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Surgery in a rural area: 1638–1868
APRIL
The
American
Journal
1975
of Surgery VOLUME NUMBER
129 4
PRESIDENTIAL ADDRESS
Surgery in a Rural Area: 1638 - 1868 Thomas Perry, Jr, MD, Providence, Rhode Island
In the past, presidents of this Society have given us learned papers on clinical subjects, the education of surgeons, and socioeconomic problems. Others have concerned themselves with medical avocations. I have chosen to enjoy myself in this fashion by preparing a paper on the history of surgery in my own state. Consideration of the accomplishments of our fellow surgeons of just a few previous generations, under difficulties unknown to us, imparts an admiration for these people and points out how they have eased the way for us. The history of the beginning of medicine and surgery in this country has been told and retold many times. Nevertheless, it is hard for us to remember, as we move from operating room, to laboratory, to bedside, that only a short while ago surgery was a primitive art, little improved since the middle ages. The majority of our early historical material deals with the advances made in the great seaboard centers of the North. What was happening in Rhode Island is probably more typical of what prevailed in this largely rural country as a whole. The early surgical history of the state seems to divide itself logically into three chapters. The first, Reprint requests should be addressed to Thomas Perry, Jr. MD, 210 High Service Avenue, North Providence, Rhode Island 02904. Presented at the Fifty-Fifth Annual Meeting of the New England Surgical Society, Waterville Valley, New Hampshire, September 26-28, 1974.
Volume 129, April 1975
from settlement in 1636 by Roger Williams until 1’700, was the real pioneer time. Secondly, the eighteenth century was a long period of near stagnation in progress. Finally, the first half of the nineteenth century saw advances in educational facilities and the formation of medical societies that upgraded practice to a point from which the profession could take off to greater things. The advent of anesthesia in 1846 was a turning point which could form a logical end to this paper on early surgery. From a more practical standpoint, surgery in the state could not flower until the first general hospital opened in 1868. 1636 to 1700 We have records of only eleven physicians and surgeons in seventeenth century Rhode Island.* All but two were from Newport, and Providence had no doctor at all, relying on nearby Seekonk, Massachusetts, where Richard Bowen settled in 1680 [I]. Of course, others with no training at all were doing the best they could, and Roger Williams himself is known to have distributed a few * John Clarke, John Cranston, Thomas Rodman, Norbert Vigneron, Samuel Ayrholt, and an unnamed Frenchman, physicians of Newport; Robert Jeffries, Henry Greenland, and Simon Cooper, surgeons of Newport; Gilbert Updike of Narragansett; and Thomas Spence of Warwick. (Collected from references 1, 2, and 3.)
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Figure 1. Doctor John Clarke, 1609-1676. From the portratt in the Redwood Library, Newport, Rhode Island.
remedies and a little light gathered from a small collection of medical volumes. If eleven seems a small number of medical men for the whole period, it should be remembered that the state contained less than 7,000 souls in 1700. Newport was a town of some 3,000 and Providence less than half that [2]. Newport boasted of having three surgeons during this period, and it is important to note that they called themselves surgeons, adhering to the European separation of surgeons and physicians. Necessarily, all the early practitioners were trained abroad, but as time went on, the apprentice system produced almost all our physicians and surgeons. In a rural land, they all did general practice. It has been pointed out that this was pretty much so in rural England too, with the separation of physicians and surgeons confined to the cities. Still, some doctors in this country were always known for their proficiency in surgery whereas others avoided it [3]. We know little of the surgery of those early Newporters. Presumably, as in Europe, they were less educated and kept poorer records than did their physician contemporaries. They cannot have done much more than simple procedures dealing with infections, superficial tumors, and trauma, although on occasion they may have essayed a herniotomy or cut for stones. In the absence of material about them, it is perhaps worthwhile to get the flavor of the time by considering John Clarke (Figure
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l), the first physician of the state [4]. He arrived in Portsmouth in 1638 with a group of nearly 1,000 Massachusetts dissenters and practiced until his death in 1676. Born in England, he studied in Leyden, where he spread himself over the fields of law, medicine, and theology. During his life, he was proficient in all three fields. John Clarke was the pastor of Newport’s first church, which to this day rejoices in the name of the United Baptist John Clarke Memorial Church of Newport. Clarke was one of the colony’s leaders from the start. His contributions include authorship, with William Dyer’s assistance, of a remarkable code of laws for the colony of which it is said, “Unencumbered by superfluous verbiage that clothes our modern statutes in learned obscurity, embracing as it does the whole body of law, . . . and for vigor and originality, . . . it presents a model of legislation which has never been surpassed” [5]. Clarke went back to England with Roger Williams in 1651 to get a new charter for the colony. This took him thirteen years to accomplish, during which time he supported himself by his medical practice, His persistence paid off, however, for he obtained a remarkable document still preserved at our state house where it served as the state constitution until 1843. After greetings from the King, it begins, “Whereas we have been informed by the humble petition of our servant John Clarke . . . .” Thomas W. Bicknell, the historian, states that this charter “has been universally recognized as the most liberal state paper ever issued by the English Crown” [5]. Wilbur Nelson, Clarke’s biographer, says, “In it absolute religious freedom was for the first time secured and guaranteed . . . . The principals it embodied. . . still live. . . in the government of every state in the Union and many countries as well” [4].
1700 to 1800
Between 1700 and 1800, the population of the state increased about tenfold to 69,000. The pioneer life developed into a prosperous mercantile and farming society. The spermaceti candle manufacturing plant and the Hope furnace for producing bog iron, both Brown family enterprises, are examples of the beginning of small industry [6]. Numerous trading vessels made Narragansett Bay their home. Medicine was making slow but steady progress. Our physicians increased in number with the rise of population, but their education changed little. Although there was still a trickle of foreign-edu-
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cated physicians, most served an apprenticeship. After a few years, these men would receive a certificate of some sort and strike out on their own. There was no form of licensure, and those who were interested in trying their hand at surgery did so. The first medical school to open in the country was at the College of Philadelphia in 1765, followed by King’s College Medical School in 1768 and Harvard in 1780, but it was some time before their influence was felt in Rhode Island [3]. Prior to the appearance of the schools, series of lectures were given from time to time throughout the country, but they were evanescent to say the least. The first of these of which this country has any record were delivered in Newport in 1754, 1755, and 1756 [I]. These were anatomic lectures given by William Hunter, Hunter had studied in Edinburgh under the elder Monro and was a relative of the distinguished London Hunters. There is no record of the success of this enterprise, but considering the small number of physicians at the time, it is remarkable t.he lectures lasted as long as they did. Things were still pretty primitive. Hospitals were temporary affairs for epidemics, and the first medical journal in the country did not appear until 1797. Interest and progress in surgery did receive a needed stimulus from the events of the Revolutionary War and resulting contact with English and French surgeons. Issac Senter (Figure Z), a Newport doctor of the latter part of the century, has left behind enough material so that a pretty good image of how he lived and practiced can be reconstructed. He is perhaps typical of the best in the profession, rather than the average, for he had a good library, published his observations occasionally in the European and early American journals, and was often sought as a consultant in Newport and the surrounding towns. In contrast, many doctors, particularly in the smaller communities, were forced to supplement their incomes from farming or other activities. Isaac Senter was born in Londonderry, New Hampshire, in 1753 [I]. He studied medicine under Thomas Moffatt of Newport who, in turn, had been educated in his native Scotland. The Revolutionary War separated these two, for Moffatt’s Toryism led him to leave the country and Senter joined the Rhode Island troops in Cambridge after Concord and Lexington. He has left us an exciting journal of his experiences with Benedict Arnold in the grueling winter march through Maine, the siege of Quebec, and his capture and
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Figure 2. Doctor Isaac Senter, 1753- 1799. From the portrait, probably by Samuel King, owned by the Rhode Island Historical Society.
subsequent release [7]. The journal is devoted more to the hardships of the expedition than to medical matters, but the futility of surgical practice of the time comes through in accounts of a fatal chest injury and an unsuccessful thigh amputation. Senter left the Army in 1779 and, aft,er a year in East Greenwich, moved to Newport where he married and raised a family of four. He died in 1799 (as did George Washington) at the age of fortyfive. Senter kept accurate records year after year, not only of his practice but also of all his expenses, professional and domestic. These are all carefully preserved in the stacks of the Rhode Island Historical Society and from them can be gained a fair idea of what he was doing [R]. In 1787, for instance, there are 2,737 entries of charges for services, or about fifty-four in an average week. Almost all the work was performed in patients’ homes. Although Senter was widely known as a surgeon, there are only thirty-nine entries for what could be considered surgical procedures in that year. These included drainage of numerous abscesses and sixteen tooth extractions. He reduced six major limb fractures, reduced two hernias, and tapped a hydrocele. There is also the record of his receiving a fee for attending a lithotomy, and one wonders whether we had an itinerant stonecutter
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in these parts. He performed sixty deliveries in that same year. Senter was one of the early generation of physician obstetricians in the country. Midwives presided over all the deliveries until about 1750 when male accoucheurs first became acceptable [3]. Apparently, the physicians’ superior training led the public to regard them as more satisfactory than the completely uneducated midwives, women often from a low level of society. In other years, many interesting items are recorded. Venesections were frequent but not he inoculated for alarmingly so. On occasion, smallpox. We find record of his crossing the Bay to Charlestown to trepan a skull, an operation for imperforate anus, amputation of an apprentice’s leg, and many other procedures. There are many notations of excisions for cancer of the back, lip, nose, neck, and breast. Unfortunately, we do not know how he did these procedures nor whether his patients survived. We do know that he had an excellent library that included surgical works by Joseph Warner of Guys Hospital and Sir Astley Cooper. From these accounts he should have been able to do an acceptable job for the times. For instance, he would know that breast cancer was considered to demand removal of all or most all of the breast and occasionally axillary metastases through a separate incision. In considering why Isaac Senter performed so little surgery, the lack of anesthesia must play a major role. In its absence, abdominal surgery was just about impossible. And why send for the doctor to drain an abscess? It would hurt no more nor less if grandmother opened it, and besides, it would probably break anyway. Descriptions of amputations and other procedures often began with how the patient was restrained by attendants or apparatus and may have ended with a word about the sufferer’s fortitude. Lack of anesthesia put speed at a premium, thus encouraging hemorrhage. Not only did the patient need uncommon courage, but also the surgeon must have had to have a strong stomach and a cold heart. Senter must have lived pretty well. His fees seem small to us, but they have to compare with his expenses. He regularly received $8 for a delivery. A thigh amputation was $20. Inoculating a man and his wife for smallpox cost $14, hut it must be remembered that this probably entailed daily house calls for a week while they were recovering from their mild attacks. He received $4.50 for setting a fractured femur. House calls were $0.50, but
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there was usually a small additional charge for dressings or medication or both. “Rising in the night” cost $2. However, Senter paid $1 a day to a man to build a fence, and another man received $1.50 a day for working on his house. He bought a live hog of 122 pounds for $5. A shirt cost $1.50. His son, Nathan, who went to Rhode Island College, now Brown, had quarterly bills averaging less than $25. Regrettably for the community, at the height of his career, seeing more cases and writing more papers, Senter died of a febrile illness of short duration. Among the few other surgeons in the state in Senter’s time was his almos_t exact contemporary, Peter Turner, who had settled in East Greenwich, some 12 miles south of Providence, on the west side of Narragansett Bay. He too received a good bit of his surgical knowledge in the Revolutionary Army. We do not know as much of him as we do of Senter, but he is said to have performed the surgery for 10 miles around. Of course, he had a considerable general practice besides. An account of an episode that tells us a great deal about Peter Turner and the practice of his times has been handed down to us [9]. A young man in town suffered a self-inflicted accidental knife wound in the groin while holding a shoe in his lap for repair. Hemorrhage was furious. Turner was found just returning on the packet from a consultation across the Bay in Warren. He mounted a waiting horse and rode hard for a few miles to reach his patient. A quick appraisal of the precarious situation convinced him that the boy’s life could be saved only by ligation of the femoral artery. This was done forthwith, and his patient lived to old age with a functioning limb. Turner is credited with bringing the profession to respectability in his community. His predecessors eked out a marginal existence, perhaps because they were practicing marginal medicine with herbs, nostrums, and kindliness. Turner’s worth was recognized, and he received compensation which is said to have set modest but adequate standards that lasted for half a century [9]. 1800 to 1888 In understanding the state of the art of surgery in the first half of the nineteenth century, two isolated fragments from the literature of the time are particularly illuminating. One of these is the obituary of Nathanial Miller [IO], physician and surgeon of Franklin, Massachusetts, on the Rhode
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Island border, who died in 1848 at the age of seventy-seven. Among other things are discussed his originality and facility in such procedures as cataract extraction, removal of bladder stones via the perineal approach, and hernia operations. It is stated that, “his surgical practice increasing rapidly, soon extended over so wide an extent of territory as to engross the most of his time.” We should not form a misguided impression of the extent of Miller’s surgery, for the account goes on to say, “For many years his operations averaged nearly one a month.” Obviously, if surgery was taking so much of his time, he must have spent a great deal of it consulting, performing minor procedures, and just getting from place to place. The fact is, of course, that he had a large general practice. These quotations concerning Miller’s surgery assume special importance when one reads in the 1824 Boston Medical Intelligencer, “It is said, but with how much truth, we are unable to determine that the celebrated Dr. Miller of Franklin, Massachusetts does a third part of the chirugical business of Rhode Island” [II]. Although these figures cannot be classed as statistics, the conclusion is inescapable that there just was not much surgery being carried out in Rhode Island (or probably anywhere else at that time). Despite this, changes were gradually taking place in medicine that would lead to a firm foundation for advances to come. Medical schools were appearing. State medical societies designed to upgrade the profession were formed. Although scientific progress moved at a snail’s pace, an outlet was appearing for what progress there was in the form of medical journals, the first of which, “The had already appeared in Medical Repository,” New York in 1797. In 1811, Brown University in Providence started the seventh medical school in the country and the third in New England. In its first incarnation, it survived seventeen years. The history of this short-lived episode in medical education has been adequately recounted in the past, most recently and completely by my colleague, Seebert J. Goldowsky [la]. A brief mention of its presence and activities is nevertheless germane to the present discussion. Like all schools of its time, it was small by our present day standards, graduating altogether only eighty-eight MD’s. Graduating classes at Harvard during those years averaged 14.5 pupils. Each student at Brown was required to attend two full courses of lectures on anatomy, surgery, chemistry, and the theory and practice of physick, a total of six months of lectures. (Figure 3.) To re-
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Figure 3. Circular describing the Brown Medical S&ool circa 1822.
ceive his MD degree, he had to “have studied three years (including the time of lectures) with physicians of approved reputation” and to have presented an acceptable dissertation. These requirements are typical of those in other schools. The school proved a casualty of an era of student unrest, perhaps of some interest in that it was reborn a century and a half later during a time when some considered students more out of contact than ever before. The closing came when the corporation, presumably at President Wayland’s suggestion, “Resolved, That no Salary or other compensation be paid to any Professor, Tutor, or other officer who shall not during the course of each and every term occupy a room in one of the colleges (to be designated by the President) and assiduously devote himself to the preservation of order and instruction of the students . . .” Obviously, the small faculty, usually three in number, who received most of their income from patients’ fees would not submit, and the school soon dwindled into limbo. Although this episode in medical education was transient, it did help account for a profound change in the training and level of knowledge of Rhode Island physicians, for most of the graduates settled locally. Thus, Usher Parsons, who had been Professor of Anatomy and Surgery, could state in 1859, “In 1800, there were not five medical graduates in the State. At the present time, there are not five . . . who have not graduated as doctors of medicine” [ 131.
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Figure 4. Illustration in the October 1814 “New England Journal of Medktne and Surgery” accompanying William C. Bowen’s case of shoulder amputation.
Figure 5. Doctor Usher Parsons, 1788-1868. Surgeon, teacher, scholar, and civic and professional leader of Providence, Rhode island.
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Although the first steps in medical education were being made, there was still no control over what type of medicine or surgery was being practiced. All that was needed to be a physician or surgeon was patients. Literally, anyone could practice if he wished. State licensure came to Rhode Island late in 1895 [14]. To fill the void, in 1812, a state medical society was chartered by forty-six doctors who considered themselves meeting agreed upon standards of professional competence. Fellowship in the society conferred a degree of distinction in the eyes of the populace, although it had no direct effect in preventing others from prescribing to an all too often, gullible public [15]. Although all sorts of quackery prevailed, one interesting group of practitioners deserves special attention: the bonesetters. Bonesetters were men of little or no conventional education, often claiming hereditary powers, who treated fractures, dislocations, and related musculoskeletal complaints. Some developed a high degree of skill, but they often practiced something akin to chiropractic. There are accounts of marvelous cures of chronic disabling pain, relieved instantly by manipulation of joints that were “out.” In this country, the best known bonesetters were from the Sweet family. The Sweets first settled in Rhode Island, and at least six generations practiced their art in the state from the late 1600’s well into the present century [16]. Members of the family carried their trade into Connecticut, New York, New Jersey, and perhaps further. Their accomplishments were well known and accepted by members of all levels of society, including Aaron Burr’s daughter and Governor Dewitt Clinton. As time went on, the later members of the Sweet family melded into the orthodox practice of medicine. John Sweet, MD of Hartford, board-certified in orthopedic surgery, gives an interesting history of the family and refutes the idea that the skill was hereditary, considering it more a matter of environment. He states, “From early childhood, the boys of the family have seen their parents ‘perform bonesetting operations’, and the principles of the procedure have been explained in detail.” He also states, “My grandfather, Charles Sweet of Lebanon, Connecticut followed the teaching of Sir Astley Cooper” [ 171. In general, the more legitimate medical community looked down on bonesetters. The fact that their better qualities were appreciated by some appears from a heated exchange between Doctor Joseph Comstock of Lebanon, Connecticut, and Doctor Dan King of Taunton, Massachusetts, ap-
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pearing in the 1846 “Boston Medical and Surgical [ Z&21], Comstock, although living over Journal” the line in Connecticut, was a past president of the Rhode Island Medical Society. He probably published more than any of his contemporaries in the area, and his opinions had to be listened to and, in this case, they were answered. Comstock defended the Sweets. King accused him of siding with men of “ignorance and barbarity.” Comstock concludes his remarks with advice to the medical men to pay attention to the bonesetters’ good points. He felt that: (1) the bonesetters, by dealing with living bones and muscles and understanding their interactions, had the advantage over the surgeons who learned from lifeless skeletons; (2) in instances of dislocations, they used the bones themselves as levers; and (3) in reducing fractures and dislocations, they were able to “seize the precise moment when the muscles and mind are in entire state of quietude and relaxation.” From this, one has to conclude that the bonesetters had something to teach us. There were still no hospitals as we know them. Many towns had their smallpox hospitals from 1750 on, and there was a military hospital in Providence during the Revolutionary War. There was also a hospital for sailors on the present Rhode Island Hospital grounds for part of the final half of the nineteenth century. Butler Hospital for the Insane received its first patients in 1847. Not until 1868 did Rhode Island Hospital open its doors as the first general hospital in the state [15,22]. Thus, it can be seen that even after 1800, Rhode Island surgeons, as was the case everywhere, except in a few large cities, continued to do their operations in the home or. occasionally, on their own premises. Of these early nineteenth century surgeons, we know little. The “Boston Medical Intelligence? for 1824 complains, “We hardly recollect a medical publication that has ever emanated from Rhode Island. The physicians have neither a periodical journal, nor, in fact, leisure to publish, even if they possessed a medium of sending their thoughts into the world; but no where do we find a more able class of practitioners, or those who deserve to be held in higher estimation by the public at large” [II]. The facts here are only a little overstated. Articles from the state did appear from time to time, mostly in “The New England Journal of Medicine and Surgery” and its successors. These were most often simple case reports; however, along with scraps of information concerning addresses before the Rhode Island Medical Society, one can gain a
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little insight into surgery of the time. l’rrhaps this can best be illustrated by brief sketches cbt’t.he activities of two more of the leading surgeons of’ the time. Nathaniel Miller of Franklin, Massachuset,t,s, has already been mentioned. William C. Bowen is chosen partly because he represented the fifth and last generation of Bowens, beginning with the previously mentioned Richard of Seekonk [I]. All the Bowens lived in or near Providence, and some had large surgical practices. After graduation from linion (:ollege, William C. Bowen returned to Providence to pract,ice with his uncle, Pardon Bowen, from 1803 until 1806. He then took the unusual step, for his time, of studying abroad for five years in Edinburgh, Holland, Paris, and finally London, where he was a pupil of Sir Astley Cooper. On his return to this country, he was chosen Professor of Chemistry in the newly opened program at Brown. Despite t,his, Bowen was an accomplished surgeon, as shown from his case of “Fungous Hematodes,” published in 1814 [23]. (Figure 4.) In this case, Bowen took the precaution of ligating the subclavian artery before the arm amputation. IJnfortunately for Brown, the profession, and the state, William C. Bowen died the year after the paper was published, supposedly from lung damage incurred from experimenting with chlorine for the bleaching industry. In the history of the medical profession in Rhode Island, in the first issue of the “Rhode Island Medical ,Journal,” it is said that,, “In the death of William C. Bowen, Rhode Island lost the brightest ornament of the medical profesof prosion,” and that, “with his ardor in pursuit fessional knowledge, he could not fail of attaining to great celebrity.” Of all the medical personalities in Rhode Island’s past, Usher Parsons (Figure 5) stands head and shoulders above the rest. Every local medical history buff in the state knows about Parsons and, like as not, has written or spoken about him. Hopefully, a definitive biography will appear in the near future. Parsons was born in 1788 in Alfred, Maine, of a farming family, but earned most of his medical education t.hrough school teaching. He studied under John Warren in Boston for six months in 1811, and this, with attendance at a few lectures, enabled him to be passed by the Censors of the Massachusetts Medical Society as a “Practitioner of Medicine” [24]. Parsons soon joined the Navy and was sent to the Great Lakes region where he was Oliver Hazard Perry’s surgeon on the 1,awrence in the Battle
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TABLE
I
Summary
of Major
(Parsons,
1848)
Limb Amputations
Extremities
Lower Extremities
4 3 0 0 1 8
12 1 2 1 0 16
Upper
______ Trauma Malignancy Arteriosclerosis Frost bite ? Osteomyelitis Total
of Lake Erie. This was the making of his career. From his account of the fray, one finds that he had a pretty rough experience but came off well [24,25]. Of the 150 men on the Lawrence, twentythree were killed outright or died within a few hours. His working space during the encounter was about 10 feet square for the treatment of some sixty wounded men. Five cannon balls passed through this room while he was working, killing two of his patients. He performed at least six leg amputations in the first twenty-four hours during and after the battle. When it was over, he cared for all the wounded of the fleet and was commended to the Navy Secretary by Perry for losing only three of nearly one hundred, a truly remarkable record for that time or any other. It can be ascribed partly to his skill and partly to a little luck in the minimal amount of sepsis. Parsons himself felt it was due to a good diet and the pure air of the region. Usher Parsons returned to Harvard in late 1817 for a term at the medical school and received his MD degree three months later. After another three years in the Navy, he was appointed Professor of Anatomy and Surgery at Dartmouth but stayed only one term. In April 1822, he came to Providence where he assumed the anatomy and surgery professorship at Brown. That fall he married Doctor Oliver Wendell Holmes’ sister, Mary. She died three years later, leaving one son. Parsons never remarried. Parsons wrote extensively. His volume, “Sailor’s Physician and Friend,” went through five editions. He won the Boyleston Essay prize four times. Not all of his papers were on surgical subjects, but we find articles on cancer of the breast, periostitis, gunshot wounds of the thorax, and a case of hysterectomy in 1851 [24]. In 1848, Parsons published a partial summary of what he calls his large surgical cases up to that time. Noting that “hospital” surgeons were recording their results, he felt it a good idea to have in
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the literature the work that was being done by a “private” practitioner [26]. He lists only five types of cases, including one of removal of a bladder stone and one (the governor of the state) of exenteration of the orbit for malignancy. Both patients survived surgery, but the malignant lesion of the eye recurred in two years with a fatal outcome. In the matter of breast amputation for malignancy, his results are not very striking, but he was probably operating on few, if any, early cases. Of the sixteen cases listed, eleven had been treated five years or more before publication, and four of these passed the five year mark living and well. However, his survival statistics were probably headed for a nose ,dive, because of the five patients treated within five years, three had died of cancer and the other two had survived only one year. Daland [27] would probably tell us that these statistics are but little better than those for untreated breast carcinoma. Finally, there were twenty-four major limb amputations. (Table I.) Two of these patients had amputation in 1847, but only one received ether. The record of only two deaths is, of course, excellent for the time, but Parsons believed it could have been better if he had delayed amputation of a leg in one case of trauma. He cautions against surgery before the pulse has stabilized. In addition to his medical school teaching, Parsons had some fifty private pupils in whom he took a great interest over the years. He sometimes taught several at one time, and in the winter he often had private dissecting classes. Parsons was a man of many interests. He worked with the fledgling American Medical Association from its start in 1847 and was Vice President in 1851. He became the leading scholar of his time in local Indian archeology and wrote a lengthy biography of Sir William Pepperrell, the leader in 1745 of the attack on Louisberg. In 1851, when Parsons was President of the Providence Medical Association, he called for the establishment of a general hospital in the city. A committee was formed with Parsons as chairman and attempts were made to raise money. Nothing came of it at that time, but from this beginning, the Rhode Island Hospital emerged. On October 1, 1868, Parsons, then in his eighty-first year and feeble and infirm, was on the platform for the opening exercises. Nine days later he attended the first major surgical procedure in the institution. Death came less than three months thereafter [24].
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Usher Parsons’ active surgical life ended shortly after the discovery of anesthesia. On this subject, his physician son states, “He never became so fully at home with it as the later generation of surgeons. In the greater part of his operations, the only anesthetics at his command were such as laudanum and brandy, and the words of encouragement and sympathy.” With this reminder of great things ahead comes the logical ending of this discourse. A few conclusions can be drawn. First of all, not much surgery was performed and what there was seems pretty crude in our eyes. Secondly, there were no surgeons as we know them. There were general practitioners, with an inclination towards surgery, who established reputations in their field and often did most of the operating for miles. Surgery rarely, if ever, constituted the bulk of their practice. Finallv. the entire medical profession was improving its lot, although with glacial slowness. There was gradual progress in medical education. Although quackery abounded, physicians began to police themselves through their own medical societies. They projected hospitals, even if Rhode Island’s dream of such an institution had to wait until 1868. Thus, the stage was set for the phenomenal advances of the anesthesia era. We are today in their debt for their courage and tenacity in difficult times. Acknowledgment: I wish to thank Helen DeJong, Librarian of the Rhode Island Medical Society Library, for her encouragement and assistance in the preparation of this paper.
References 1. Parsons U. Ray I, Collins GL: History of the medical profession in Rhode Island. CommunicatRI M Sot 1: 1, 1877. 2. Population of Rhode Island. Manual of the State of Rhode Island, 1953-9. p 364. 3. Shryock RH: Medicine and Society in America, 1660-1860. New York, New York University Press, 1960.
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4. Nelson W: The Hero of Aquidneck. A Life of Dr. John Clarke. Bloomfield, New Jersey; Schafer, 1954. 5. Bicknell TW: The Story of Dr. John Clarke. Providence, The Author, 1915. 6. Hedges JB: The Browns of Providence Plantations. Volume 1. The Colonial Years. Providence, Brown University, 1968. 7. Senter I: The Journal of on a Secret Expedition Against Quebec, Under the Command of Colonel Benedict Arnold, in September 1775. Philadelphia, Historical Society of Pennsylvania, 1846. 8. Senter I: Collected Papers. In the Rhode Island Historical Society Library, Providence, Rhode Island. 9. E&edge JH: Early medical history of Kent County, Rhode Island. Rl Med J23: 135, 1940. 10. Obituary of Dr. Nathaniel Miller. Med Communicat Mass M Sot 8: 171. 1854. 11. Medical literature in Rhode Island. Editorial. Boston M lntellig 2: 38. 1824. 12. Goldowsky SJ: The beginnings of medical education in Rhode Island. RI Med J 38: 498, 1955. 13. Parsons U, Ray I, Collins GL: Medical education in Rhode Island. Communicat RI M Sot 1: 55, 1877. 14. Casey TB, Kelly EF. DiMaio M. Myrick JC: Medical licensure in Rhode Island. A review of the history RI bled J 45: 625, 1962. 15. Goldowsky SJ: The Rhode Island Medical Society. I. The first fifty years: 1812-1862, p 3. The History of. the Rhode Island Medical Society and Its Component Societies, 1812-1962. East Providence, Roger Williams, 1966. 16. Lewis RV: Personal communication and unpublished manuscript. 17. Swett PP: Notes on the history of orthopedic surgery in Connecticut. Part 2. Conn Med 10: 206, 1946. 18. Comstock J: On the study of living anatomy. Boston M & S J 49: 500, 1854. 19. Comstock J: The study of living anatomy. Reply to Dr. King. BostonM&SJ50:61, 1854. 20. King D: Hereditary skill in bone-setting. Boston M & S J 50: 12, 1854. 21. Kino D: Medical science and the natural bone-setters. Bos& M & S J 50: 77, 1854. 22. Chapin CV: Epidemics and medical institutions, chapt 1. State of Rhode Island and Providence Plantations, A History, vol 2 (Field E, ed). Boston, Mason, 1902. 23. Bowen WC: Case of fungus haematodes amputated at the articulationof theshoulder. NEnglJM& S3: 313, 1814. 24. Parsons CW: Memoir of Usher Parsons, M.D., of Providence, R.I. Providence, Hammond, Angell. 1870. 25. Parsons U: Surgical account of the naval battle on Lake Erie, on the 10th of September 1813. N Engl J M & S 7: 313, 1818. 26. Parsons U: Statistics of large surgical operations. Am J M SC n.s. 15: 359, 1848. 27. Daland EM: Untreated cancer of the breast. Surg Gynecol Obstet 44: 264 1927.
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The
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PRESIDENTIAL ADDRESS
Surgery in a Rural Area: 1638 - 1868 Thomas Perry, Jr, MD, Providence, Rhode Island
In the past, presidents of this Society have given us learned papers on clinical subjects, the education of surgeons, and socioeconomic problems. Others have concerned themselves with medical avocations. I have chosen to enjoy myself in this fashion by preparing a paper on the history of surgery in my own state. Consideration of the accomplishments of our fellow surgeons of just a few previous generations, under difficulties unknown to us, imparts an admiration for these people and points out how they have eased the way for us. The history of the beginning of medicine and surgery in this country has been told and retold many times. Nevertheless, it is hard for us to remember, as we move from operating room, to laboratory, to bedside, that only a short while ago surgery was a primitive art, little improved since the middle ages. The majority of our early historical material deals with the advances made in the great seaboard centers of the North. What was happening in Rhode Island is probably more typical of what prevailed in this largely rural country as a whole. The early surgical history of the state seems to divide itself logically into three chapters. The first, Reprint requests should be addressed to Thomas Perry, Jr. MD, 210 High Service Avenue, North Providence, Rhode Island 02904. Presented at the Fifty-Fifth Annual Meeting of the New England Surgical Society, Waterville Valley, New Hampshire, September 26-28, 1974.
Volume 129, April 1975
from settlement in 1636 by Roger Williams until 1’700, was the real pioneer time. Secondly, the eighteenth century was a long period of near stagnation in progress. Finally, the first half of the nineteenth century saw advances in educational facilities and the formation of medical societies that upgraded practice to a point from which the profession could take off to greater things. The advent of anesthesia in 1846 was a turning point which could form a logical end to this paper on early surgery. From a more practical standpoint, surgery in the state could not flower until the first general hospital opened in 1868. 1636 to 1700 We have records of only eleven physicians and surgeons in seventeenth century Rhode Island.* All but two were from Newport, and Providence had no doctor at all, relying on nearby Seekonk, Massachusetts, where Richard Bowen settled in 1680 [I]. Of course, others with no training at all were doing the best they could, and Roger Williams himself is known to have distributed a few * John Clarke, John Cranston, Thomas Rodman, Norbert Vigneron, Samuel Ayrholt, and an unnamed Frenchman, physicians of Newport; Robert Jeffries, Henry Greenland, and Simon Cooper, surgeons of Newport; Gilbert Updike of Narragansett; and Thomas Spence of Warwick. (Collected from references 1, 2, and 3.)
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Figure 1. Doctor John Clarke, 1609-1676. From the portratt in the Redwood Library, Newport, Rhode Island.
remedies and a little light gathered from a small collection of medical volumes. If eleven seems a small number of medical men for the whole period, it should be remembered that the state contained less than 7,000 souls in 1700. Newport was a town of some 3,000 and Providence less than half that [2]. Newport boasted of having three surgeons during this period, and it is important to note that they called themselves surgeons, adhering to the European separation of surgeons and physicians. Necessarily, all the early practitioners were trained abroad, but as time went on, the apprentice system produced almost all our physicians and surgeons. In a rural land, they all did general practice. It has been pointed out that this was pretty much so in rural England too, with the separation of physicians and surgeons confined to the cities. Still, some doctors in this country were always known for their proficiency in surgery whereas others avoided it [3]. We know little of the surgery of those early Newporters. Presumably, as in Europe, they were less educated and kept poorer records than did their physician contemporaries. They cannot have done much more than simple procedures dealing with infections, superficial tumors, and trauma, although on occasion they may have essayed a herniotomy or cut for stones. In the absence of material about them, it is perhaps worthwhile to get the flavor of the time by considering John Clarke (Figure
348
l), the first physician of the state [4]. He arrived in Portsmouth in 1638 with a group of nearly 1,000 Massachusetts dissenters and practiced until his death in 1676. Born in England, he studied in Leyden, where he spread himself over the fields of law, medicine, and theology. During his life, he was proficient in all three fields. John Clarke was the pastor of Newport’s first church, which to this day rejoices in the name of the United Baptist John Clarke Memorial Church of Newport. Clarke was one of the colony’s leaders from the start. His contributions include authorship, with William Dyer’s assistance, of a remarkable code of laws for the colony of which it is said, “Unencumbered by superfluous verbiage that clothes our modern statutes in learned obscurity, embracing as it does the whole body of law, . . . and for vigor and originality, . . . it presents a model of legislation which has never been surpassed” [5]. Clarke went back to England with Roger Williams in 1651 to get a new charter for the colony. This took him thirteen years to accomplish, during which time he supported himself by his medical practice, His persistence paid off, however, for he obtained a remarkable document still preserved at our state house where it served as the state constitution until 1843. After greetings from the King, it begins, “Whereas we have been informed by the humble petition of our servant John Clarke . . . .” Thomas W. Bicknell, the historian, states that this charter “has been universally recognized as the most liberal state paper ever issued by the English Crown” [5]. Wilbur Nelson, Clarke’s biographer, says, “In it absolute religious freedom was for the first time secured and guaranteed . . . . The principals it embodied. . . still live. . . in the government of every state in the Union and many countries as well” [4].
1700 to 1800
Between 1700 and 1800, the population of the state increased about tenfold to 69,000. The pioneer life developed into a prosperous mercantile and farming society. The spermaceti candle manufacturing plant and the Hope furnace for producing bog iron, both Brown family enterprises, are examples of the beginning of small industry [6]. Numerous trading vessels made Narragansett Bay their home. Medicine was making slow but steady progress. Our physicians increased in number with the rise of population, but their education changed little. Although there was still a trickle of foreign-edu-
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cated physicians, most served an apprenticeship. After a few years, these men would receive a certificate of some sort and strike out on their own. There was no form of licensure, and those who were interested in trying their hand at surgery did so. The first medical school to open in the country was at the College of Philadelphia in 1765, followed by King’s College Medical School in 1768 and Harvard in 1780, but it was some time before their influence was felt in Rhode Island [3]. Prior to the appearance of the schools, series of lectures were given from time to time throughout the country, but they were evanescent to say the least. The first of these of which this country has any record were delivered in Newport in 1754, 1755, and 1756 [I]. These were anatomic lectures given by William Hunter, Hunter had studied in Edinburgh under the elder Monro and was a relative of the distinguished London Hunters. There is no record of the success of this enterprise, but considering the small number of physicians at the time, it is remarkable t.he lectures lasted as long as they did. Things were still pretty primitive. Hospitals were temporary affairs for epidemics, and the first medical journal in the country did not appear until 1797. Interest and progress in surgery did receive a needed stimulus from the events of the Revolutionary War and resulting contact with English and French surgeons. Issac Senter (Figure Z), a Newport doctor of the latter part of the century, has left behind enough material so that a pretty good image of how he lived and practiced can be reconstructed. He is perhaps typical of the best in the profession, rather than the average, for he had a good library, published his observations occasionally in the European and early American journals, and was often sought as a consultant in Newport and the surrounding towns. In contrast, many doctors, particularly in the smaller communities, were forced to supplement their incomes from farming or other activities. Isaac Senter was born in Londonderry, New Hampshire, in 1753 [I]. He studied medicine under Thomas Moffatt of Newport who, in turn, had been educated in his native Scotland. The Revolutionary War separated these two, for Moffatt’s Toryism led him to leave the country and Senter joined the Rhode Island troops in Cambridge after Concord and Lexington. He has left us an exciting journal of his experiences with Benedict Arnold in the grueling winter march through Maine, the siege of Quebec, and his capture and
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Figure 2. Doctor Isaac Senter, 1753- 1799. From the portrait, probably by Samuel King, owned by the Rhode Island Historical Society.
subsequent release [7]. The journal is devoted more to the hardships of the expedition than to medical matters, but the futility of surgical practice of the time comes through in accounts of a fatal chest injury and an unsuccessful thigh amputation. Senter left the Army in 1779 and, aft,er a year in East Greenwich, moved to Newport where he married and raised a family of four. He died in 1799 (as did George Washington) at the age of fortyfive. Senter kept accurate records year after year, not only of his practice but also of all his expenses, professional and domestic. These are all carefully preserved in the stacks of the Rhode Island Historical Society and from them can be gained a fair idea of what he was doing [R]. In 1787, for instance, there are 2,737 entries of charges for services, or about fifty-four in an average week. Almost all the work was performed in patients’ homes. Although Senter was widely known as a surgeon, there are only thirty-nine entries for what could be considered surgical procedures in that year. These included drainage of numerous abscesses and sixteen tooth extractions. He reduced six major limb fractures, reduced two hernias, and tapped a hydrocele. There is also the record of his receiving a fee for attending a lithotomy, and one wonders whether we had an itinerant stonecutter
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in these parts. He performed sixty deliveries in that same year. Senter was one of the early generation of physician obstetricians in the country. Midwives presided over all the deliveries until about 1750 when male accoucheurs first became acceptable [3]. Apparently, the physicians’ superior training led the public to regard them as more satisfactory than the completely uneducated midwives, women often from a low level of society. In other years, many interesting items are recorded. Venesections were frequent but not he inoculated for alarmingly so. On occasion, smallpox. We find record of his crossing the Bay to Charlestown to trepan a skull, an operation for imperforate anus, amputation of an apprentice’s leg, and many other procedures. There are many notations of excisions for cancer of the back, lip, nose, neck, and breast. Unfortunately, we do not know how he did these procedures nor whether his patients survived. We do know that he had an excellent library that included surgical works by Joseph Warner of Guys Hospital and Sir Astley Cooper. From these accounts he should have been able to do an acceptable job for the times. For instance, he would know that breast cancer was considered to demand removal of all or most all of the breast and occasionally axillary metastases through a separate incision. In considering why Isaac Senter performed so little surgery, the lack of anesthesia must play a major role. In its absence, abdominal surgery was just about impossible. And why send for the doctor to drain an abscess? It would hurt no more nor less if grandmother opened it, and besides, it would probably break anyway. Descriptions of amputations and other procedures often began with how the patient was restrained by attendants or apparatus and may have ended with a word about the sufferer’s fortitude. Lack of anesthesia put speed at a premium, thus encouraging hemorrhage. Not only did the patient need uncommon courage, but also the surgeon must have had to have a strong stomach and a cold heart. Senter must have lived pretty well. His fees seem small to us, but they have to compare with his expenses. He regularly received $8 for a delivery. A thigh amputation was $20. Inoculating a man and his wife for smallpox cost $14, hut it must be remembered that this probably entailed daily house calls for a week while they were recovering from their mild attacks. He received $4.50 for setting a fractured femur. House calls were $0.50, but
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there was usually a small additional charge for dressings or medication or both. “Rising in the night” cost $2. However, Senter paid $1 a day to a man to build a fence, and another man received $1.50 a day for working on his house. He bought a live hog of 122 pounds for $5. A shirt cost $1.50. His son, Nathan, who went to Rhode Island College, now Brown, had quarterly bills averaging less than $25. Regrettably for the community, at the height of his career, seeing more cases and writing more papers, Senter died of a febrile illness of short duration. Among the few other surgeons in the state in Senter’s time was his almos_t exact contemporary, Peter Turner, who had settled in East Greenwich, some 12 miles south of Providence, on the west side of Narragansett Bay. He too received a good bit of his surgical knowledge in the Revolutionary Army. We do not know as much of him as we do of Senter, but he is said to have performed the surgery for 10 miles around. Of course, he had a considerable general practice besides. An account of an episode that tells us a great deal about Peter Turner and the practice of his times has been handed down to us [9]. A young man in town suffered a self-inflicted accidental knife wound in the groin while holding a shoe in his lap for repair. Hemorrhage was furious. Turner was found just returning on the packet from a consultation across the Bay in Warren. He mounted a waiting horse and rode hard for a few miles to reach his patient. A quick appraisal of the precarious situation convinced him that the boy’s life could be saved only by ligation of the femoral artery. This was done forthwith, and his patient lived to old age with a functioning limb. Turner is credited with bringing the profession to respectability in his community. His predecessors eked out a marginal existence, perhaps because they were practicing marginal medicine with herbs, nostrums, and kindliness. Turner’s worth was recognized, and he received compensation which is said to have set modest but adequate standards that lasted for half a century [9]. 1800 to 1888 In understanding the state of the art of surgery in the first half of the nineteenth century, two isolated fragments from the literature of the time are particularly illuminating. One of these is the obituary of Nathanial Miller [IO], physician and surgeon of Franklin, Massachusetts, on the Rhode
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Island border, who died in 1848 at the age of seventy-seven. Among other things are discussed his originality and facility in such procedures as cataract extraction, removal of bladder stones via the perineal approach, and hernia operations. It is stated that, “his surgical practice increasing rapidly, soon extended over so wide an extent of territory as to engross the most of his time.” We should not form a misguided impression of the extent of Miller’s surgery, for the account goes on to say, “For many years his operations averaged nearly one a month.” Obviously, if surgery was taking so much of his time, he must have spent a great deal of it consulting, performing minor procedures, and just getting from place to place. The fact is, of course, that he had a large general practice. These quotations concerning Miller’s surgery assume special importance when one reads in the 1824 Boston Medical Intelligencer, “It is said, but with how much truth, we are unable to determine that the celebrated Dr. Miller of Franklin, Massachusetts does a third part of the chirugical business of Rhode Island” [II]. Although these figures cannot be classed as statistics, the conclusion is inescapable that there just was not much surgery being carried out in Rhode Island (or probably anywhere else at that time). Despite this, changes were gradually taking place in medicine that would lead to a firm foundation for advances to come. Medical schools were appearing. State medical societies designed to upgrade the profession were formed. Although scientific progress moved at a snail’s pace, an outlet was appearing for what progress there was in the form of medical journals, the first of which, “The had already appeared in Medical Repository,” New York in 1797. In 1811, Brown University in Providence started the seventh medical school in the country and the third in New England. In its first incarnation, it survived seventeen years. The history of this short-lived episode in medical education has been adequately recounted in the past, most recently and completely by my colleague, Seebert J. Goldowsky [la]. A brief mention of its presence and activities is nevertheless germane to the present discussion. Like all schools of its time, it was small by our present day standards, graduating altogether only eighty-eight MD’s. Graduating classes at Harvard during those years averaged 14.5 pupils. Each student at Brown was required to attend two full courses of lectures on anatomy, surgery, chemistry, and the theory and practice of physick, a total of six months of lectures. (Figure 3.) To re-
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Figure 3. Circular describing the Brown Medical S&ool circa 1822.
ceive his MD degree, he had to “have studied three years (including the time of lectures) with physicians of approved reputation” and to have presented an acceptable dissertation. These requirements are typical of those in other schools. The school proved a casualty of an era of student unrest, perhaps of some interest in that it was reborn a century and a half later during a time when some considered students more out of contact than ever before. The closing came when the corporation, presumably at President Wayland’s suggestion, “Resolved, That no Salary or other compensation be paid to any Professor, Tutor, or other officer who shall not during the course of each and every term occupy a room in one of the colleges (to be designated by the President) and assiduously devote himself to the preservation of order and instruction of the students . . .” Obviously, the small faculty, usually three in number, who received most of their income from patients’ fees would not submit, and the school soon dwindled into limbo. Although this episode in medical education was transient, it did help account for a profound change in the training and level of knowledge of Rhode Island physicians, for most of the graduates settled locally. Thus, Usher Parsons, who had been Professor of Anatomy and Surgery, could state in 1859, “In 1800, there were not five medical graduates in the State. At the present time, there are not five . . . who have not graduated as doctors of medicine” [ 131.
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Figure 4. Illustration in the October 1814 “New England Journal of Medktne and Surgery” accompanying William C. Bowen’s case of shoulder amputation.
Figure 5. Doctor Usher Parsons, 1788-1868. Surgeon, teacher, scholar, and civic and professional leader of Providence, Rhode island.
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Although the first steps in medical education were being made, there was still no control over what type of medicine or surgery was being practiced. All that was needed to be a physician or surgeon was patients. Literally, anyone could practice if he wished. State licensure came to Rhode Island late in 1895 [14]. To fill the void, in 1812, a state medical society was chartered by forty-six doctors who considered themselves meeting agreed upon standards of professional competence. Fellowship in the society conferred a degree of distinction in the eyes of the populace, although it had no direct effect in preventing others from prescribing to an all too often, gullible public [15]. Although all sorts of quackery prevailed, one interesting group of practitioners deserves special attention: the bonesetters. Bonesetters were men of little or no conventional education, often claiming hereditary powers, who treated fractures, dislocations, and related musculoskeletal complaints. Some developed a high degree of skill, but they often practiced something akin to chiropractic. There are accounts of marvelous cures of chronic disabling pain, relieved instantly by manipulation of joints that were “out.” In this country, the best known bonesetters were from the Sweet family. The Sweets first settled in Rhode Island, and at least six generations practiced their art in the state from the late 1600’s well into the present century [16]. Members of the family carried their trade into Connecticut, New York, New Jersey, and perhaps further. Their accomplishments were well known and accepted by members of all levels of society, including Aaron Burr’s daughter and Governor Dewitt Clinton. As time went on, the later members of the Sweet family melded into the orthodox practice of medicine. John Sweet, MD of Hartford, board-certified in orthopedic surgery, gives an interesting history of the family and refutes the idea that the skill was hereditary, considering it more a matter of environment. He states, “From early childhood, the boys of the family have seen their parents ‘perform bonesetting operations’, and the principles of the procedure have been explained in detail.” He also states, “My grandfather, Charles Sweet of Lebanon, Connecticut followed the teaching of Sir Astley Cooper” [ 171. In general, the more legitimate medical community looked down on bonesetters. The fact that their better qualities were appreciated by some appears from a heated exchange between Doctor Joseph Comstock of Lebanon, Connecticut, and Doctor Dan King of Taunton, Massachusetts, ap-
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pearing in the 1846 “Boston Medical and Surgical [ Z&21], Comstock, although living over Journal” the line in Connecticut, was a past president of the Rhode Island Medical Society. He probably published more than any of his contemporaries in the area, and his opinions had to be listened to and, in this case, they were answered. Comstock defended the Sweets. King accused him of siding with men of “ignorance and barbarity.” Comstock concludes his remarks with advice to the medical men to pay attention to the bonesetters’ good points. He felt that: (1) the bonesetters, by dealing with living bones and muscles and understanding their interactions, had the advantage over the surgeons who learned from lifeless skeletons; (2) in instances of dislocations, they used the bones themselves as levers; and (3) in reducing fractures and dislocations, they were able to “seize the precise moment when the muscles and mind are in entire state of quietude and relaxation.” From this, one has to conclude that the bonesetters had something to teach us. There were still no hospitals as we know them. Many towns had their smallpox hospitals from 1750 on, and there was a military hospital in Providence during the Revolutionary War. There was also a hospital for sailors on the present Rhode Island Hospital grounds for part of the final half of the nineteenth century. Butler Hospital for the Insane received its first patients in 1847. Not until 1868 did Rhode Island Hospital open its doors as the first general hospital in the state [15,22]. Thus, it can be seen that even after 1800, Rhode Island surgeons, as was the case everywhere, except in a few large cities, continued to do their operations in the home or. occasionally, on their own premises. Of these early nineteenth century surgeons, we know little. The “Boston Medical Intelligence? for 1824 complains, “We hardly recollect a medical publication that has ever emanated from Rhode Island. The physicians have neither a periodical journal, nor, in fact, leisure to publish, even if they possessed a medium of sending their thoughts into the world; but no where do we find a more able class of practitioners, or those who deserve to be held in higher estimation by the public at large” [II]. The facts here are only a little overstated. Articles from the state did appear from time to time, mostly in “The New England Journal of Medicine and Surgery” and its successors. These were most often simple case reports; however, along with scraps of information concerning addresses before the Rhode Island Medical Society, one can gain a
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little insight into surgery of the time. l’rrhaps this can best be illustrated by brief sketches cbt’t.he activities of two more of the leading surgeons of’ the time. Nathaniel Miller of Franklin, Massachuset,t,s, has already been mentioned. William C. Bowen is chosen partly because he represented the fifth and last generation of Bowens, beginning with the previously mentioned Richard of Seekonk [I]. All the Bowens lived in or near Providence, and some had large surgical practices. After graduation from linion (:ollege, William C. Bowen returned to Providence to pract,ice with his uncle, Pardon Bowen, from 1803 until 1806. He then took the unusual step, for his time, of studying abroad for five years in Edinburgh, Holland, Paris, and finally London, where he was a pupil of Sir Astley Cooper. On his return to this country, he was chosen Professor of Chemistry in the newly opened program at Brown. Despite t,his, Bowen was an accomplished surgeon, as shown from his case of “Fungous Hematodes,” published in 1814 [23]. (Figure 4.) In this case, Bowen took the precaution of ligating the subclavian artery before the arm amputation. IJnfortunately for Brown, the profession, and the state, William C. Bowen died the year after the paper was published, supposedly from lung damage incurred from experimenting with chlorine for the bleaching industry. In the history of the medical profession in Rhode Island, in the first issue of the “Rhode Island Medical ,Journal,” it is said that,, “In the death of William C. Bowen, Rhode Island lost the brightest ornament of the medical profesof prosion,” and that, “with his ardor in pursuit fessional knowledge, he could not fail of attaining to great celebrity.” Of all the medical personalities in Rhode Island’s past, Usher Parsons (Figure 5) stands head and shoulders above the rest. Every local medical history buff in the state knows about Parsons and, like as not, has written or spoken about him. Hopefully, a definitive biography will appear in the near future. Parsons was born in 1788 in Alfred, Maine, of a farming family, but earned most of his medical education t.hrough school teaching. He studied under John Warren in Boston for six months in 1811, and this, with attendance at a few lectures, enabled him to be passed by the Censors of the Massachusetts Medical Society as a “Practitioner of Medicine” [24]. Parsons soon joined the Navy and was sent to the Great Lakes region where he was Oliver Hazard Perry’s surgeon on the 1,awrence in the Battle
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TABLE
I
Summary
of Major
(Parsons,
1848)
Limb Amputations
Extremities
Lower Extremities
4 3 0 0 1 8
12 1 2 1 0 16
Upper
______ Trauma Malignancy Arteriosclerosis Frost bite ? Osteomyelitis Total
of Lake Erie. This was the making of his career. From his account of the fray, one finds that he had a pretty rough experience but came off well [24,25]. Of the 150 men on the Lawrence, twentythree were killed outright or died within a few hours. His working space during the encounter was about 10 feet square for the treatment of some sixty wounded men. Five cannon balls passed through this room while he was working, killing two of his patients. He performed at least six leg amputations in the first twenty-four hours during and after the battle. When it was over, he cared for all the wounded of the fleet and was commended to the Navy Secretary by Perry for losing only three of nearly one hundred, a truly remarkable record for that time or any other. It can be ascribed partly to his skill and partly to a little luck in the minimal amount of sepsis. Parsons himself felt it was due to a good diet and the pure air of the region. Usher Parsons returned to Harvard in late 1817 for a term at the medical school and received his MD degree three months later. After another three years in the Navy, he was appointed Professor of Anatomy and Surgery at Dartmouth but stayed only one term. In April 1822, he came to Providence where he assumed the anatomy and surgery professorship at Brown. That fall he married Doctor Oliver Wendell Holmes’ sister, Mary. She died three years later, leaving one son. Parsons never remarried. Parsons wrote extensively. His volume, “Sailor’s Physician and Friend,” went through five editions. He won the Boyleston Essay prize four times. Not all of his papers were on surgical subjects, but we find articles on cancer of the breast, periostitis, gunshot wounds of the thorax, and a case of hysterectomy in 1851 [24]. In 1848, Parsons published a partial summary of what he calls his large surgical cases up to that time. Noting that “hospital” surgeons were recording their results, he felt it a good idea to have in
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the literature the work that was being done by a “private” practitioner [26]. He lists only five types of cases, including one of removal of a bladder stone and one (the governor of the state) of exenteration of the orbit for malignancy. Both patients survived surgery, but the malignant lesion of the eye recurred in two years with a fatal outcome. In the matter of breast amputation for malignancy, his results are not very striking, but he was probably operating on few, if any, early cases. Of the sixteen cases listed, eleven had been treated five years or more before publication, and four of these passed the five year mark living and well. However, his survival statistics were probably headed for a nose ,dive, because of the five patients treated within five years, three had died of cancer and the other two had survived only one year. Daland [27] would probably tell us that these statistics are but little better than those for untreated breast carcinoma. Finally, there were twenty-four major limb amputations. (Table I.) Two of these patients had amputation in 1847, but only one received ether. The record of only two deaths is, of course, excellent for the time, but Parsons believed it could have been better if he had delayed amputation of a leg in one case of trauma. He cautions against surgery before the pulse has stabilized. In addition to his medical school teaching, Parsons had some fifty private pupils in whom he took a great interest over the years. He sometimes taught several at one time, and in the winter he often had private dissecting classes. Parsons was a man of many interests. He worked with the fledgling American Medical Association from its start in 1847 and was Vice President in 1851. He became the leading scholar of his time in local Indian archeology and wrote a lengthy biography of Sir William Pepperrell, the leader in 1745 of the attack on Louisberg. In 1851, when Parsons was President of the Providence Medical Association, he called for the establishment of a general hospital in the city. A committee was formed with Parsons as chairman and attempts were made to raise money. Nothing came of it at that time, but from this beginning, the Rhode Island Hospital emerged. On October 1, 1868, Parsons, then in his eighty-first year and feeble and infirm, was on the platform for the opening exercises. Nine days later he attended the first major surgical procedure in the institution. Death came less than three months thereafter [24].
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Usher Parsons’ active surgical life ended shortly after the discovery of anesthesia. On this subject, his physician son states, “He never became so fully at home with it as the later generation of surgeons. In the greater part of his operations, the only anesthetics at his command were such as laudanum and brandy, and the words of encouragement and sympathy.” With this reminder of great things ahead comes the logical ending of this discourse. A few conclusions can be drawn. First of all, not much surgery was performed and what there was seems pretty crude in our eyes. Secondly, there were no surgeons as we know them. There were general practitioners, with an inclination towards surgery, who established reputations in their field and often did most of the operating for miles. Surgery rarely, if ever, constituted the bulk of their practice. Finallv. the entire medical profession was improving its lot, although with glacial slowness. There was gradual progress in medical education. Although quackery abounded, physicians began to police themselves through their own medical societies. They projected hospitals, even if Rhode Island’s dream of such an institution had to wait until 1868. Thus, the stage was set for the phenomenal advances of the anesthesia era. We are today in their debt for their courage and tenacity in difficult times. Acknowledgment: I wish to thank Helen DeJong, Librarian of the Rhode Island Medical Society Library, for her encouragement and assistance in the preparation of this paper.
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4. Nelson W: The Hero of Aquidneck. A Life of Dr. John Clarke. Bloomfield, New Jersey; Schafer, 1954. 5. Bicknell TW: The Story of Dr. John Clarke. Providence, The Author, 1915. 6. Hedges JB: The Browns of Providence Plantations. Volume 1. The Colonial Years. Providence, Brown University, 1968. 7. Senter I: The Journal of on a Secret Expedition Against Quebec, Under the Command of Colonel Benedict Arnold, in September 1775. Philadelphia, Historical Society of Pennsylvania, 1846. 8. Senter I: Collected Papers. In the Rhode Island Historical Society Library, Providence, Rhode Island. 9. E&edge JH: Early medical history of Kent County, Rhode Island. Rl Med J23: 135, 1940. 10. Obituary of Dr. Nathaniel Miller. Med Communicat Mass M Sot 8: 171. 1854. 11. Medical literature in Rhode Island. Editorial. Boston M lntellig 2: 38. 1824. 12. Goldowsky SJ: The beginnings of medical education in Rhode Island. RI Med J 38: 498, 1955. 13. Parsons U, Ray I, Collins GL: Medical education in Rhode Island. Communicat RI M Sot 1: 55, 1877. 14. Casey TB, Kelly EF. DiMaio M. Myrick JC: Medical licensure in Rhode Island. A review of the history RI bled J 45: 625, 1962. 15. Goldowsky SJ: The Rhode Island Medical Society. I. The first fifty years: 1812-1862, p 3. The History of. the Rhode Island Medical Society and Its Component Societies, 1812-1962. East Providence, Roger Williams, 1966. 16. Lewis RV: Personal communication and unpublished manuscript. 17. Swett PP: Notes on the history of orthopedic surgery in Connecticut. Part 2. Conn Med 10: 206, 1946. 18. Comstock J: On the study of living anatomy. Boston M & S J 49: 500, 1854. 19. Comstock J: The study of living anatomy. Reply to Dr. King. BostonM&SJ50:61, 1854. 20. King D: Hereditary skill in bone-setting. Boston M & S J 50: 12, 1854. 21. Kino D: Medical science and the natural bone-setters. Bos& M & S J 50: 77, 1854. 22. Chapin CV: Epidemics and medical institutions, chapt 1. State of Rhode Island and Providence Plantations, A History, vol 2 (Field E, ed). Boston, Mason, 1902. 23. Bowen WC: Case of fungus haematodes amputated at the articulationof theshoulder. NEnglJM& S3: 313, 1814. 24. Parsons CW: Memoir of Usher Parsons, M.D., of Providence, R.I. Providence, Hammond, Angell. 1870. 25. Parsons U: Surgical account of the naval battle on Lake Erie, on the 10th of September 1813. N Engl J M & S 7: 313, 1818. 26. Parsons U: Statistics of large surgical operations. Am J M SC n.s. 15: 359, 1848. 27. Daland EM: Untreated cancer of the breast. Surg Gynecol Obstet 44: 264 1927.
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