Rare Ectopic Pregnancy, again








Rare Ectopic Pregnancy






The First Oophorectomy

Having had an oophorectomy, I am incredibly interested in the surgical removal of ovaries.  Removal of one ovary is called a unilateral oophorectomy; removal of both is bilateral.  Usually, when an ovary is removed, the fallopian tube associated with it is also removed.  This is called a salpingo-oophorectomy.  My interest usually lies in new surgical techniques and the philosophical implications of an oophorectomy.  But, of course, my training in history leads me inevitably to investigating the historical genesis of the oophorectomy.

So, where and when was the first successful oophorectomy performed, you ask?  Actually, it happened just down the road from here in Danville, Kentucky on Christmas Day, 1809.  Who’d have guessed it, right?  Actually, this is not the most talked about first in medical history so it could have easily passed me by had I not spent a summer in Danville five years ago.  There is a statue to the surgeon who performed the first oophorectomy (referred to then as an ovariotomy) alongside his interred remains in a park very near Centre College in Danville.

Ephraim McDowell, the surgeon in question, was a sparsely trained country surgeon in Kentucky between 1795 and 1830.  He studied medicine at various places in Virginia and Scotland, though never attained a degree.  (He was later granted an honorary M. D. in 1825 from the University of Maryland.)  He married Sarah Shelby, the daughter of the first Governor of Kentucky Isaac Shelby.  McDowell’s practice was nothing out of the ordinary until December 13, 1809 when he was summoned to attend to a woman in Green County, Kentucky about 60 miles away.

This woman, Jane Todd Crawford, 46, was believed to be pregnant past term.  Upon examination, McDowell diagnosed a very large ovarian tumor.  He explained to Crawford the dangers of both leaving the tumor untreated and of operating on the tumor.  No such operation had been performed successfully before, so she would almost certainly die as a result, though she was likely to die quickly otherwise.  She decided to move forward with the surgery.  She arrived at McDowell’s house on Christmas as prescribed to undergo the operation.

McDowell began the surgery without the aid of anesthetics or antiseptics.  The procedure took 25 minutes.  He removed a cystic mass, partially solid and partially liquid, weighing 22.5 pounds.  Crawford not only recovered, but lived for thirty-two more years.  McDowell did not write up the notes on this case until seven years afterward in which time he performed several more abdominal surgeries successfully.  When he did write up his notes, he mentioned that when visiting Crawford in her room five days following the surgery he found her making her bed.  (Having undergone the same procedure with modern benefits and a tumor only half that size, I can tell you that is nothing short of miraculous.)

The reasons McDowell and subsequent scholars have pointed to as the reasons why his surgical techniques are several in number.  First of all, McDowell carefully cleansed every surface he touched including bathing Crawford’s intestines before replacing them in the abdomen.  Also, McDowell removed the blood that collected in Crawford’s open abdomen before suturing the incision.  Blood left in the body following surgery accounted for a great number of illnesses and deaths during that time.  Another step taken by McDowell to ensure success was placing a ligature at the base of the affected fallopian tube where it met the uterus.  This ensured that blood would not continue to flow to the ovary and tumor during the operation.  Furthermore, McDowell closed the abdomen with large interrupted sutures including adhesive to promote the apposition of skin.

McDowell’s innovations and sheer daring culminated in an achievement that is often referred to as the founding of abdominal surgery.  There is some debate over whether he was the first to perform an “ovariotomy,” though it seems clear to me he was.  It is a stretch to say he was the first to successfully perform an abdominal surgery, especially considering the first recorded, mutually-successful cesarean section was performed in 1500 in Switzerland.  In any event, McDowell’s techniques were pioneering and generally successful.  Modern procedures still closely resemble what McDowell did in 1809.  Questions?  Comments?  Go for it.

Vaginal Rejuvenation

While there are a myriad of possible gynecological surgeries, which ones do women elect to have performed?  In the past tubal ligation and varying degrees of hysterectomy have been the most popular elective gynecological surgeries.  In the 1990s, though, elective c-sections began to boom.  Recently, however, a growing movement has developed in backlash to the increased number of unnecessary c-sections in the United States–both voluntary and involuntary.  Now, there is a new trend towards cosmetic gynecological surgeries such as “vaginal rejuvenation” procedures.

What are currently the most popular “vaginal rejuvenation” surgeries?  Labiaplasties are rising in popularity.  A labiaplasty is a plastic surgery that involves tightening of loose labial folds or removal of extra tissue of the vulva.  After childbirth, with age, because of disease, or because of genetics women may have labia that they feel is large or perhaps too loose.  Surgeons can perform reductions of this tissue to make it smaller and/or tighter feeling.  These surgeries can now be done with the assistance of laser, which are meant to help the healing process.  The American College of Obstetricians and Gynecologists (ACOG) issued a statement in 2007 stating that there is no documentation of the efficacy and safety of such a procedure.  The risks include those inherent with any surgical procedure (clots, bad reaction to anesthesia, etc), botched outcome leading to further complications or surgeries, and the ring of scar tissue created causing issues with childbirth.  A woman with such scar tissue would be less likely to be able to deliver vaginally, and would face enormous complications if she did.  Young women have labiaplasties more often than older women, thus the concern for childbirth.

Other “vaginal rejuvenation” surgeries include hymenorrhaphy and vaginoplasty.  Hymenorrhaphy is rarer than labiaplasty and bears fewer risks.  It is a simpler surgery in which an already ruptured hymen is recreated in order for the woman to prove (or feign) virginity.  Vaginoplasties are much more invasive and dangerous.  A vaginoplasty is performed in order to tighten or reconstruct vaginal muscles.  Reasons for vaginoplasty can include disease, childbirth, or other trauma to the vagina.  However, many women now seek vaginoplasties because they feel it will increase their pleasure and sensitivity during sex.  As the ACOG points out, though, there is no evidence to support this assumption.  Vaginoplasties are also very common among males seeking gender reassignment surgeries, as a vagina can be created out of penile or scrotal tissue.  Most associations and societies of plastic and cosmetic surgeons do not yet count or keep track of the abovementioned plastic surgeries, or have only recently begun tracking them.  So it is difficult to say how many such surgeries are performed every year.  However, it is clear even from the basic figures that the numbers of these elective surgeries are increasing exponentially every year.  (One figure shows that about 600 were performed in 2005, 1,000 in 2006, and over 4,000 in 2007.)  It is a whole other topic to discuss the socio-psychological reasons why women choose such surgeries, but what do you think?  Would you ever be willing to go under the knife for such a procedure?  Other comments or questions?  Shoot!