SURGERY and SURGEONS in 18TH-CENTURY LONDON Sir Clifford

Home , Percivall Pott, Samuel Sharp (surgeon), William Cheselden, William Hewson (surgeon)

SURGERY AND SURGEONS IN 18TH-CENTURY LONDON Thomas Vicary Lecture delivered at the Royal College of Surgeons of England on 26th October 1967 by Sir Clifford Naunton Morgan, M.S., F.R.C.S., F.R.C.O.G., Hon. F.A.C.S. Honorary Consulting Surgeon, St. Bartholomew's, St. Mark's and Royal Masonic Hospitals, and King Edward VII Hospital for Officers

THE ENDOWMENT OF the annual Vicary Lecture by the Worshipful Com- pany of Barbers of the City of London in 1919 has reforged the link, broken in 1745, between this ancient Guild and the Royal College of Surgeons of England. In November last, the foundation stone of the new Barber-Surgeons' Hall-to replace that destroyed by bombing during the last World War (Fig. 1)-was laid by the Lord Mayor of London, Sir Lionel Denny, past- Master of the Barbers' Company. The Barbers are looking forward to the day when Surgeons and Barbers may once again dine together in the Barber-Surgeons' Hall. The hand of Providence would appear to bless the friendship between the Company and the College for, though at the dissolution of the Barber- Surgeons' Company the famous Holbein painting of the granting of the Royal Charter to the Barber-Surgeons' Company remained with the Barbers, it has now been revealed that the painting bought by the Surgeons in 1786 was, in fact, Holbein's original cartoon (Cohen, 1967). The Bar- bers and the Surgeons thus share the hallmarks of the great master and each painting is a part of the other. Furthermore, the painting and the cartoon, which were sent separately out of London for safety during the last war, were found quite fortuitously side by side in Wales, the country of Henry Tudor. In this lecture, which encompasses the last decades of the Barber- Surgeons' Company and the new Corporation of Surgeons, I will endeavour to recall, against a backcloth of 18th-century London, a few of those surgeons who, either by their foresight, writings, surgical skill or research, blazed the trail to modern surgery. The Royal Charter granted to the Company in 1540 by Henry VIII was followed by those of succeeding monarchs. These later Royal Charters, including that of Charles I, which required a Court ofExaminers, endeavoured to enhance the standard of surgical education and encourage advances in the art, as is shown by the granting of the Freedom of the Company, without the usual fine, to John Douglas in 1723 for his new method of cutting for stone. The Surgeons within the Company were enabled to improve surgical training by the selection of better educated apprentices bound for seven 1 SIR CLIFFORD NAUN rON MORGAN years to Master Surgeons, and the teaching of anatomy which, by anatomical dissection and operation on contralateral structures, became applied to surgical procedures. However, the name " Barber-Surgeon " led to confusion, dishonesty and corruption, exacerbated by the Bishop of London's right to grant a licence to practise. Quacks and untrained surgeons grew in number, in spite of many appeals by the Company to Parliament for increased power of control of surgical practice.

Fig. 1. Barber-Surgeons' Hall in Monkwell Street (destroyed during the bombing in 1940). The Surgical Treatises of Richard Wiseman (Fig. 2a)-Master of the Barber-Surgeons in 1665 and Sergeant-Surgeon to Charles Il-record the standard of surgery during the last decades of the 17th century. Published in 1676, this text-book, the best then written, remained popular for over a hundred years and was praised by Percivall Pott. Wiseman practised during the twilight period between Elizabethan surgery and the dawn of scientific surgery in the latter half of the 18th century. He served in the Dutch Navy, in the Royalist Forces in the Civil War and, after Cromwell's victory, in the Spanish Navy, returning to England after the Restoration. In his book he mentioned that the cautery and caustics frequently had to be used as alternative treatment, because many patients abhorred the knife and thus sought the aid of quacks. 2 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON Wiseman's writings reveal his skill and reasoning, as exemplified in the treatment of suffocation in a child during tonsillectomy, performed by the use of the snare and probe scissors, preceded by the application of a caustics Temporary post-operative regurgitation of fluid through the nose, he noted, was due to injury of the palate by the snare. Although the anatomy and aetiology of the types of haemorrhoids were described, treatment was non-operative and external applications were used, including "the fur of a hare" and suppositories. Degree of rectal

Fig. 2. (a) Richard Wiseman (1622-1676). (b) Charles Bernard (1650-1711). prolapse following operations for bladder stone or childbirth depended upon the extent of injury to the musculature, and for its control he resorted to " a couple of sticks, whittled and placed near the anal orifice ". He reported 10 successful operations for anal fistula and stated that some such cases were inoperable. Cancer of the rectum was diagnosed by its appearance and palpation, but treatment by cauterisation resulted in a painful death. The importance of correct fitting of a truss and the need for continuous satisfactory positioning, especially in children, was emphasized. The dissolute behaviour of the Court provided him with much experience in the treatment of gonorrhoea, but the cause of urethral stricture was not known. 3 SIR CLIFFORD NAUNTON MORGAN Erysipelas and ulceration of the scalp occurred in gentlemen of the period, who paid great attention to their coiffure, including the practice of boiling of the hair! Though he believed in the " magic of the Royal Touch " for scrofula, when the " Touch " was not available surgical operation could help. Lymphadenitis was the commonest manifestation of tuberculosis, which he stated also attacked bone, tendons and membranous structures, but not the nervous system. The differential diagnosis between inflammation and cancer of the breast was stressed and amputation for the latter recommended. D'Arcy Power refers to him as honest and independent, being one of the first consulting surgeons, since he practised in close association with a physician and only accepted patients who were referred to him by a doctor. Wiseman's text-book and Code of Practice undoubtedly did much to enhance the status of the surgeon. The growing number and influence of surgeons, the recognition by the College of Physicians in 1664 that surgical treatment was necessary in trauma and for certain diseases, and the irksome, expensive and frustrating traditional civic duties in the Livery Company caused increasing unrest among the Surgeons. Furthermore, they considered their union with the Barbers a handicap to progress, but repeated petitions to Parliament for separation were un- successful. The increasing competition in the training of surgeons by the two City Hospitals, St. Bartholomew's and St. Thomas's, is recorded in the Minutes of the Barber-Surgeons' Company in 1695. The surgeons of St. Thomas's Hospital were accused of " breeding so many illiterate and unskilled pretenders to surgery'" and of qualifying any person, however unfit, after only six or 12 months' apprenticeship. In 1702 the Governors of St. Thomas's ruled that a surgeon could not take more than three " cubs " at a time and for not less than one year. The surgeons then agreed not to accept apprentices without three references from reliable persons, such references to be sent to the Barber-Surgeons' Company. However, practice in the City of London, or within a radius of seven miles, was only permitted after admission to the Freedom ofthe Barber-Surgeons' Company. As the result of the foundation of more hospitals in London during the first half of the 18th century, the old apprenticeship system within the Barber-Surgeons' Company diminished, since the more ambitious trainees favoured attachment to hospital surgeons, for not only were there more opportunities for gaining experience, but also a better chance of a hospital appointment. It was the custom of the Governors and members of the staff and sometimes patients of the two City hospitals to march in procession to church 4 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON at Easter-tide, the surgeons walking in front of the Governors. The behaviour of some surgeons was uninhibited, rough, ungentlemanly and dishonest. On one such solemn occasion, Mr. Felton, Senior Surgeon at St. Thomas's Hospital, finding his junior, Mr. Ridout, placed in front of him, proceeded to assault and beat his colleague. Four years later, in 1703, Mr. Felton, together with the Senior Physician, was dismissed for embezzling fees paid for the treatment of seamen wounded in the War of the Spanish Succession. PREStNT STATE

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(a) (b) Fig. 3. (a) The anonymous letter to Charles Bernard. (b) Sanitation in 18th- century London. An anonymous letter (published in 1703) to Charles Bernard (Fig. 3a), Master of the Barber-Surgeons' Company, entitled The Present State of Chirurgerie with some Short Remarks on the Abuses committed, records the sorry state of surgical practice at the beginning of the 18th century. The author appealed to the Company to provide better care of Her Majesty's subjects and quoted examples of unskilled practice which could be verified by patients occupying beds in the City Hospitals, so preventing the admission of the needy. He wrote, "A cheat in physick or chirurgerie is so very facile and so difficult to discover. Chirurgerie has somewhat of a disadvantage, whereas in physick very often an abuse is never detected." The letter also stated that a Bishop's licence could be purchased and that counterfeit licences were available. Amongst the examples of mal- 5 SIR CLIFFORD NAUNTON MORGAN practice mentioned were " the purchase of aloes unfit for horses " by a prosperous and fashionable doctor, and a surgeon calling himself " the unborn doctor ", who specialized in amputation of the breast for cancer. He claimed cures by referring new patients to those whose breast he had removed and " cured ", many for innocent tumours or chronic mastitis. " The number of breasts cut off by this man is scarce to be believed." The writer reminded Bernard of his statement that he had never yet seen a cure of the disease and that rapid dissemination followed operation. Bernard was probably the first English surgeon to make this observation. Charles Bernard (Fig. 2b) was elected Assistant Surgeon to St. Bartholo- mew's Hospital in 1683 by Royal Command, a system which was abolished the following year, his salary being £40 per annum. The most prominent surgeon of his time in London, he became Sergeant-Surgeon to Queen Anne soon after her Coronation in 1702. He was instrumental in per- suading the Queen to remit a large sum, nearly £1,000, for which the Company was bound to the Royal Exchequer, and also succeeded in obtaining the dismissal of the Sheriff of London for failing to deliver bodies of criminals for dissection. In the early 18th century some surgeons, often unattached to hospitals, were skilled lithotomists and, in the main, general surgeons usually declined to perform this operation because the operative mortality and morbidity were high. It is noteworthy that Charles Bernard, within a few years of taking up the appointment of lithotomist at St. Bartholomew's Hospital, relinquished the post, even though he was a surgeon renowned for his skill. He was a famous bibliophile and his magnificent library was mentioned by his friend Jonathan Swift in the Journal to Stella, yet he left no published professional works. Bernard was one of the first well-read and scholarly surgeons and, possibly following his example, the 18th-century surgeons became more cultured, both in professional matters and also in social behaviour. ANATOMY The difficulties in procuring bodies in the latter part of the 17th century continued into the next century. The scarcity of public bodies for dissection at Barber-Surgeons' Hall was reported by Charles Bernard in the Minutes of the Company in 1706, together with the difficulty of appointing teachers of anatomy, since many of the surgeons of the Company declined the office. Private schools for dissection and tuition were established and the trade of the resurrectionists flourished. Even the body of a beggar, found dead from choking with bread outside St. Thomas's Hospital, was carried into the Hospital by a passing stranger, who obtained a good price for " his brother's body ". Cheselden in 1714 was reprimanded by the Company for dissecting privately, and was cautioned on merely promising not to give anatomical 6 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON lectures at the same time as those being held at the Barbers' Hall. The reprimand undoubtedly stimulated Cheselden to increase his efforts for a break with the Barbers. A gruesome incident recorded in the Minutes of the Barber-Surgeons' Company in 1740 caused much consternation in Barber-Surgeons' Hall. The body of Duell, a youth aged 16, hanged for rape, came to life when laid out for dissection (Fig. 4). He fully recovered within two hours following blood-letting and the administration of warm wine. Constantly glancing around the theatre in terror, he muttered repeatedly, " Don't, don't, don't ". He was returned to Newgate Prison, reprieved and trans- ported, and it was said that later, changing his name to Deverell, he became a prosperous merchant and presented a gilded leather screen to the Company for saving his life. NEWSt ion o srom th es i

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Fig.toimroe4. Pamphlette artandanddrawingscecpublishedof sugeyin 1740it isdepictingneesrrefytotathe incident of Duell's revival. Following the separation of the Surgeons from the Barbers in 1745, there was less public objection to dissection and mor e total popuavailable at Surgeons' Hall, the hospitals and private schools, such as the Hunters'. SOCIAL CONDITIONS In order to appreciate the brave attempts of the surgeons of the period to improve the art and science of surgery, it is necessary briefly to portray the conditions of 18th-century London. The population of London in the mid-18th century was approximately three-quarters of a million, about one-tenth of the total population of England and Wales. The highways were poor, pavements non-existent and filth abounded. Travel was difficult and a coach to Edinburgh took from 10 to 21 days, though a horseman by forced riding accomplished this distance in 73 hours. SIR CLIFFORD NAUNTON MORGAN Wesley, the travelling Evangelist, sometimes covered as many as 60 miles a day on horseback. The noise of horse traffic on cobbled roads, the bellowing hawkers, the poorly lighted streets-in spite of the linkmen- and the gloom of the candle-lit homes and hostelries all added to the dis- comfort of a bustling city. The conditions were appalling: malnutrition was common though food was comparatively cheap and plentiful, overcrowding, child-labour, prostitutes, unruly mobs and all kinds of crime and cruelty thrived tLeFanu, 1957). The overall mortality rate was high, the five-year infant .... .4';:Kl; "! ..o

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Fig. 5. Hogarth's caricature entitled " Gin Lane ". mortality rate being 50 per cent. Londoners were aware of the danger of contagion, probably as the result of the outbreaks of plague in the previous century. When buying a piece of meat at the butcher's, the purchaser lifted off the meat with her own hands and deposited the money in a bowl of vinegar. Sanitation was primitive (Fig. 3b), and epidemics of smallpox and typhus took their toll. The marshy ground west of Tot- tenham Court Road and elsewhere resulted in much malaria until the City spread westwards to land leased by lordly landowners, such as Burlington, Cavendish and Grosvenor. The wealthy, in the main, were very rich, over-ate and were intemperate, and immorality was rife. The annual consumption of cheap and potent spirits in the first half of the century was 7,000,000 gallons, and in spite of legislation the death-rate 8 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON from alcoholism was nearly 10,000 per annum. Hogarth's " Gin Lane" (Fig. 5) and Sir Charles Hanbury's verse- "Riot and slaughter once again Shall their career begin: And ev'ry parish sucking babe Again be nursed with gin" drew attention to the scourge. Finally, in 1751, a new Act, which controlled illicit sales and increased the price, reduced the consumption to about two million gallons. At the beginning of the century the only hospitals in London offering medical and surgical treatment were St. Bartholomew's and St. Thomas's. In addition, however, there were Bedlam, Bridewell, and the Royal Hospital, Chelsea. The public began gradually to realize its duty to the sick and poor. Their unhappy state prompted the great Quaker philan- thropist, John Bellers (1645-1725) to write an essay entitled " Towards the Improvement of Physick in Twelve Proposals ". Amongst these proposals was the erection of hospitals in and near London, special hospitals for the treatment of tuberculosis, smallpox, venereal disease, etc., and for the incurable and the blind. It was advocated that more post- mortems should be done. Post-mortem examinations were uncommon in the 18th century, except by those having museums, such as John Hunter who, on the advice of his brother William, did many post-mortems for Dr. Pringle soon after his arrival in London. Further recommendations included the establishment of medical schools at the Universities of Oxford and Cambridge, State support for hospitals and that teaching bodies, such as the Barber-Surgeons' Company and the College of Physicians, should also be subsidized, an opinion perhaps still held to-day. HOSPITALS The building of hospitals by public subscription commenced at the beginning of the century, first in London, where the old-established hospitals of St. Bartholomew and St. Thomas were not entirely charitable institutions, since certain fees and securities from patients were required before admission. In 1707 Thomas Guy, a Governor of St. Thomas's Hospital, became the first private benefactor to endow hospital buildings, when he paid for three new wards. Guy, who printed Bibles for Oxford University, was one of the more fortunate speculators in the South Sea Bubble. Westminster Infirmary Following Guy's example, the Westminster Charitable Society was established and a few years later founded the Westminster Infirmary in 1719, Cheselden being one of the first surgeons. Guy's Hospital In 1721 Guy obtained permission from his fellow Governors of St. 9 SIR CLIFFORD NAUNTON MORGAN Thomas's Hospital to build nearbyahospital for those incurables for whom there was no accommodation in the parent hospital. Guy's was the first completely new hospital to be built by voluntary subscription and opened its 12 wards, providing 435 beds, in January 1725 (Fig. 6a). Guy's bequest to his hospital of nearly a quarter of a million pounds was a most munifi- cent gift at a time when the value of the pound was almost eight times that of to-day and a family could live on 10 shillings a week.

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(b) Fig. 6. New hospital wards in the 18th century. (ia) Guy's (c. 1725). (b) The Middlesex (end of century). There was complete reciprocity in teaching between the two hospitals in St. Thomas's Street, which became endangered by the quarrels of the surgeons. However, the breach was healed when Benjamin Cowell of St. Thomas's, the main cause of disunity, was forced to resign in 1768. An amicable relationship continued even after a separate medical school was formed at Guy's in 1825. The final rift occurred in 1836, when Guy's students were refused admission to the operating theatre at St. Thomas's. Fighting ensued and a porter was assaulted, the students being charged in the police court and fined. St. Bartholomew's Hospital James Gibbs's plan for the rebuilding of St. Bartholomew's Hospital in four blocks around a square was commenced in 1730, but was not com- 10 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON pleted until 1766, money being provided by a public appeal. Each ward had a Nurse's Room attached and water was pumped to each floor. The daily allowance of beer was three pints per patient and the Hospital brewed its own beer. In 1755 " night watchers " were provided for the wards. The patients paid fees to the nurses of Is. to 6s. 6d. for those patients with venereal disease. The Matron, however, charged no fees, but was given a salary, a house, beer, fuel and candles, and at one period was permitted to retail beer. St. George's Hospital This was founded in 1733 in Lanesborough House and, owing to the poor facilities at the Westminster Infirmary, many of the medical staff became attached to the new hospital but were still permitted to attend the Infirmary. Among specialist appointments were those of Cheselden as lithotomist and Ranby for couching for cataract. The number of patients admitted during the first month was 143, including cases of fracture, tuberculosis, intermittent fever, ulcers, tumours of the breast, bladder stones and gravel, lymphadenitis and many " tumours ", probably pyaemic abscesses following smallpox. The London Hospital John Harrison, a surgeon, and his friends founded the London Hospital in 1740 at a meeting in the Feathers Tavern. The funds available were meagre and the hospital originated in a house leased for £16 a year, the caretaker and his wife being paid £20 annually. When the Hospital was opened, the capital remaining was only ls. From such a beginning has grown London's largest teaching hospital. One of John Harrison's apprentices, and later surgeon to the Hospital, was Henry Thomson, the first to perform the operation of amputation at the hip joint before 1780. Of this operation Percivall Pott said: . . . amputation in the joint of the hip is not an impracticable operation (although i t be a dreadful one) I very well know: I cannot say that I have ever done it, but I have seen it done . . . " The Middlesex Hospital (Fig. 6b) In 1745 the Middlesex Hospital was started with 15 beds " for the sick and lame of Soho ", in two small houses in Windmill Street owned by Mr. Gooch, who became Governor of the Hospital. Nine years later the Middlesex moved to its present site, where a hospital of 64 beds was built and four years later, in 1758, an operating theatre. Funds were raised by Garrick from a charity performance of Much Ado about Nothing and Arne, the composer of Rule, Britannia, offered an oratorio. The Middlesex was the first hospital to designate a ward for cancer patients. This idea of John Howard, surgeon to the Hospital, and of Samuel Whitbread, in 1791, culminated one year later in the foundation of the Cancer Charity for the relief of patients and for controlled clinical 11 SIR CLIFFORD NAUNTON MORGAN cancer research. Patients were to be admitted " for an unlimited time, until relieved by art or released by death ". Charles Bell, the great neurophysiologist, who came to London in 1804, being unacceptable in Edinburgh at this time, was appointed Surgeon to the Middlesex Hospital in 1815, and in the same year visited Brussels to help with the wounded in the Battle of Waterloo. Bell's appointment added much to the prestige of the Hospital. The wards in the new hospitals were in no way attractive and little attention was paid to the creature comforts of the patients. The average cost of food per patient was 4d. a day, which was raised to 6d. towards the end of the century. A full-time bug-catcher was employed at Guy's in 1740 at £40 a year. It was the rule that junior hospital surgeons must inform the senior of any impending operation and request his presence or assistance at all extraordinary operations and further, until 1745, unless a member of the Court of the Barber-Surgeons' Company were on the hospital staff, an examiner of the Company must be consulted in all serious cases. The medical staffs were kept under strict control by the hospital Governors. For example, a surgeon at St. George's Hospital would be fined 5s. for the Poor Box if he arrived later than 8 a.m. in summer or 9 a.m. in winter. BARBER SURGEONS OF THE 18th CENTURY Complete biographies of many of the surgeons of the first half of the century are scarce, since few possessed a University degree and, unlike the physicians, were not recorded in a College Roll. Ambrose Dickins (1687-1747) at the age of 15 was apprenticed for seven years to Charles Bernard in 1702. He married his chief's daughter and succeeded him as Sergeant-Surgeon to Queen Anne at the early age of 23. He testified to the cure of " The King's Evil " by the Royal Touch, a custom which apparently ceased in 1714, four years after his Royal Appointment. He was later Sergeant-Surgeon to George I and George II. He was appointed to the Staff of the Westminster Infirmary in 1721, being a close friend of Claude Amyand, the son of a Huguenot refugee, who was then the principal surgeon. Dickins and Amyand, both past- Masters of the Barber-Surgeons' Company and Sergeant-Surgeons, were two of the six lessees of Lanesborough House and, upon the foundation of St. George's Hospital, were appointed Senior Surgeons to the new Hospital, together with Cheselden. Dickins became a member of the Court of the new Company of Surgeons and also Examiner a few years before his death, but Amyand died as a result of an accident in 1740. Amyand, Sergeant-Surgeon in 1728, will be remembered as one of the first and most ardent advocates of smallpox inoculation. Following trial inoculation of criminals at Newgate and six Charity School children with 12 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON no deaths, he was commanded to inoculate the Princesses Amelia and Caroline, aged 11 and 9, and thus inoculation received Royal approval.

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Fig. 7. (a) John Freke (1688-1756). (b) William Cheselden (1688-1753). (c) Samuel Sharp (17? -1778). (d) William Bromfield (1712-1792). John Freke (Fig. 7a) was elected Assistant Surgeon to St. Bartholomew's Hospital in 1726 and Surgeon three years later. He was the first Curator of the Hospital Museum, which consisted mainly of urinary calculi for public display. Until his appointment, stones were sent to the Counting House, in order to assess fees due to the s-urgeons. In 1727 Freke was 13 SIR CLIFFORD NAUNTON MORGAN appointed Ophthalmic Surgeon and was paid 6s. 8d. for each cataract couched, the standard fee for all major operations. He became the third Master of the new Company of Surgeons in 1747. Apart from being a dextrous surgeon, he was a scientist and scholar and experimented in electricity, and wrote on its influence on man and plants. Henry Fielding, aware of Freke's interest in electricity, refers to him by name in Tom Jones. Freke wrote an essay on The Art ofHealing and noted the need for and the difficulty of removing lymphatic nodes in cancer of the breast. He further advocated early drainage ofempyema and recommended that, after incision of the skin and muscles, the pleura should be burst through with a finger and a cannula inserted. William Cheselden The life of this great surgeon (Fig. 7b) of the first half of the 18th century has been written by Zachary Cope and needs little repetition. He was

Fig. 8. The frontispiece of Cheselden's Osteographia. taught anatomy by the great anatomist William Cowper, and at the age of 15 became apprenticed to Ferne, lithotomist at St. Thomas's Hospital. After the death of William Cowper, Cheselden, a superb anatomist and lithotomist, taught anatomy privately and at St. Thomas's Hospital and thus pioneered private anatomical schools in London. His first text-book on anatomy was written when he was 25 and remained a standard text- book for nearly 100 years. Twenty years later, in 1733, he published his well-known Osteographia (Fig. 8), assisted by Sharp and Belchier, who are sketched on the frontispiece. Both became surgeons at Guy's. Cheselden failed to get on the staff of St. Thomas's Hospital in 1714, when Joseph Paul was appointed, but was elected Assistant Surgeon in 1718 and became full Surgeon one year later. He was also on the staff of the Westminster Infirmary, the new St. George's Hospital, and the Royal Hospital, Chelsea. 14 SURGERY AND SURGEONS IN 1 8TH-CENTURY LONDON After employing the supra-pubic approach for the removal of bladder stone, advocated by Douglas (1719), he published in 1723 a treatise on this method, pointing out amongst its dangers the opening of the peritoneum. He finally abandoned the operation for a modification of the lateral lithotomy of Frere Jacques, which was first performed in England at Bart's by John Bamber, who eventually became a physician. Cheselden performed lithotomy in one minute or less, and in 213 operations lost only 20 patients. He was also a renowned ophthalmologist and in 1729 was the first surgeon to perform an iridotomy for blindness. His contemporaries regarded him above all else as a great anatomist, who was the first English surgeon to write and teach surgical anatomy. Though Sergeant-Surgeon to Queen Caroline, Cheselden, having lost favour, was not summoned during the Queen's fatal illness. One of the last Wardens of the Barber-Surgeons' Company, he became the second Master of the Company of Surgeons, following Ranby. Like many good anatomists, Cheselden was an accomplished draughts- man and took an active part in the design ofthe new Company of Surgeons' Hall and also drew up plans for old Putney Bridge. Popular, gay and kind, he was keen on boxing and became proficient in the art. Among his patients were Isaac Newton and Hans Sloane, and one of his pupils was Thomas Cadwalader from Philadelphia (1728). Cadwalader, who was of Welsh descent, became the first practical anatomist in America, performed the first post-mortem and pioneered inoculation for smallpox. With Benjamin Franklin he was a founder of the first American Hospital in Philadelphia in 1751. Samuel Sharp Samuel Sharp (Fig. 7c) was Cheselden's apprentice at St. Thomas's Hospital in 1724 and also studied surgery in France. He was appointed to Guy's Hospital in 1733, eight years after its opening, and was the first great Guy's surgeon. Sharp realized the need for an English surgical text-book and in 1739 published A Treatise on the Operations of Surgery with Descriptions and Representation of the Instruments used in performing them. In the preface Sharp writes: " There is no treatise of character on that subject written in our language. I believe that this is no great occasion to apologise for this undertaking." An apology is certainly not necessary, as his writings record with simplicity and sincerity the practice, if not the principles, of surgery of the period in much detail. He is respected for his originality and wide experience. It is only possible to give an incomplete precis of the subjects dealt with in this book. He maintained that a probe director should be of silver, so that it could be bent, and also that fine needles were necessary to avoid damage to a tendon. The use of caustics was condemned, as was the inclusion of nerves when an artery is ligatured. 15 SIR CLIFFORD NAUNTON MORGAN Plaster sutures were recommended for superficial wounds, especially on the face, since there was less scarring-just like the modern "micropore" adhesive strips. For the repair of a hare-lip, the edges of the wound should be united by means of two silver pins, bound together with a figure-of-eight wax thread. John Hunter used this method much later for the repair of a double hare-lip. Contused and lacerated wounds, with loss of substance, where there was likely to be an undiscovered foreign body, should not be sutured-just as in the 1914-18 war. An anchor dressing was described and sutured wounds were not to be disturbed. Complete division of a partially divided tendon, in order to aid its suture, was condemned, since flexion or extension of the joint would relax the tendon. Immobiliza- tion of a joint in its correct position would not lead to contracture. He stated that an inguinal hernia must be congenital when there was gut in the tunica vaginalis. The common practice of destruction of the skin by caustics in the treatment of inguinal hernia, to avoid a truss, increased the risk of subsequent strangula- tion. Operation was necessary for strangulated hernia when " milder methods " failed and he warned against rough handling. Good reasons were given for condemning the current practice of reducing the unopened sac into the abdomen at operation. A portion of the wound should be left open in case the bowel sloughed later. If the surgeon were not " steady with the knife", when a finger could not readily enlarge the abdominal ring, a pair of probe-scissors was advocated. Scrotal hernia, unless strangulated, should not be operated upon, for the inconvenience of a large scrotal hernia was better than death. These facts concerning the treatment of hernia differ but little from those expressed by William Lawrence in his Treatise on Hernia, published in 1806, 67 years later. Transillumination with a candle was of value in the differential diagnosis of a hydrocele and he also injected hydroceles with spirits of wine. It was noted that carcinoma of the testicle did not start in the epididymis, but in the body. Ano-rectal abscesses were not uncommon, owing to the amount of fat in this region, and good drainage might avoid a fistula. Retention of the urine should be treated by supra-pubic and not perineal puncture. Sharp considered that the disposition to develop stone was not acquired, but inborn. A detailed account of the anatomical structures divided in lateral perineal lithotomy was given and the risk of severe haemorrhage or damage to the rectum was slight, whilst retention and fistula formation were rare. The technique of drainage of an empyema and tracheotomy was described, and the latter operation considered quite safe. Prognosis of a slowly growing cancer of the breast was better than a fast-growing tumour, amputation being unwise for the latter. Cancer adherent to the deeper structures, or when there were " knots" in the axilla which could not be removed, should not be operated upon. When considering fractures of the skull, he warned against the mistake of confusing a suture line with a fracture and reminds us that Hippocrates made such a mistake. Contra-coup injuries were also recognized and the danger of opening the sagittal sinus with a trephine, which should be conical in shape. In 1746, owing to ill-health, Sharp ceased lecturing Naval surgeons and his lectures were continued by William Hunter, forming the nucleus from which the famous Hunter School developed. Sharp revisited Paris in 1749, and five years later published A Critical Enquiry into the Present State of Surgery, in which he praised the French surgeons and stated that " there has never been a period of time in which any art was more cultivated than surgery has been in the last 30 years". Mention was now made of resection of gangrenous bowel. 16 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON When the ends of intestine are close together they could be anastomosed, as already mentioned in animal experiments by Cheselden in England. The method of anastomosis was the placing of one end of the bowel one-eighth of an inch inside the other, secured by four sutures, one of which fixed the anastomosis to the peritoneum, the wound being left partially open. Surgeons were too precipitate in judging mortified intestine, but when gangrenous the bowel should be left in the abdominal wound and not be returned to the abdomen. In a postscript, Sharp recorded a new French method of control of arterial bleeding by agaric, a preparation of fungus from oak trees, which was used by Faget, who in 1739 was the first surgeon to excise the rectum. Sharp also described the open operation for cataract one year after Daviel in France. Later, in 1773, Warner of Guy's also described this operation in more detail, and thus to Guy's must go the credit for intro- ducing the method into England. Sharp's books were widely read on the Continent and were translated into French, Italian and Spanish. He visited the Continent on several occasions, particularly Italy and France, and wrote two books on Italy. In fact, Dr. Johnson thought " there was a great deal of matter in them ". His writings show that Sharp was broad-minded, observant, wise, honest and undoubtedly a safe surgeon. William Hunter called in Sharp to verify the fact that pus formation could occur without a breach of surface. This was demonstrated by stripping the lymph from the pleural surface of the lung in a case of empyema. John Ranby John Ranby (1703-1773) was granted the Diploma of the Barber- Surgeons' Company as a foreign brother in 1722, having been apprenticed at the age of 12 to Edward Barnard, a foreign brother of the Company. He was Surgeon to the new St. George's Hospital and to the Chelsea Hospital upon Cheselden's resignation in 1752. In spite of his inelegant manners, harsh voice and strong passions, he was appointed to the Household of George 1I and operated upon Queen Caroline. Hervey's Memoirs, when describing the Queen's death, record that Ranby administered purges, blood-letting, blistering and a clyster without success. The Memoirs mention the bitter quarrel, resulting in hatred, between the Prince of Wales and his parents and the cruel dis- regard of a son for his dying mother. The secret of the Queen's umbilical hernia was not divulged by the King to the doctors for three days! Ranby performed the operation, merely incising the integuments over the swelling, since he stated that otherwise the guts would " fall out into the bed ". The Queen exhibited great fortitude during the operation, chaffing Ranby about his wife, and requested that the operation ceased while she laughed, when an assistant holding a candle burnt his wig. The hernia was further incised on succeeding days and on the 9th day (20th November 1737), following the occurrence of a large faecal fistula, the Queen died. Ranby, however, 17 SIR CLIFFORD NAUNTON MORGAN was appointed Sergeant-Surgeon to the King and accompanied him at the Battle of Dettingen (1751), being the last surgeon to accompany a monarch into battle. From notes made on the battlefield, he wrote The Method of Treating Gunshot Wounds and recommended Peruvian bark for suppuration. His great influence at Court and with Parliament played an important part in the foundation of the Company of Surgeons. Ranby was rewarded by being appointed its first Master and was re-elected on two other occasions, though he had never been elected to the Court of the old Company, as he was a foreign brother. THE COMPANY OF SURGEONS In December 1744 the surgical members of the Court of Assistants of the Barber-Surgeons' Company submitted a proposal for separation, and a committee of ten, consisting of an equal number of Barbers and Surgeons, was appointed to report. Ambrose Dickins, Sergeant-Surgeon, and Freke were among the five surgeons nominated, but Cheselden, though a Warden, was not included. In spite of the opposition of the Barbers, the Surgeons petitioned Parliament for separation in January 1745, and Royal Assent was granted within a few months. The Company of Surgeons for the promotion of the Science as well as the Art of Surgery was established, and Surgery as a profession now became fully recognized. The new Company of Surgeons, however, was little more than a mere separation of Surgeons from Barbers. The Company was bound by Bye-laws of the old joint Company, and although new Bye-laws were approved in 1748 they were not printed until 1778. Furthermore, the Surgeons were without their own Hall until 1752. These early difficulties led to financial and administrative troubles, which were not readily overcome, owing to the fact that the surgeons, although good craftsmen, acted like prima donnas and were unbusinesslike. The teaching of anatomy in the new Company on two or three days a week did not flourish, even though the eminent anatomists, Pott and William Hunter, were elected as first Masters of Anatomy in 1753. This was partly due to the excellence of the private schools, especially the Hunters', where classes were held daily, and the difficulty of acquiring teachers, since many of the best teachers, including John Hunter, preferred to pay the necessary fine rather than teach anatomy in the Company's Hall. The control of the Company gradually passed into the hands of the ten members of the Court of Assistants who were Examiners. Examiners, appointed for life, were the most regular attendants at meetings, since examining, and the rule that an Examiner had to be called in for con- sultation by a private surgeon when a patient was dying or an amputation was contemplated, was financially rewarding. The Company of Surgeons became nothing more than an examining body, satisfied that, as long as 18 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON examinations were carried out, teaching could look after itself. Young apprentices were thus compelled to find their own teachers from among the members of the Company, such as Bromfield, Pott, Warner, Hunter, etc. William Bromfield William Bromfield (Fig. 7d), an apprentice of John Ranby, commenced lecturing on anatomy and surgery in 1741 and attracted many students. He was appointed to St. George's Hospital in 1742, through his master's influence with the Prince of Wales. He is best remembered as a Founder of the Lock Hospital for venereal diseases in 1746, to which he became Surgeon. The need for such a hospital was apparent for, in 1748, 100

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.# .&e tedw. A)_1S WOW 0 eS1.e a A 1wengV d* 1. . hw _ 1.5ein to-mt "k .TiaA0--4. do ate ffi-Oa m 6 TO Bits wX, or, i Mr A _ of s c FDOUR W a -seb GENofe,r.117.1 -wpelPLACAS:hUL _-us hemV f L - Aloed. Waod tso pwuhmsetweAoms -0u v.g i.o ,' > * #,^lqO'J tSZ*~ 0< ^ :^zt-.eu8 r, (wsum; /tsi:*vita5,%1CL41e.CK ou i. ow Iw 4m e1 IdI ' ueW55i.-S kWiu"iV,uIAi1t#. mO tof*AP. CROorO a~s' VI 'd.it f|_ mmii wdahut|t,410lw iis hre. MANaSION KOU*IsdAaiLttadksIW uhime_il &a,*erw i*5 5.6 Mass'>X..tum. adL1;tiniu6|,d¢< ,Ytidb Fig. 9. An advertisement in a daily newspaper for Percivall Pott's lectures. married women-many almost naked, penniless and starving-were admitted. Bromfield had many friends in the theatrical world and he re- wrote The City Match, an old comedy of 1639, which was performed in 1755 at Drury Lane to raise funds for the Hospital. He operated upon Handel and the proceeds of the premiere of his patient's " Judas Maccabeus " were donated to the Hospital. His portrait, painted for the Lock Hospital, in 1773, is now at the Royal College of Surgeons. He was appointed to accompany George III's bride, Princess Charlotte of Mecklenburg, to London in 1761 and became Surgeon to the Household. A successful surgeon and Master of the Company in 1769, when Senior Warden in 1768 he was one of John Hunter's examiners. Hunter was his pupil at St. George's in 1754. Bromfield, though dextrous, was arrogant and not very intelligent, and it was thus understandable that he quarrelled with Hunter, who became his colleague at St. George's Hospital. 19 SIR CLIFFORD NAUNTON MORGAN In his main publication, Chirurgical Observations and Cases (1773), he stated that further advances in the art of surgery could be prevented by jealousy, obstinacy and fear of criticism, and that many surgeons were dull and lazy. He condemned bleeding in concussion and for inflammation, and though opium had been contra-indicated in head injuries, he had used Dover's powder successfully, as it relieved spasm and produced sweating. He advocated conservation of the skin, removal of a molar tooth for infection of the maxillary antrum for drainage and lavage, and warned against meddling with a carbuncle. He stated that " hypothesis was of little use until confirmed by experiment and there was need for an impartial investigation of results and methods employed". A keen botanist, he was author of An Account ofEnglish Nightshades.

Fig. 10. (a) Percivall Pott (1713-1788). (b) Joseph Warner (1717-1801). Percivall Pott Percivall Pott (Fig. lOa) was apprenticed to Edward Nourse (1701-1761) at St. Bartholomew's in 1729. Nourse was the last Barber-Surgeon appointed to the Hospital, where he started the first regular course of instruction in anatomy and surgery, and his syllabus of lectures in anatomy was very popular. Pott, who succeeded him in 1745, was the first member of the Company of Surgeons to be so elected. Pott, in a jocular manner, used to tell his students at Bart's that they should always remember they were taught by a Barber-Surgeon! He often arrived at the Hospital in a red coat, sometimes wearing a sword. His writings on many and varied surgical subjects had much influence on the surgery of the latter half of the century, both in England and on the Continent, and his name is still held in great esteem. Scholarly and well-read, he bridged the gap between the Barber-Surgeons and the Surgeons and, during his generation, was an outstanding teacher 20 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON and popular lecturer (Fig. 9). Admission to his lectures was sometimes free or for a small fee. Among his many pupils were John Hunter, Blicke and Abernethy, and his patients included Samuel Johnson and Garrick. Pott, a clinical surgeon, was conservative both in treatment and ideas and critical of surgeons whose ambition was " to beat the clock " when operating. He described amputation as " terrible to bear and horrible to see ". Temperate in an intemperate age, gentlemanly and humble, he avoided the quarrels prevailing among surgeons. Even though there were disagreements with the Hunters regarding priorities, William Hunter wrote, " he treated me for the most part with the language of a gentleman, for which I thank him". A compound fracture-dislocation of the ankle joint, following a fall from his horse at Southwark in 1756-when his old chief, Nourse, saved him from an amputation-stimulated him to write whilst he was incapacitated. His first publication was a treatise on Rupture, followed four years later by Injuries of the Head. Among the causes of injury were " a toss from an ox in Smithfield " and " assault by a mob when trying to rescue a man from the Press Gang ". The history of the latter case, the first " Pott's Puffy Tumour ", is of note, since it demonstrates his clinical and pathological acumen. He observed that there was no external evidence of injury in the unconscious patient, who recovered in an hour, and doubted the presence of intra- cranial damage. On the 12th day the patient had a temperature, com- plained of his head and died five days later. Post-mortem examination revealed an extra-dural abscess. Pott noted the long delay in onset of symptoms and described the stripping of the pericranium, the dead bone and inflamed dura. His keen clinical observation was also shown in his writings on diseases ofthe spine. He noted that the paraplegia associated with deformity might recover spontaneously, especially when an abscess occurred. He, in fact, tried to produce an abscess, not realizing that rest would suffice. The College owns his book on hydrocele written entirely in his beautiful handwriting. Pott played an active part in the Company of Surgeons, and was the first Master of Anatomy with William Hunter, Master of the Company in 1765 and examined John Hunter for his diploma. He remained on the staff of Bart's until one year before his death, aged 75. Many of Pott's statements are very apt and the need for humility among surgeons is expressed by one of them: ' The business of good surgery is to assist Nature, but Nature will sometimes get the better even of the worst." Just before he died, he remarked, " My lamp is almost extinguished, I hope that it has burned for the benefit of others ". 21 SIR CLIFFORD NAUNTON MORGA Joseph Warner Joseph Warner (Fig. lOb), apprenticed to Samuel Sharp at Guy's in 1734, assisted his master as a lecturer in anatomy in 1741 after obtaining his diploma. In 1745 he was appointed to Guy's and volunteered to serve under the Duke of Cumberland in the 1745 Rebellion. Warner held the unique distinction of being a member of all three surgical institutions in London, since he was a Barber-Surgeon, twice Master of the Company of Surgeons in 1755 and 1784, and the first member of the College of Surgeons in 1800. He contributed but little to surgical literature, but his Treatise on Surgery with Remarks gives a good account of contemporary practice in London. He also wrote on the human eye and, as already recorded, was an exponent of the new open operation for cataract. He was the first surgeon to ligate the common carotid artery (1775). John Hunter The life and works of John Hunter (Fig. 11) are so well known that no apology is needed for only brief reference to the Father of the Scientific Principles of Surgery which, until his day, was, in the main, only an Art. John Hunter, a shy and friendly man, was a popular lecturer and teacher who attracted the most able students. He was a prolific writer and a member of many scientific societies. His contemporary renown as a surgeon, although he had a large and fashionable practice, was undoubtedly over- shadowed by the competition of other surgeons, such as Bromfield, Warner, Hawkins and particularly Pott, all of whom were not only long- lived but remained in practice for many years. His surgical prowess was not widely known until the publication of his complete works in 1835 and the preaching of the gospel of experimentation, observation and deduction by his pupils after his death in 1793. The skill and daring of surgeons reached their peak in Hunter's day in operations for the all too common aneurysms. It would appear that operative mortality was less than that for strangulated hernia since the hazard of gangrene could be treated by amputation. The principles of Hunter's operation for popliteal aneurysm (1785) were based upon exact anatomical knowledge of the collateral circulation, and the observation that slowing of the blood stream by partial arterial ob- struction produced obliteration of the aneurysm. This method was practised for nearly 14 centuries. Even after the introduction of anaesthesia and antisepsis, the requisites for safe surgery, until the advent of modern vascular surgical techniques surgeons had reason to remember Hunter for this and for many other discoveries. John Hunter's help was sought when gynaecological and obstetric patients required operation. Two Caesarean sections in London were reported, one in 1771 and the other in 1776 by Dr. William Cooper. The first of these operations was performed by Henry Thomson of the 22 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON London Hospital, in a house in Rose and Crown Court, Shoe Lane, with the assistance of John Hunter, who held the intestines within the abdomen whilst Thomson closed the belly with four quilled sutures. The mother died a few hours following the operation but the baby was born alive. Thomson wrote: " As soon as the child was taken out of the uterus, the air having a free admission to the lungs, it cried as heartily as children commonly ... do when they are born in the natural way ". The child was noted to have a tumour communicating with the meninges and containing a portion of the brain. The writer gave an excellent description of the meningo-encephalocele from which the child died two days later.

Fig. 11. John Hunter (1728-1793). The second operation was upon a case of Dr. William Cooper's, a multiparous woman who had very severe osteomalacia. John Hunter was asked to perform a Caesarean section, which was done in August 1774, " with coolness, humanity and skill ". The mother died but the child survived and was alive at least six months later. In Great Britain the first Caesarean section was performed by Smith of Edinburgh in 1737; both mother and baby died. The first case in which the mother survived was operated upon by an illiterate Irish midwife, Mary Donaly of Tyrone, a year later. Following delivery of a dead baby she realized that she had nothing with which to close the abdomen. She called for tailor's needles and silk which had to be carried a distance of one mile whilst she held the abdominal incision with her hands. 23 SIR CLIFFORD NAUNTON MORGAN In 1793 James Barlow of Blackburn was the first surgeon to perform the operation, following which the mother survived though the baby died. The researches of the Hunters' outstanding co-workers, Hewson and Cruikshank, have tended to be overlooked in the wide range of Hunterian experimentation. William Hewson William Hewson (Fig. 12a) came from Newcastle and studied at St. Thomas's and Guy's, as well as with the Hunters. He impressed William with his capabilities and during the absence of John for two years during the Seven Years' War, Hewson took his place. After a year in Edinburgh he became Hunter's partner. He published an article on Paracentesis of Pneumothorax, including Observations on Wounds of the Lungs. His most important work was the Demonstration ofLymphatics in Fish, Birds and Amphibia and that coagulation of the blood was due to a" coagulable lymph ".

Fig. 12. (a) William Hewson (1739-1774). (b) Benjamin Gooch (d. 1780). His death at the age of 35 from septicaemia cut short what might have been a promising surgical career. William Cruikshank William Cruikshank (Fig. 13) was a Classical Scholar destined for the Church. However, his association with Dr. John Moore of Glasgow made him change to medicine. William Hunter invited him to London to replace Hewson and he proved such an excellent assistant and teacher of anatomy that he was finally invited to become a partner. Although an anatomist and physiologist, he practised as a surgeon, particularly amongst the poor. It was said of him that " His door was never closed against suffering and sorrow ". His nervousness prevented him from becoming an outstanding surgeon, though he had three famous patients, Joshua Reynolds, his neighbour in Leicester Square, Samuel Johnson and Lord Nelson. Johnson described him as " a sweet-blooded man " and during his fatal illness, while Cruikshank was scarifying his oedematous legs, exclaimed, "1I want life, are you afraid of giving pain? Deeper, deeper." X24 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON After his surgeon's departure, the patient seized a lancet and scissors and cut deeply and thus perhaps hastened his death. Cruikshank's greatest work, following Hewson's demonstration of lymphatics in animals, was The Absorbent Vessels of the Human Body. He studied the regeneration of nerves, the impregnated ovum in a rabbit's uterus and the absorption of calomel from the mouth in the treat-

Fig. 13. William Cruikshank (1745-1800). ment of syphilis. He demonstrated insensible water loss from the skin by placing his hand in a sealed jar and also measured the fluid loss from the lungs. Over 150 years later the significance of these latter discoveries has been of great importance in the control of fluid balance. Cruikshank's intemperate life led to his death from apoplexy at the age of 55. In order to bring into sharper focus the state of surgery in London during the latter half of the century, the opinions and impressions of a provincial surgeon and, particularly, students from the American Colonies -which at that time were in the early stages of medical education-are of value. 25 SIR CLIFFORD NAUNTON MORGAN Benjamin Gooch (d. 1780) (Fig. 12b), surgeon to the Shottesham Infirmary and later consulting surgeon to the Norfolk and Norwich Hospital (1771), visited the London Hospitals at the request of the Bishop of Norwich to report on their practice and administration. In 1758 he published a book on Cases and Practical Remarks in Surgery. In the preface, dated 1757, he wrote: " It may be said that Surgery has arrived at such a degree of perfection in Great Britain as leaves no room for France any longer to boast of her supremacy. A journey to Paris is no longer necessary to complete a Surgeon's education." This opinion entirely differs from that of Sharp in his book published a few years previously (1754).

(a) (b) Fig. 14. (a) Thomas Cadwalader (1707-1779). (b) William Shippen (173-1808). Gooch praised the surgeons of London and remarked: " The funda- mentals of surgery are now so well known and established that little seems left to be done." He was of the opinion, however, that the observation and reporting of uncommon cases would, nevertheless, prove of value and recorded, amongst others, a case of burns following fire when a house was struck by a meteor. He also wrote a text-book for young surgeons in 1767. Students from the American Colonies sought the guidance of Benjamin Franklin and his friend, Dr. John Fothergill, a distinguished London physician. Their advice was that London provided the best opportunities to learn the practice of surgery, but they should then proceed to Edinburgh University for lectures and the M.D. examination. Among the American students studying in London at this time was John Jones, who was apprenticed to his uncle, Thomas Cadwalader (Fig. 14a), in Philadelphia. Jones was a pupil of Pott and on his second 26 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON visit to London in 1750 also attended the Hunters' lectures and dissections. He wrote the first surgical text-book in America in 1775 on Plain, Concise, Practical Remarks on the Treatment of Wounds and Fractures, which he described as simply a compilation from Ranby, Pott, Hunter and others. He probably performed the first lithotomy in America. He became the first Professor of Surgery in the New York Medical School (1768) and was one of the first surgeons at the New York Hospital which, though founded by Royal Charter in 1771, was not established until 1779, because the building was used as a barracks by British troops until it was evacuated during the American War of Independence. William Shippen (Fig. 14b), who was apprenticed to his father in Philadelphia, arrived in London in 1758 and spent almost a year at the Hunters' house in Covent Garden. It is very fortunate that young Shippen kept a short diary (July 1759-January 1760), from which one gets a vivid picture of the life of a medical student and the conditions in London. Shippen's day started at 6 a.m. and finished at 10 p.m. Hospitals were visited every day, sometimes including Sundays. In addition, there were lectures and prosections. He writes of a typical day thus: " Rose at 6, operating till 8, breakfast at 9, dissected till 2, dined till 3, dissected till 5, lecture till 7, operated till 9, supper till 10, then bed." He records his pleasure when he sat, sometimes late at night, talking to John Hunter, who had a happy knack of taking students into his con- fidence, stimulating them to observe, enquire and try the experiment. He was quite outspoken regarding some aspects of London life, describing Bartholomew Fair as " vile and ridiculous ", and dancing as having " no proper decorum or regularity ". During his time in London, Britain was at war with France (the Seven Years' War) and the British Empire was founded. He mentions the church bells constantly ringing for British victories. Illuminations to celebrate the Fall of Quebec, about which he was very pleased, did not, in his opinion, compare with those in Philadelphia! He liked visiting Shooters Hill, where he could see beautiful English countryside. He often went to the theatre, where he enjoyed Garrick, particularly in King Lear. Hunter's School, where lectures started at 5 p.m., was near the theatre, where cheap seats were available to those who arrived early. In fact, Hunter had to change the time of his lectures from 5 p.m. to 2 p.m., owing to the competition from the theatre. In addition to his other activities, Shippen attended lectures and practice of Colin Mackenzie, the famous man-midwife, a great friend of the Hunters, who assisted them in their work on the foetal circulation. His diary records seeing Mr. Hunter extract a steatomatous tumour from the upper eyelid and vivisect a dog to study the lacteals and thoracic duct. Of his visit to Bart's, where he saw Pott operating upon an inguinal hernia, he writes: " The neatest operation for bubonocele I ever saw by 27 SIR CLIFFORD NAUNTON MORGAN Mr. Pott, a very clever, neat surgeon ". At Guy's he saw Mr. Warner use hare-lip pins and a figure-of-eight twisted thread to repair a wound of the urethra and, on another occasion, operate on a cancerous breast and lip. He was greatly impressed by Warner's dexterity. At St. George's he wit- nessed Hawkins and Bromfield cut for stone and do an amputation. Among the text-books he favoured were Lewis's Chemistry, Warner's Surgical Cases-which within the first year was in the second edition- Douglas's Treatise on Hydrocele, and Pott's Fistula Lachrymalis. Shippen spent two years in London and one year in Edinburgh, where he obtained an M.D. for his thesis on Attachment of the Placenta to the Uterus. After spending six months in France, he returned to Philadelphia

Fig. 15. John Morgan (1735-1789). in 1762 and started the first lectures on anatomy and obstetrics. He helped John Morgan in the foundation of the new Medical School in Philadelphia in 1765, and was later appointed the first Professor of Anatomy and Surgery. John Morgan (Fig. 15), the son of a poor Welsh family who migrated to Philadelphia, was apprenticed to Dr. Redman, to whom he became ser- vant and general factotum, as well as being a nurse and assistant. At the age of 20 it was necessary for Morgan to earn a living as an apothecary at the hospital. However, he relinquished these appointments in Philadel- phia to join the Frontier Forces fighting the French. He had a chequered military career and refused to obey orders; he was also accused of stealing chickens. He decided to come to Britain in 1760 upon the advice of English surgeons whom he had met in the Forces. Morgan studied with Hunter for one year and, when William decided to cease lecturing, he pleaded on behalf of his fellow-students that he would alter his decision. In a letter to Dr. Hunter he wrote: " A consideration of ye irreparable loss we must have sustained should you intermit lectures at so critical a Junc- 28 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON ture, gave us room to hope you might be prevailed upon, by our Petition, to favor us with a second course." Hunter acceded to the request and was presented with a silver cup by the students. John Morgan spent two years in Edinburgh studying under Dr. Cullen and obtained the M.D. for a thesis on Suppuration and theformation ofPus. He pointed out that pus was formed only in inflamed blood vessels and was always preceded by evidence of inflammation. Sharp, in his book published over 20 years previously, had mentioned this latter fact.

Fig. 16. (a) Philip Syng Physick (1768-1837). (b) John Collins Warren 1778-1856).

Morgan returned to Philadelphia in 1763, having become an M.D., a Licentiate of the College of Physicians, and an F.R.S. He had also acquired French honours. A man offoresight, he wrote four dissertations on The Reciprocal Advantages of the Perpetual Union between Great Britain and the American Colonies. He was a good organizer and chief protagonist in the foundation of the first Medical School in America in 1765, to which he was appointed Professor of Medicine. During the American War of Independence both Morgan and Shippen held high rank in the Medical Services. Unfortunately they became enemies and a charge of malpractice and misconduct in organization of medical supplies was made against Shippen by Morgan. Shippenwas court-martialled and exonerated. Benjamin Rush, who signed the Declaration of Independence, succeeded 29 SIR CLIFFORD NAUNTON MORGAN Morgan on his death in 1789, as Professor of Medicine. Rush wrote in his diary, when he found Morgan dead in a hovel, surrounded by books, " What a change from his former rank and his prospects-a man who once filled half the world with his name, had now scarcely friends enough to bury him." The last American students to be directly influenced by John Hunter were Wright Post of New York and Physick from Philadelphia. Wright Post (1766-1828) spent two years in London from 1784. He introduced vascular surgery-which he had learned from Hunter and, particularly, Astley Cooper-into America. He performed the first successful ligation of the subclavian artery for brachial aneurysm, an operation which Abernethy and Astley Cooper had failed to perfect. Post became the first Professor of Surgery at the new Columbia Uni- versity, New York, in 1792. Philip Syng Physick (Fig. 16a) was regarded by Hunter as his most able student, whom he asked to be his partner. Within a year of arriving in London, Physick was appointed House Surgeon at St. George's Hospital and gained the Diploma of the Company of Surgeons. After visiting Edinburgh he returned to Hunter and helped him in the preparation of specimens and it is likely that Physick prepared some of the specimens still in the Hunterian Museum. Physick and his master were close friends and his regard for Hunter amounted to veneration. Hunter's opinion of his last American student proved correct and Physick became Professor of Surgery at the University of Pennsylvania in 1803 and had a most distinguished career as a surgeon in America, and is rightly called " The Father of American Surgery ". Surgical publications during the latter part of the century were sparse and, apart from articles on special subjects-such as those by Pott, Douglas and others-there had been no recent comprehensive text-book for students until a System of Surgery by Benjamin Bell (1749-1806), Professor of Surgery in Edinburgh, was published in 1782. Bell had a wide reputation as a teacher and his book reveals that the science of surgery had advanced but little since Sharp's book written over 40 years previously. In his preface, Bell wrote " a rage has prevailed during the last 50 years for invention of new instruments . . . " and the object of his book was " to endeavour to divest the Art from all this useless machinery ". He wisely stated that " Success in surgical operations depends more on minute attention to every circumstance relating to them than to any particular dexterity in one part of them ". An incision of adequate length should be made rapidly with one sweep of the knife, since a second incision increased the pain. Thereafter the surgeon should proceed carefully. Pain was lessened by opium and by preliminary com- pression of the nerves supplying the part. 30 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON He considered that " the admission of air to wounds was highly pernicious ". He noted that the inclusion of other tissues in arterial ligation increased the risk of secondary haemorrhage and that amputation did not cure tetanus, which usually occurred during the latter stages of healing of a wound. His opinion regarding the cause and treatment of severe inflammation following blood-letting, however, is surprising, for, though agreeing with Hunter, who had demonstrated inflammation of the vein in horses, Bell was of the opinion that the primary source of the infection was a damaged nerve or tendon. In grave inflammation he recommended division of these structures!

Fig. 17. Apparatus for resuscitation including administration of a clyster (illustration from Savigny's instrument catalogue of 1798). Tobacco and Peruvian bark were extensively used during the 18th century. Tobacco had been known since 1577 as a useful drug for the local treatment of war wounds and severe constipation. Surgeons relied greatly on a tobacco clyster (Fig. 17) in the treatment of ileus and irreducible hernia, probably due both to its syncopal effects and muscular relaxation. Heister considered that its use made operation for irreducible hernia unnecessary. The high operative mortality of strangulated hernia caused surgeons to give a tobacco enema, either by infusion or by tobacco smoke, as a last resort before deciding upon operative treatment. This practice was continued well into the 19th century and William Lawrence in his excellent Treatise on Hernia, published in 1806, mentions 31 SIR CLIFFORD NAUNTON MORGAN its value. Infusion was often preferred, since the apparatus for injecting smoke-a long tube and bellows-was frequently out of order! The Royal Humane Society, of which Hunter was a member, recommended a clyster of tobacco smoke in cases of drowning, though Hunter was cautious in his opinion. The other popular drug was Peruvian bark, introduced into Europe by a Jesuit monk in 1632. Only large irritant doses were effective as an in- testinal stimulant, but in non-toxic doses it controlled fevers and was a useful tonic, especially when administered in red port. THE COLLEGE OF SURGEONS The status of the Company of Surgeons did not improve in spite of the appointment of Professors of Anatomy in 1766 and Professors of Surgery in 1790. Gunning, surgeon to St. George's Hospital (1760), when Master of the Company in 1789, strongly criticized the affairs of the Company and remarked: " Your theatre is without lecturers, your Library without books and is now an office for your Clerk and your Committee Room his Parlour." The Bye-laws were flagrantly disregarded and, following an illegal Court held in 1796, when William Cooper was Master and Cline was elected to the Court, the Company was dissolved and ceased to have any power in November 1797. A petition was presented to Parliament for the formation of a College of Surgeons, but was lost, due mainly to the opposition of Lord Thurloe in the Lords. At the hearing Lord Thurloe remarked: " There is no more science in surgery than in butchery." To which Gunning replied that he should allow a butcher to set his broken leg and then he would soon learn the difference. Following the rejection of the Bill, meetings took place between the Court of Assistants and a Committee of opposing surgeons, and agree- ment was reached regarding the structure of a new College. An application to the King for a Charter was made and granted on 22nd March 1800. James Earle, surgeon to St. Bartholomew's, was probably instrumental in obtaining the prefix " Royal " from George III. He was Pott's son-in-law and Master of the College in 1807. John Abernethy and Astley Cooper At the turn of the century, the two outstanding surgeons in London were Abernethy and Astley Cooper (Fig. 18), both pupils and champions of John Hunter. The biographies of Astley Cooper and Abernethy, by Lord Brock and John Thornton respectively, require no amplification. John Abernethy, a rude and somewhat eccentric Northern Irish Scot, a friend of Edward Jenner, was appointed Surgeon to Bart's in 1787 on Pott's retirement. He was a student of Pott and Blicke at the Hospital and of Blizard at the London Hospital. Blizard, who saw patients at 32 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON Batson's Coffee House in Cornhill, was probably the last surgeon to adopt this accepted mode of practice. Both Abernethy and Blizard were scrupulous in their teaching duties and care of hospital patients. Though worshipped by his students for his kindly understanding and instruction, Abernethy's brusque manner made him unpopular with patients, but he treated rich and poor alike. He often stood with his hands in his breeches pockets, even when addressing Royalty. On such an occasion the Duke of York asked him did he know to whom he was speaking? His reply was: "Suppose I do-what of that?" His advice

Fig. 18. (a) John Abernethy (1764-1831). (b) Astley Cooper (1768-1841). to the over-indulgent Duke was " cut off the supplies, as Wellington did, and the enemy will leave the citadel ". The nursing staff was not immune to his manners. It is related that he suspected that one of the ward sisters was an alcoholic. One day, meeting this somewhat corpulent Bart's ward sister in the Square, he remarked, poking her midriff with his cane, " If that is not a bottle of gin, Ma'am, I'T beg your pardon ". It is said there was a noise of broken glass and the smell of gin soaking her frock! Abernethy disliked operating and was usually sick before an operation, yet he was the first surgeon to tie the external iliac artery for aneurysm. He also attempted the classification of malignant tumours. The first regular medical school in London was founded by Blizard and Dr. Maclaurin at the London Hospital in 1785. This was followed by Bart's in 17911, when Abernethy requested the building of a surgeons' 33 SIR CLIFFORD NAUNTON MORGAN theatre. Schools were established at the united hospitals, St. Thomas's and Guy's, soon afterwards. The first anatomical school at a hospital was started at St. Thomas's. John Collins Warren (Fig. 16b) was the last American student in London in the 18th century. His letters to his father, recorded in Edward Churchill's book To Work in the Vineyard of Surgery, portrayed the life and fashion of London and Londoners, and something of the surgeons. He wrote that " there is no necessity for acting as though the people were all cheats and thieves " and stated that " money will glide from you, if not prudent ". He told his father that he could " accommodate himself to English manners better than he could to English weather ". In 1799 Collins Warren became a dresser at Guy's to William Cooper, who was a kindly man, though a stern disciplinarian, who enjoyed teaching but was not a good surgeon. When a terrified patient, whose leg he was about to amputate, fled from the room, he said: " By God, I am glad he is gone! " His nephew, Astley Cooper, said of him: " My uncle is a man of great feeling, too much so to be a surgeon." He did not like or under- stand Hunter and admitted he slept at his lectures. William Cooper had no respect for the Americans, since they had seceded from the British Empire before maturity! Astley Cooper was first apprenticed to his uncle William at Guy's but requested to be transferred to Cline at St. Thomas's. Cline, who adored Hunter, had much influence on Astley Cooper and undoubtedly encour- aged him to attend John Hunter's lectures. Cline thought well of his pupil and invited Astley Cooper to give some of his lectures in 1791. Abernethy's lectures at Bart's commenced at 7 p.m., and those of Astley Cooper at 8 p.m., and students who wished to attend both shared a cab and hastened across London Bridge to be at Guy's on time. When Astley Cooper was appointed to the staff of Guy's in 1800, Warren worked under him and described his teacher as " a young man with the greatest natural ability and almost adored at the hospitals ". He mentioned Astley Cooper's advice: " Let Nature alone, she will open that abscess better than you can." It was only after watching Astley Cooper, and particularly Cline, "Whose operations for aneurysm and hernia were grand ", at work, that he wrote to his father and confirmed the fact that he wished to become a surgeon, since now he had " experienced the pleasure ", whereas before " only the difficulties of an operation. The surgeons trust no theory, but experiment is the only creed." He returned to Boston in 1802 and became a Founder of the Massa- chusetts General Hospital and, as Senior Surgeon in 1846, operated upon the first patient anaesthetized with sulphuric ether administered by Morton for removal of a tumour of the jaw. The Warren Museum, founded by 34 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON him at Harvard, was based on Hunterian philosophy passed to him through Astley Cooper. Abernethy became President of the Royal College of Surgeons of England in 1826 and Astley Cooper in 1827 and 1836. They both, particularly Abernethy, had to contend with the rebel members, led by Wakley, Editor of the Lancet, and a co-editor, William Lawrence, Abernethy's pupil and Surgeon at Bart's, who accused the College of being a " closed shop ". When he was elected to the Council, William Lawrence became more docile and paid tribute posthumously to his old chief, Abernethy. Neither Lawrence nor Blizard favoured early retirement. Lawrence died of a stroke at the age of 87, whilst ascending the main College staircase on his way to examine, and Blizard was still on the Court of Examiners when he died aged 92! Until the anatomizing of bodies of criminals ended following the Anatomy Act of 1834, the P.R.C.S. had the unsavoury duty of receiving bodies for dissection. The College hired a house in Cock Lane, near Newgate, for this purpose. Richard Owen, a pupil of Abernethy, lecturer in Comparative Anatomy at St. Bartholomew's and later Conservator of the Hunterian Museum, because he required fresh eyes for anatomical research, was given permission to be present when bodies were delivered to the President, Sir William Blizard. The President, arrayed in full Court Dress, awaited the bodies on the first floor. Sir Norman Moore, who died in 1922, relates in his History of St. Bartholomew's Hospital Owen's description of the ghastly scene. Owen recalled with distaste the shouts of the crowd below, the rumbling of the cart and the heavy tramp of the hangman on the stairs. The executioner, coarsely dressed, entered with a body on his back which he let fall with a thud upon a table. The President made a small incision over the sternum and bowed to the hangman. The 18th and latter part of the 17th centuries produced a galaxy of immortal stars in the Arts, pioneers such as Captain Cook and Joseph Banks-and scientists, including Newton, Linnaeus, Watt. etc. A microscope which magnified 40/160 times was used by Leeuwenhoek (1632-1723), who first saw bacteria, and by Robert Hooke (1635-1705), who was Boyle's assistant. A London doctor, Nehemiah Grew (1664- 1712), led the way to the study of cytology by his microscopic research into the structure of plants, whilst Stephen Hales (1677-1761), an English country parson, through his work on the nutritional mechanism in plants, instigated the study of haemo-dynamics. During the 18th century, medical scientists appeared to have disregarded the microscope, and John Hunter rarely used it. He stated that false appearances were produced by distortion. Hewson, however, was a microscopist and his slides are in the Hunterian Museum. 35 SIR CLIFFORD NAUNTON MORGAN Towards the end of the century the old phlogiston theory was disproved by Black's discovery of carbon dioxide and, together with Priestley and Lavoisier, the composition of air and respiratory exchange were unfolded. The scientists of the 18th century were, in the main, content to consoli- date and classify new knowledge, though the science of electricity was greatly advanced, and pathology and morbid anatomy were just beginning. The individualistic attitude of the majority of surgeons resulted in petty quarrels, an unhappy and stagnant Company of Surgeons and tardy publication and correlation of discoveries, due both to the lack of team- work and the paucity of Medical Societies. The art of surgery, however, was consolidated and advanced by careful clinical observation, specializa- tion and superb manual skill under poor conditions, without anaesthesia and knowledge of the aetiology of infection. A few surgeons, such as the Hunters and their co-workers, Hewson and Cruikshank, were cognizant of the scientific approach to surgery, a concept which did not flourish until the 19th century, when discoveries made over a century before were exploited. John Hunter's pupils, Abernethy and Astley Cooper, together with Charles Bell from Edinburgh, were placed on the threshold of the development of modern surgery. Percivall Pott, whose contributions to surgery were based mainly on pathology, made a remark over 200 years ago which is still true to-day, when surgeons are probing many problems, such as those of organ and skeletal transplantation and of malignant disease: " Many and great are the improvements which the Chirurgical Art has received in the last 50 years; and many thanks are due to those who contributed to them; but when we reflect how much still remains to be done, it should rather excite our industry than inflame our vanity." For nearly 200 years the Barber-Surgeons' Company of the City of London, during a period when there were no facilities in English Univer- sities for medical training and only a few in hospitals, in spite of many difficulties and obstructions-episcopal and otherwise strove to raise the standard of the Craft and Art of Surgery. The Royal College of Surgeons of England appreciates the debt owed to the Barber-Surgeons' Company and cherishes our ancient association.

ACKNOWLEDGEMENTS I wish to acknowledge my thanks to many who have assisted me in the preparation of this lecture, particularly Miss Jessie Dobson, Mr. W. R. LeFanu, and the staff of the Library of the Royal College of Surgeons of England, Mr. E. Gaskell of the Wellcome Historical Medical Library, and Mr. J. L. Thornton, Librarian at St. Bartholomew's Hospital. I also thank the Departments of Medical Illustration of the Royal College of 36 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON Surgeons, St. Bartholomew's and St. Mark's Hospitals; together with my colleague Mr. Henry Thompson; my secretary, Mrs. Parry Richards; and Miss Mary Marks. Figures 2 (b), 3 (b), 5 and 6 (a) have been reproduced from the Wellcome Historical Medical Museum and Library by courtesy of the Wellcome Trustees; Figure 3 (a) by courtesy of the Trustees of the British Museum; Figures 7 (a) and 9 by courtesy of St. Bartholomew's Hospital, and Figure 12 by courtesy of the Norfolk and Norwich Hospital.

SELECTED REFERENCES BARLOW, J. (1798) Medical Records and Researches. London, Cox and Johnson. Page 154. BELL, W. J., Jnr. (1965) John Morgan. Philadelphia, Univ. Pennsylvania Press. BLOMFIELD, J. (1933) St. George's 1733-1933. London, Medici Society. BROMFIELD, W. (1773) Chirurgical Observations and Cases. 2 vols. London, Cadell. COHEN, B. (1967) Ann. Roy. Coll. Surg. Engl. 40, 179. COOPER, W. (1771) Medical Observations, and Inquiries, 4, 261. - (1776) Medical Observations and Inquiries, 5, 217. CORNER, B. C. (1951) William Shippen, Jnr. Philadelphia, American Philosophical Society. DICTIONARY OF NATIONAL BIOGRAPHY (1880-1900) Various memoirs. GOOCH, B. (1758) Cases and Practical Remarks in Surgery. London, Wilson and Durham. HEISTER, L. (1768) A General System of Surgery, translated. 8th edit. London, J. Whiston. LEFANU, W. R. (1957) Ann. Roy. Coll. Surg. Engl. 21, 390. MCINNES, E. M. (1963) St. Thomas's Hospital. London, Allen and Unwin. MOORE, N. (1918) The History of St. Bartholomew's Hospital. 2 vols. London, Pearson. PEACHEY, G. C. (1910) The History of St. George's Hospital. London: Bale, Sons and Danielsson. POOL, E. H., and McGOWAN, F. J. (1929) Surgery at the New York Hospital one hundred years ago. New York, Hoeber. Ricci, J. V. (1949) The Development of Gynaecological Surgery and Instruments. Philadelphia, Blakiston. ROBINSON. R. H. 0. B. (1949) Brit. J. Urol. 21, 47. SHARP, S. (1739) Treatise on the Operations of Surgery. London, Watts. STEWART, D. (1742) Medical Essays and Observations, 5, 439. THOMSON, H. (1771) Medical Observations and Inquiries, 4, 272. THOMSON, J. (1816) Report of Observations made in the British Military Hospitals in Belgium, after the Battle of Waterloo; with some remarks upon amputation. Edinburgh, Blackwood. Page 264. WILKS, S., and BETTANY, G. T. (1892) A Biographical History ofGuy's Hospital. London: Ward, Lock, Bowden. YOUNG, S. (1890) Annals of the Barber-Surgeons. London: Blades, East and Blades.

SYMPOSIUM: PRE- AND POST-OPERATIVE MANAGEMENT THE FOURTH IN the series of week-end symposia on specialized topics will be held in the College on 27th and 28th January, when the subject will be " Pre- and Post-Operative Management ". Full details and application forms may be obtained from the Secretary, Royal College of Surgeons of England. The fee for attending the Symposium will be three guineas, which will include the cost of coffee, lunch and tea on the Saturday. 37