Howard Atwood Kelly

For the British Admiral, see Howard Kelly (Royal Navy officer).

Dr. Howard Kelly
Born	(1858-02-20)February 20, 1858 Camden, New Jersey
Died	January 12, 1943(1943-01-12) (aged 84) Baltimore, Maryland
Nationality	United States
Alma mater	University of Pennsylvania
Occupation(s)	Obstetrician/Gynecologist, Professor, Writer

Howard Atwood Kelly (February 20, 1858 – January 12, 1943), M.D., L.L.D, was an American male gynecologist. He obtained his B.A. degree and M.D. degree from the University of Pennsylvania. He was most known with William Osler, William Halsted, and William Welsch as the "Big Four" founding professors at the Johns Hopkins Hospital in Baltimore, Maryland.He was credited with establishing gynecology as a new specialty, by developing new surgical approaches to women only diseases and through pathological research. He also had several medical innovations including improved cystoscope, Kelly's Clamp, Kelly's Speculum, and Kelly's forceps. As a Fundamentalist Christian, he received doubt towards his medical professionalism.

Early Life and Education

Howard Kelly was born in Camden, New Jersey, the son of Henry Kuhl Kelly and Louisa Warner (Hard) Kelly. His family had a history in politics (Kelly's father's great grandfather, Michael Hillegas, was the first Treasurer of the United States), business, real estate and civil service, but Howard Kelly was the first with achievement in medicine. He was raised with strong religious influence from his parents, especially his mother. Later he recalled,"I owe my real start in life to my mother, who began to teach me the Bible." In Civil War times, when his father was at the war-front serving as a lieutenant in the 118th Pennsylvania Volunteers, the young Howard Kelly spent his free time observing nature and studying Bible with her mother in Chester (15 miles southwest of Philadelphia). In the fall of 1867, Howard Kelly entered the Faires Classical Institute. There, he developed an interest in languages, biology, natural science, and botany. In 1873, at age 15, he started his undergraduate education at the University of Pennsylvania. During his college years, he was the president of the Franklin Scientific Society. At the age of 17, he became a member of the Philadelphia Academy of Natural Sciences. He received his B.A. degree in 1877.

Medical Career

Medical Education

After graduating with a B.A. in 1877, he enrolled in Penn's Medical School. At Penn Medical School, he was deeply interested in anatomy and in 1882 he graduated with the Anomaly Prize from the Demonstrator of Morbid Anatomy. He received his M.D. degree in 1882 and began his residency in the Episcopal Hospital at Kensington, Pennsylvania. During his residency, he opened a small hospital five miles away from downtown Kensington because there was yet a place for gynecology as a specialty in the Episcopal Hospital. He rented rooms in a two-story house in a working district. He saw patients in the day and slept on the sofa at night with a string tied to his toe so that whenever there was a tug on the spring, he would be woken up to give medical aids.Kelly not only provided aids at the small clinic but also went to patients' homes for operations.Later, assisted by a group of Philadelphia philanthropist women, he was able to afford to move the hospital location to Norris Square, where he could afford an operation room. This little hospital later became the Kensington Hospital for Women. This hospital is the sixth women's hospital in the United States, There, he created the Kelly stitch that lifted the retroflexed uterus to the anterior abdominal wall and also applied aseptic techniques. In addition to that, he also performed the first successful case of C-section in Philadelphia. Thus, he earned his reputation as an innovator in surgical techniques and a dexterous surgeon.

From 1886 to 1888, Kelly traveled to Europe to observe surgeons of abdominal and pelvic operations. He visited England, Scotland, and Germany. When he was Leipzig in 1886, he was introduced to the palpation of female ureters in their lower pelvic portions by Max Saenger.In Berlin in 1888, he worked with pathologist Rudolf Virchow to determine the best way to catheterize ureters from an anatomical standpoint. Then, in Prague in 1888, he also observed Czech physician Parel Pawlik catheterizing ureters using a glass-partitioned speculum, who also later enlightened him to create air cystoscope. In 1888, he returned to the University of Pennsylvania, to become an associate professor of obstetrics under the recommendation of William Osler, who dubbed him the "Kensington colt" because of his young age.

Medical Career at Hopkins

In 1889, William Osler enlisted Howard Atwood Kelly as chair of gynecological surgery of The Johns Hopkins School of Medicine. As one of the founding chairs of The Johns Hopkins School of Medicine, Howard Atwood Kelly was part of The Big Four, four men who were known as the founding faculty of the medical school. These four men consisted of William Steward Halsted, William Osler, and William H. Welch, and Howard Atwood Kelly, the youngest founding chair. Furthermore, after three years in Baltimore, Kelly founded the Howard A. Kelly Hospital, which was active until 1938. Kelly was not only known for his skills, but also his charitable heart. At The Johns Hopkins School of Medicine, Kelly didn’t require his patients to pay for surgical fees. Ironically though, in his private practice, he charged a lot of money for his surgical techniques and medical services.

Medical Achievements

In the early 1890s, Howard Atwood Kelly pursued the field of urogynecology and developed new surgical techniques to improve surgery for his patients. Kelly first learned about different organs such as the bladder, and with this foundation of knowledge, he was able to catheterize ureters using air cystoscopy. His application of cystoscopy to catheterize ureters was one of the first usages of endoscopy in this field. Other innovations included the Kelly's stitch, surgical clamp, and speculum.[13]

To promote safety during surgery, Kelly used nitrous oxide for anesthesia, absorbable sutures during operations, and electrical lights for better lighting during surgery. He also was one of the first surgeons to use an operating suit, clothing made up of sterilized linens. Additionally, in order to minimize the possibility of wound infection, he invented the wound sealing procedure. First, he soaked two layers of sterilized gauze with celluloid in and bichloride to secure the dressing to the skin. Then, he dusted the surface with iodoform and boric acid powder. Finally, until the stitches were removed, the wound was not exposed. [3]

During the late 1890s, Kelly became interested in gynecological cancers. To reduce bleeding for cervical and endometrial cancers, he ligated the internal iliac artery, a technique that would come to be used in postpartum hemorrhages. Kelly also dabbled with the use of radium in 1904. Obtaining radium from Madame Marie Curie, Kelly used the radium to treat uterine hemorrhages and fibroid tumors and published these techniques as the “Radium in the Treatment of Uterine Hemorrhage and Fibroid Tumors” in the Journal of the American Medical Association in 1914. Additionally, in 1917, his own clinic had about 5.5 grams of radium and was one of the country’s leading centers for radiation therapy for cancer treatment at the time.

Medical Innovation

• Gynecology — One of Kelly's most important innovations is the establishment of gynecology surgery as a specialty. In the past, there only existed general surgery while specialties were only doctors' private investigations. However, Kelly, through his publication of Operative Gynecology established a systematic approach to the gynecological medicine and surgery.
• Kelly's sign — Because during operations, ureter prefers adhering to the peritoneum instead of maintaining its normal position along the psoas muscle, it is crucial to differentiate ureter from other tissues. Kelly's sign is a technique of applying gentle pressure to the ureter to cause peristalsis, or worm-like muscle contraction to identify the ureter.

• 

  A reduced male cystoscope in holding position.

  Air cystoscope — When Kelly was observing Czech physician Parel Pawlik, , he came up with the idea that  instead of using water distension of the bladder and a glass lens, by putting the patient in the knee-chest position, an air cystoscope can be used to distend the bladder with air and visualize the interior of the bladder. Throughout the 1890s, Kelly kept improving his air cystoscope. The final product and procedure he published as such.

1. The perfected cystoscope consists of a cylinder with a certain diameter and about 8 centimeters in length with a handle that can be firmly grasped with a smooth surface on the obturator to ensure a smooth introduction.
2. The patient's urethra is dilated with successive sizes of dilators after anesthesia of 5% solution of cocaine.
3. The cystoscope is cleaned and sterilized with boric acid and cotton.
4. The patient is placed in a knee-breast position.
5. The obturator is first introduced and then with a finger stabilizing the obturator the speculum is also introduced, then the obturator is immediately withdrawn.
6. As long as the patient is in a position of elevated hips, the bladder will be more or less dilated with air. Thus, by wearing some sort of illumination device on the head, the doctor can examine the interior of the bladder.

• Kelly speculum — A rectal speculum, tubular in shape and fitted with an obturator.There is also Kelly's small cylindrical specular, in which Nos.12-15 are special designs in the cystoscopic set are specially designed for virgins.

• Kelly's forceps(Kelly's Clamp) – Kelly's forceps are curved hemostatic forceps that resemble a pair of scissors. Instead of sharp teeth or blade of scissors, these forceps have blunt grips. They are used to clamp vessels to control blood flow and arguably among the most common and best known surgical instruments. In his Operative Gynecology, Kelly describes their value as (1) having jaws longer than usual and gently curved (2) the tips being able to grasp the tissue before the first shoulder is reached. There are also subcategories like the tenaculum forceps and the alligator forceps.
• Kelly's Plication(Kelly's Operation, Kelly's Stitch): Kelly's Plication is frequently used in treating SUI (Stress Urinary Inconsistence), SUI is caused by the relaxation of tissues around the base, neck of the bladder, and near the urethra.The procedure is applied to the vesical neck in anterior vaginal repairand goes as follow: First, an incision is made in the anterior vaginal wall. Then, urethropexy is performed to support the urethra by placing two sutures (one near the urethral meatus into the pubo cervical fascia on the left and on the right to form a U shape, the other underneath the first one to regain the normal urethra position).

Medical Illustration

While Kelly was writing his book Operative Gynecology, he collaborated with the father of medical illustration, Max Brodel. In Baltimore, the two men worked alongside each other such that Kelly would conduct his surgeries and Broedel would compose stereographic photographs which would be published later on for use by students and surgeons while maintaining a complete understanding of the subject matter of each illustration he would compose.[10]  Later on, he would also invite Hermann Becker and August Horm as well, drawing clear sketches for them and explaining to them all the pathology, surgical procedures, and anatomy with either simplified diction or vivid imagery. Kelly became the contemporary frontrunner in the field of gynecology upon publishing two volumes of his Operative Gynecology, which included the medical illustrations in 1898. Meanwhile, Brodel's illustrations were instigating a permanent shift in the field of medical illustrating.[14]

Educator

Kelly influenced not only the surgical field but also the field of academia as well. As the first professor of gynecology, Kelly established a leading training program in gynecology, through which Kelly raised future leaders in the fields of gynecology and medicine. Having felt constrained by his early residency education, Kelly decided to present all possible opportunities to his interns to ensure that they receive what he thought to be the best education possible. Accordingly, Kelly placed heavy responsibilities on the hospital Staff, especially his interns and assistants. Not only did he encourage his interns to go abroad and observe, but he also subsidized some of his assistants to publish their work. He opposed teaching through lecturing and performing operations in a big amphitheater because he felt that students could see very little of the procedure. While the students benefitted very little, the patients were also intimidated by the group of medical students. Instead, he emphasized listening carefully to the patients, making careful observations, and memorizing the operations. Thus, students with exceptional interests in gynecology under him have the opportunity to investigate in laboratory work, examine the patients, and listen to patients' report of their symptoms.[15] William T. Howard Jr, one of Kelly's resident praised his method of instruction, "Throughout the operation, in a running talk, he described each procedure, and in abdominal cases what he found, and what he intended doing at each step at why. Whenever practicable, he let the students and visitors view each step."[16]

By the time he reached the end of his career, Kelly had written over 550 articles and books that covered subjects such as appendectomy, the use of radium, electrosurgery, urogynecology, and ureteral catheterization. Additionally, he also had publications about medical history, religion, herpetology, and botany. [12]

Personal life

Family

In 1889 Danzig, Germany, Howard Atwood Kelly became the husband of a woman named Olga Elizabeth Laetitia Bredow, with whom he spent a honeymoon in Paris, France. In Baltimore, they raised nine children together in accordance with the Episcopal faith, of which Kelly was a devout follower. Additionally, out of the nine children that they had together, only Edmund Kelly went on to study in the field medicine.[12]

Naturalist

Kelly’s mother would take him, from an early age, on walks through nature that would come to cultivate his interest in the environment and his enjoyment of nature and animals.[12] In his own home, Kelly not only collected several dozen cages filled with different types of reptiles but also observed variations of exotic snakes. Not only did Kelly observe his reptiles, but he also learned how to handle rattlesnakes and harvest their venom to the extent that he became able to teach others.Later on in his career, Kelly received the title of Honorary Curator by The Division of Reptiles and Amphibians at The University of Michigan.[12]

Not only was Kelly interested in reptiles, but he was also fascinated with mycology. His interest with mycology included mushroom identification, mycophagy, and research on mycologists. Similarly to collecting reptiles, Kelly collected a variety of different fungi and kept a list of species and observations.  As time went on, Kelly would purchase numerous pieces of mycology literature adding to his growing library. [17] Later in 1924, with the help of Louis Krieger, Kelly also compiled The Catalogue of the Mycological Library of Howard Kelly (1924), with over 400,000 entries. an archive of artworks, 7000 titles on mushrooms, and replicas of fungi. In 1928, Kelly donated his library, paintings, and mycological collection to the Herbarium of the University of Michigan.[19] This collection has been designated as The L. C. C. Krieger Mycological Library and Collections. [20]

Religion

Kelly was devoted to the Episcopal faith. His religious life began with his mother teaching him about the Bible. As a teenager, Kelly would read the original Greek and Hebrew texts of the Bible and even passed out New Testament scripture to his fellow peer exhibiting his early attempts at evangelism. [12] As an adult, Kelly kept the Sabbath, read the Bible daily, and wrote books about religion such as A Scientific Man and the Bible. In accordance to his faith, Kelly was a prohibitionist, opposing the idea of using birth control. [6]

Furthermore, Kelly also prepared sermons for all denominations when ministers or pastors became unavailable on Sundays, supported missionaries, and worked hard to stop prostitution.  He wanted to prevent people from being punished by sin and so even provided housing for former prostitutes who needed temporary lodging when they quit their practices and professed Christian beliefs. [12]

Death

In Union Memorial Hospital, Baltimore, Maryland, Howard Atwood Kelly and his wife Olga Elizabeth Laetitia Bredow died on January 12, 1943. Kelly passed away at 84 years old and his wife, at 53 years old, only six hours apart from each other.[6] With a joint funeral at the Memorial Episcopal Church, the married couple was buried at Woodlawn Cemetery in Baltimore, Maryland.

Recognition/Honors

Some of his awards:

• Received the Honorary Degree of Doctor of Laws from the University of Pennsylvania in 1907
  • also from the University of Aberdeen, Washington College, Washington and Lee, and Johns Hopkins 
• Named an honorary fellow of Universities in Edinburgh, Glasgow, Dublin, London, Paris, Rome, Berlin, Leipzig, Bucharest, Vienna, Kiev, and Lima.

• Founding member of the American College of Surgeons in 1913
• Honorary curator division reptiles and amphibians, University of Michigan Museum of Zoology
• Johns Hopkins Kelly Gynecologic Oncology Service named after Howard Atwood Kelly 

• In 1943 a U.S. Liberty ship was christened the Howard A. Kelly. 
• he served as president of the Southern Surgical and Gynecological Society in 1907 and of the American Gynecological Society in 1912.
• Emeritus Professor of Gynecological Surgery in the Johns Hopkins University
• The Howard A. Kelly Alumni Society is established to honor Howard Kelly by the physicians and alumni of the Gynecology & Obstetrics Department to appreicate his innovations and contributions in the practice and teaching of gynecology & Obstetrics. The society aims to perpetuate his idea and continue to advance women's health care.

Bibliography

Some of his many publications:

Medical

A page in Kelly's Operative Gynecology (1906)

• Operative Gynecology (two volumes, 1899)

• The Vermiform Appendix and its Diseases (1905, 1909)

• Walter Reed and Yellow Fever (1906, 1907)
• Medical Gynecology (1908)
• Gynecology and abdominal surgery, with Charles P Noble (1908)
• Myomata of the Uterus, with T. S. Cullen (1909)
• Cyclopedia of American Medical Biography (1912)
• Diseases of the Kidneys, Ureters, and Bladder, with C. F. Burnam, (two volumes, 1914)
• American Medical Biographies with Walter L. Burrage (1920), 2nd edition of Cyclopedia of American Medical Biography
• Gynecology (1928)
• Dictionary of American medical biography: lives of eminent physicians of the United States and Canada, from the earliest times(1928)

Naturalist

• American Medical Botanists (1913)
• Lafayette Houghton Bunnell, M.D., discoverer of the Yosemite(1921)
• Snakes of Maryland(1936)

Social

• The influence of segregation upon prostitution and upon the public(1912)

See also

• Works by or about Howard Atwood Kelly at Wikisource

 This article incorporates text from a publication now in the public domain: Gilman, D. C.; Peck, H. T.; Colby, F. M., eds. (1905). "Kelly, Howard Atwood". New International Encyclopedia. Vol. 11 (1st ed.). New York: Dodd, Mead. p. 434.