at Guy's Hospital in London (Fig. 2), suggested that tubal resection could be performed during cesarean section or as an interval procedure for the purpose of sterilization: ". . . if you intercept the contact between the semen and the rudiments, you insure sterility .... To preclude the possibility therefore, of a second need for the incision, before closing the abdomen (after performing a cesarean section), the operator, I conceive, ought to remove a portion, say one line, of the Fallopian tube, right and left, so as to intercept its caliberthe larger blood vessels being avoided. Mere divisions of the tube might be sufficient to produce sterility, but the further removal of a portion of the tube appears to be surer practice. I recommend' Received August 11,1980; accepted September 17, 1980. *Presented at the International Congress on Female Endoscopic Sterilization, July 21, 1980, Williamsburg, Virginia. tReprint requests: Alvin M. Siegler, M.D., One Hanson Place, Brooklyn, New York 11243.
610
611
COMMUNICATIONS·IN·BRIEF
Vol. 34, No.6
TABLE L Significant Historical Developments in Tubal Sterilization Author
Haighton Blunde1l 2
l
Year
Contribution
1809 1828
Tubal section in rabbits Suggested partial salpingectomy during cesarean section and as interval procedure Transuterine application of silver nitrate to uterine horns Tubal ligation performed with silk during repeat cesarean section Tubal ligation with catgut and partial resection performed vaginally Hysteroscopic sterilization by cauterization of tubal ostia Peritoneoscopic tubal fulguration
Froriep4 Lungren 6 Kehrer9
1849 1880 1897
Mikulicz-Radecki and Freund l l Power and Barnes l2
1927 1941
or to remove the uterus after delivery. In 1875 Dr. Samuel Smith Lungren,5 of Toledo, Ohio, reported a technique of cesarean section in the Ohio Medical and Surgical Reporter. He performed this operation on a Mrs. K, a native of Bavaria, who had a contracted pelvis. He used silver wire sutures to close the uterine incision. On May 22, 1880, Lungren performed a repeat cesarean section on the same patient. He presented this case report 1 month later in Milwaukee, Wisconsin, at the Thirty-Third Session of the American Institute ofHomoeopathy, of which he was a mem-
ber. The case was published in the Transactions the same year6 (Fig. 3). Lungren intended to remove both ovaries during the surgery to prevent further pregnancies. He wrote" ... upon exposing the uterus, search was made for the silver sutures placed there five years previously, they were seen under the peritoneum, but without any signs of irritation from their presence. It was considered
FIG. L Dr. James Blundell (1790-1877) suggested tubal ligation for sterilization.
FIG. 2. Title page of a book which contains lectures by Dr. James Blundell (1842), including descriptions of "minilaparotomy."
612
COMMUNICATIONS-IN-BRIEF
SACT I ON S'
of ItomlPopsfijg.
December 1980
plishment that had been recorded only six times previously in American medicine. 8 Dr. Samuel Smith Lungren was born in York County, Pennsylvania, August 22,1827. He was of Swedish origin. After attending high school in Philadelphia, Lungren went to Jefferson Medical College for 2 years and was graduated in 1850. He took postgraduate courses in the Homoeopathic Medical College of Pennsylvania for 2 years. Until 1860 he practiced in Hagerstown, Maryland. In November 1860, Lungren moved to Toledo, Ohio, where he became a member ofthe American Institute of Homoeopathy in 1870 and later president of the Ohio State Homoeopathic Medical Society (Fig. 4). Samuel Smith Lungren became a famous surgeon of his time, specializing in gynecologic cases, and he wrote several other articles. On March 7, 1892, Lungren died at the age of 65. Tubal ligations became more frequent after 1897. Kehrer,9 of Heidelberg, Germany, described his method of sterilization by tubal resection through an anterior colpotomy. In the ensuing years innumerable reports were published about different forms of tubal sterilization, and in 1911
FIG. 3. Title page of Transactions of the Thirty-Third Session of the American Institute of Homoeopathy. This volume contains the first description, by Lungren, of tubal ligation at cesarean section.
best not to remove them, as hemorrhage might be troublesome from the uterus at that point after closing the abdominal wound. The right ovary resembled in color varicose veins; the left was normal. It was the intention first to remove both ovaries during the operation, but decided, after mature consideration, that the risk would be lessened and the same result would be accomplished by tying both Fallopian tubes with strong silk ligatures about one inch from the uterus." The following year, this report was published in the Amer- . ican Journal of Obstetrics under the title "A Case of Cesarean Section Twice Successfully Performed on the Same Patient.,,7 The tubal ligation was carried out shortly after entering the abdominal cavity and before the uterine incision was made. Of added significance was the fact that the patient had survived a second cesarean section, an accom-
FIG. 4. Dr. Samuel Smith Lungren (1827-1892) is credited with performl1-nce of the first tubal ligation for sterilization.
Vol. 34, No.6
COMMUNICATIONS·IN-BRIEF
Stolz lO had collected 199 references on this subject. In 1927 Mikulicz-Radecki and Freund l l were the first to use a hysteroscope for tubal sterilization. They used a "curettoscope," constructed by Freund in 1924, which enabled lavage of the uterine cavity and the introduction of a probe for excision and cauterization. These authors named the procedure "nonbloody sterilization." Working on uteri already extirpated or which were subsequently to be removed, they cauterized the intramural parts of the fallopian tubes. The tissues were examined histologically, and these authors concluded that it was not sufficient merely to destroy the tubal mucosa. To prevent further recanalization, the muscularis layer needed to be coagulated as well. Although laparoscopic tubal sterilization has been an increasingly common method of interval sterilization in the last decade, at least a quarter of a century seems to have elapsed between its earliest application and subsequent popularity. In 1941, Power and Barnes 12 used a laparoscope for tubal sterilization. They described a 1 cm incision made through the skin under local anesthesia, just below and left of the umbilicus and carried through the rectus sheath. After induction ofa pneumoperitoneum with a small rubber hand pump, the peritoneoscope was inserted into the abdominal cavity. A Fallopian tube was grasped with a biopsy forceps near the cornu and fulgurating current applied until a 1 cm segment of the tube was blanched. N ei ther the number of patients operated upon nor the follow-up course was noted. These physicians were torch bearers who handed down a rich legacy. Their concepts and ideas
613
regarding techniques for tubal sterilization were innovative and daring for their time. Acknowledgments. The authors wish to acknowledge with appreciation the research of Mr. Gordon Mestler, of the Medical Library of Downstate Medical Center, and Mr. R. M. Watterson, Librarian of the Medical College of Ohio at Toledo, for their valuable help in the development of the manuscript. REFERENCES 1. Haighton J: An experimental inquiry concerning animal impregnation. Philos Trans R Soc Lond 18:112, 1809 2. Blundell J: Lectures on the Principles and Practice of Midwifery. London, Charles Severn, 1842 3. Blundell J: Lectures on the gravid uterus, and on the disease of women and children. Lecture VI. Lancet 1:257, 1828 (vide 259) 4. Froriep R: Zur Vorbeugung der Nothwendigkeit des Kaiserschnitts und der Perforation. Notiz Geburtshilfe Natur- und Heilkd 11:9, 1849 5. Lungren SS: Cesarean section-case. Ohio Med Surg Reporter 9:207, 1875 6. Lungren SS: Cesarean section. In Transactions of the Thirty-Third Session of the American Institute of Homoeopathy, Milwaukee, June 15-18, 1880, p 432 7. Lungren SS: A case of cesarean section twice successfully performed on the same patient. Am J Obstet 14:78, 1881 8. Harris RP: The operation of gastro-hysterotomy. Am J Med Sci 75:313, 1878 9. Kehrer FA: Sterilisation mittels Tubendurchschneidung nach vorderem Scheidenschnitt. Centralblatt Gynaekol 21:961, 1897 10. Stolz M: Die Sterilisation des Weibes. Samml Klin Vortraege Gynaekol 222-224:699-786, 1911 11. Mikulicz-Radecki Fv, Freund A: Ein neues Hysteroskop und seine praktische Anwendung in der Gynakologie. Z Geburtshilfe Gynaekol 92:13, 1927 12. Power FH, Barnes AC: Sterilization by means of peritoneoscopic tubal fulguration. A preliminary report. Am J Obstet Gynecol 41:1038, 1941
Vol. 34. No.6. December 1980 Printed in U.S A.
THE looTH ANNIVERSARY OF TUBAL STERILIZATION*
ALVIN M. SIEGLER, M.D., D.Sc.t AMOS GRUNEBAUM, M.D. Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, Brooklyn, New York 11203
this precaution, therefore, as an improvement of the operation." In lecture XXVII, entitled "Means of Superseding the Cesarean Operation," Blunde1l 2 suggested a method for interval sterilization by laparotomy: "In my opinion, there is: for if a woman were in that condition, in which delivery could not take place by the natural passage, provided she distrusted the circumstances in which she was placed, I would advise an incision of an inch in length in the linea alba above the symphysis pubis; I would advise further, that the fallopian tube on either side should be drawn up to this aperture; and, lastly, I would advise, that a portion of the tube should be removed, an operation easily performed, when the woman would, forever afterward, be sterile; all this, after due consideration, circumstances not forbidding. But the abdominal incision-that is bad:-true; but the Cesarean incision, that is worse. Is not that true also?" Blundell's vivid description of a "minilaparotomy" is quite precise. He described this procedure as early as 1824. 3 It is difficult to imagine that he did not perform this operation, but in none of his voluminous contributions to the medical literature could any specific acknowledgment be found. Aware of the dangers of laparotomy, Froriep4 described a different method of tubal sterilization in 1849. Using the transcervical approach, he introduced silver nitrate into the uterine cavity to stricture the upper uterine angles (tubal ostia) by chemical cauterization. As surgical techniques improved and more women survived cesarean sections, physicians became concerned about the rising incidence of repeat cesarean section and the added maternal risks of reoperation. One of the accepted methods was to induce premature labor. Another approach was to remove the ovaries during cesarean section
Probably more significant changes in obstetric and gynecologic care were accomplished during the last half of the 19th century than in the previous 2000 years. Although more than 200 different techniques of sterilization by interruption of the luminal continuity of the fallopian tube have been described, tubal sterilization is a relatively new operation. Currently, sterilization procedures account for the most common method of contraception in women over the age of 35 years. The history of tubal sterilization describes, as does the history of medicine, some of the trials and failures of the early pioneers (Table 1). A recapitulation and awareness of their attempts add immeasurably to the fascination with this subject. In 1809, Haighton 1 reported a series of experiments on animal impregnation by dividing rabbit fallopian tubes. Dr. James Blunde1l2 (Fig. 1), in his Lectures on the Principles and Practice of Midwifery given at Guy's Hospital in London (Fig. 2), suggested that tubal resection could be performed during cesarean section or as an interval procedure for the purpose of sterilization: ". . . if you intercept the contact between the semen and the rudiments, you insure sterility .... To preclude the possibility therefore, of a second need for the incision, before closing the abdomen (after performing a cesarean section), the operator, I conceive, ought to remove a portion, say one line, of the Fallopian tube, right and left, so as to intercept its caliberthe larger blood vessels being avoided. Mere divisions of the tube might be sufficient to produce sterility, but the further removal of a portion of the tube appears to be surer practice. I recommend' Received August 11,1980; accepted September 17, 1980. *Presented at the International Congress on Female Endoscopic Sterilization, July 21, 1980, Williamsburg, Virginia. tReprint requests: Alvin M. Siegler, M.D., One Hanson Place, Brooklyn, New York 11243.
610
611
COMMUNICATIONS·IN·BRIEF
Vol. 34, No.6
TABLE L Significant Historical Developments in Tubal Sterilization Author
Haighton Blunde1l 2
l
Year
Contribution
1809 1828
Tubal section in rabbits Suggested partial salpingectomy during cesarean section and as interval procedure Transuterine application of silver nitrate to uterine horns Tubal ligation performed with silk during repeat cesarean section Tubal ligation with catgut and partial resection performed vaginally Hysteroscopic sterilization by cauterization of tubal ostia Peritoneoscopic tubal fulguration
Froriep4 Lungren 6 Kehrer9
1849 1880 1897
Mikulicz-Radecki and Freund l l Power and Barnes l2
1927 1941
or to remove the uterus after delivery. In 1875 Dr. Samuel Smith Lungren,5 of Toledo, Ohio, reported a technique of cesarean section in the Ohio Medical and Surgical Reporter. He performed this operation on a Mrs. K, a native of Bavaria, who had a contracted pelvis. He used silver wire sutures to close the uterine incision. On May 22, 1880, Lungren performed a repeat cesarean section on the same patient. He presented this case report 1 month later in Milwaukee, Wisconsin, at the Thirty-Third Session of the American Institute ofHomoeopathy, of which he was a mem-
ber. The case was published in the Transactions the same year6 (Fig. 3). Lungren intended to remove both ovaries during the surgery to prevent further pregnancies. He wrote" ... upon exposing the uterus, search was made for the silver sutures placed there five years previously, they were seen under the peritoneum, but without any signs of irritation from their presence. It was considered
FIG. L Dr. James Blundell (1790-1877) suggested tubal ligation for sterilization.
FIG. 2. Title page of a book which contains lectures by Dr. James Blundell (1842), including descriptions of "minilaparotomy."
612
COMMUNICATIONS-IN-BRIEF
SACT I ON S'
of ItomlPopsfijg.
December 1980
plishment that had been recorded only six times previously in American medicine. 8 Dr. Samuel Smith Lungren was born in York County, Pennsylvania, August 22,1827. He was of Swedish origin. After attending high school in Philadelphia, Lungren went to Jefferson Medical College for 2 years and was graduated in 1850. He took postgraduate courses in the Homoeopathic Medical College of Pennsylvania for 2 years. Until 1860 he practiced in Hagerstown, Maryland. In November 1860, Lungren moved to Toledo, Ohio, where he became a member ofthe American Institute of Homoeopathy in 1870 and later president of the Ohio State Homoeopathic Medical Society (Fig. 4). Samuel Smith Lungren became a famous surgeon of his time, specializing in gynecologic cases, and he wrote several other articles. On March 7, 1892, Lungren died at the age of 65. Tubal ligations became more frequent after 1897. Kehrer,9 of Heidelberg, Germany, described his method of sterilization by tubal resection through an anterior colpotomy. In the ensuing years innumerable reports were published about different forms of tubal sterilization, and in 1911
FIG. 3. Title page of Transactions of the Thirty-Third Session of the American Institute of Homoeopathy. This volume contains the first description, by Lungren, of tubal ligation at cesarean section.
best not to remove them, as hemorrhage might be troublesome from the uterus at that point after closing the abdominal wound. The right ovary resembled in color varicose veins; the left was normal. It was the intention first to remove both ovaries during the operation, but decided, after mature consideration, that the risk would be lessened and the same result would be accomplished by tying both Fallopian tubes with strong silk ligatures about one inch from the uterus." The following year, this report was published in the Amer- . ican Journal of Obstetrics under the title "A Case of Cesarean Section Twice Successfully Performed on the Same Patient.,,7 The tubal ligation was carried out shortly after entering the abdominal cavity and before the uterine incision was made. Of added significance was the fact that the patient had survived a second cesarean section, an accom-
FIG. 4. Dr. Samuel Smith Lungren (1827-1892) is credited with performl1-nce of the first tubal ligation for sterilization.
Vol. 34, No.6
COMMUNICATIONS·IN-BRIEF
Stolz lO had collected 199 references on this subject. In 1927 Mikulicz-Radecki and Freund l l were the first to use a hysteroscope for tubal sterilization. They used a "curettoscope," constructed by Freund in 1924, which enabled lavage of the uterine cavity and the introduction of a probe for excision and cauterization. These authors named the procedure "nonbloody sterilization." Working on uteri already extirpated or which were subsequently to be removed, they cauterized the intramural parts of the fallopian tubes. The tissues were examined histologically, and these authors concluded that it was not sufficient merely to destroy the tubal mucosa. To prevent further recanalization, the muscularis layer needed to be coagulated as well. Although laparoscopic tubal sterilization has been an increasingly common method of interval sterilization in the last decade, at least a quarter of a century seems to have elapsed between its earliest application and subsequent popularity. In 1941, Power and Barnes 12 used a laparoscope for tubal sterilization. They described a 1 cm incision made through the skin under local anesthesia, just below and left of the umbilicus and carried through the rectus sheath. After induction ofa pneumoperitoneum with a small rubber hand pump, the peritoneoscope was inserted into the abdominal cavity. A Fallopian tube was grasped with a biopsy forceps near the cornu and fulgurating current applied until a 1 cm segment of the tube was blanched. N ei ther the number of patients operated upon nor the follow-up course was noted. These physicians were torch bearers who handed down a rich legacy. Their concepts and ideas
613
regarding techniques for tubal sterilization were innovative and daring for their time. Acknowledgments. The authors wish to acknowledge with appreciation the research of Mr. Gordon Mestler, of the Medical Library of Downstate Medical Center, and Mr. R. M. Watterson, Librarian of the Medical College of Ohio at Toledo, for their valuable help in the development of the manuscript. REFERENCES 1. Haighton J: An experimental inquiry concerning animal impregnation. Philos Trans R Soc Lond 18:112, 1809 2. Blundell J: Lectures on the Principles and Practice of Midwifery. London, Charles Severn, 1842 3. Blundell J: Lectures on the gravid uterus, and on the disease of women and children. Lecture VI. Lancet 1:257, 1828 (vide 259) 4. Froriep R: Zur Vorbeugung der Nothwendigkeit des Kaiserschnitts und der Perforation. Notiz Geburtshilfe Natur- und Heilkd 11:9, 1849 5. Lungren SS: Cesarean section-case. Ohio Med Surg Reporter 9:207, 1875 6. Lungren SS: Cesarean section. In Transactions of the Thirty-Third Session of the American Institute of Homoeopathy, Milwaukee, June 15-18, 1880, p 432 7. Lungren SS: A case of cesarean section twice successfully performed on the same patient. Am J Obstet 14:78, 1881 8. Harris RP: The operation of gastro-hysterotomy. Am J Med Sci 75:313, 1878 9. Kehrer FA: Sterilisation mittels Tubendurchschneidung nach vorderem Scheidenschnitt. Centralblatt Gynaekol 21:961, 1897 10. Stolz M: Die Sterilisation des Weibes. Samml Klin Vortraege Gynaekol 222-224:699-786, 1911 11. Mikulicz-Radecki Fv, Freund A: Ein neues Hysteroskop und seine praktische Anwendung in der Gynakologie. Z Geburtshilfe Gynaekol 92:13, 1927 12. Power FH, Barnes AC: Sterilization by means of peritoneoscopic tubal fulguration. A preliminary report. Am J Obstet Gynecol 41:1038, 1941