History Being Seen to Resort to a Foreigner’S House, Rendered Thursdays Are Set Apart for Operations for Cataracts, It a Most Suitable Place for the Purpose

The use of lithotomy by missionary surgeons in nineteenth-century China

L Fu Formerly Consultant Orthopaedic Surgeon, Hong Kong

ABSTRACT Modern medicine in China owes its origins to Anglo-American medical Correspondence to L Fu, missionaries who introduced Western medicine into China in the early nineteenth Flat C, 2/Floor, South Hillcrest, century. In 1835 the first medical missionary to China, the Reverend Dr Peter 3 Tuen Kwai Road, Parker, founded the Canton Ophthalmic Hospital where he pioneered lithotomy Tuen Mun, Hong Kong and other surgical operations for Chinese patients. This paper chronicles the tel. +852 97084908 subsequent development of surgery for bladder stones at that institution by Dr e-mail Parker, Dr John Kerr and their successors. Modifications of technique and [email protected] improvisations by these dedicated practitioners under less-than-optimal conditions and in an unfamiliar population, provide a unique and interesting insight into medicine of the time as practiced in China. Keywords China, bladder stones, lithotomy, missionary doctors, Peter Parker, John Kerr Declaration of Interests No conflict of interests declared.

THE INTRODUCTION OF MODERN MEDICINE INTO CHINA

Rev. Dr Parker opened China at the point of a lancet when Western cannon could not heave a bar.1 The Reverend Dr Beadle American Board of Commissioners for Foreign Missions

On 4 June 1834, a Yale graduate, the Reverend Dr Peter Parker, MD, DD (1804–1888) of Framingham, Massachusetts travelled from New York to Canton where he landed on 26 October 1834 (Figure 1).2 Sent to China under the auspices of the American Board of Commissioners for Foreign Missions with the aim of using medicine to introduce Christianity to the Chinese, Parker opened the first missionary hospital in China (the Ophthalmic Hospital) on 4 November 1835.3,4 This hospital was situated in the ‘Thirteen Factories’ district, an area outside Canton where European and American merchants resided in virtual isolation from the Chinese.5 In his first quarterly report for the period 5 November 1835 to 4 February 1836 Parker wrote:6

The factory Number 7 in Fung Ta Hong on San Tao Lan Street [Hog Lane] was rented of Howqua, [Wu How-kuan] the senior member of the co-hong [guild Figure 1 Rev Dr Peter Parker, MD, DD (1804–1888). Yale of Chinese merchants] at $500 per annum. Its retired University, Harvey Cushing/John Hay Whitney Medical Library. situation, and direct communication with a street, so that patients could come and go without annoying foreigners by passing through their hongs [business comfortably seated and prescribed for, the house can houses], or excite the observation of natives by afford temporary lodgings for at least 40 patients… history being seen to resort to a foreigner’s house, rendered Thursdays are set apart for operations for cataracts, it a most suitable place for the purpose. Besides a entropia, pterygia, and other surgical cases. large room in the second storey, where 200 may be

264 history

21,22 14,15 265 There There are

23 16,17 21 he reverted to the he reverted 27 It has been claimed that It has 15

This simple procedure was was procedure simple This 24 18 From the mid-sixteenth to the the to mid-sixteenth the From Lithotomy in nineteenth century nineteenth in Lithotomy China 19,20 Suprapubic lithotomy became more more became lithotomy Suprapubic 28 William Cheselden published a treatise treatise a published William Cheselden 26 . This involved entering the bladder via an entering the bladder This involved 25 There can be no apology for the patient being longer can be no apology for There Should under the operation. minutes than a very few size stones of a moderate be but one or two there incision and the egg), hen’s a of size the (under or than two more extraction should not occupy at most. minutes three he performed the procedure in thirtythat and seconds the procedure he performed his mortality10%. than less rate was on this ‘high operation’ for stone in 1723, but when when but in 1723, stone for ‘high operation’ this on him of plagiarism accused Douglas Lithotomy evolved into a scientific procedure in the into a scientific procedure evolved Lithotomy Hospital. Thomas’s William Cheselden of St of hands perineal method. essentially three approaches to lithotomy: the perineal, the perineal, lithotomy: to approaches three essentially the transurethral. and the suprapubic lithotomy Perineal 1. tested perineal lithotomy era, Prior to the anaesthetic of the surgeon and the courage the skill and dexterity extracting Celsus described of the patient. and resilience the over skin the cutting by child a in stone bladder a a finger by against the perineum stone that was pressed 2). (Figure rectum the in His technique, based on anatomical study, involved involved study, anatomical on based technique, His avoiding thus urethra, the membranous cutting through injuryplexuses. to the venous InfirmaryRobert Liston of the Edinburgh Royal also speed. operative of advantage the stressed 2. Suprapubic lithotomy lithotomy Suprapubic 2. a large in extracting the difficulties inherent Due to in 1561, perineal lithotomy a child through stone from to use the suprapubic Franco was forced Pierre approach. called ‘cutting on the gripe’ or the ‘lesser operation’. operation’. ‘lesser ‘cutting on the gripe’ or the called ‘cutting on complicated procedure, a more adults, For in the sixteenth century by was developed the staff’, Barolitanus. Marianus abdominal incision just above the symphysis pubis. John John pubis. the symphysis abdominal incision just above this operative Hospital revived Westminster of Douglas calling it Lithotomia in December 1719, procedure Douglassiana popular with the advent of general anaesthesia. general anaesthesia. of with the advent popular children and adolescents of the lower classes. Climate, Climate, classes. lower the of adolescents and children in the all been implicated diet have and water intake, of improved result as a years, but in recent aetiology, primary the incidence of stone bladder living conditions, in children. notably most declined, has eighteenth century in Europe, barber-surgeons and and barber-surgeons eighteenth century Europe, in famous most The lithotomy. dominated quacks itinerant characters was of these colourful and controversial Jacques. Frère as known better Beaulieu, de Jacques The 14 13 while costs were while costs were As its fame spread, As its fame spread, 9 5,10 15 5,12 St Thomas’s Hospital, London Hospital, Thomas’s St

Thomas Hollyer, lithotomist to Hollyer, Thomas 7 2011; 41:264–9 2011; In those days of strained relations of strained relations In those days 11 The hospital was an immediate success. The hospital was an immediate success. 8 I cut thirty of ye stone in one year and all lived, and all lived, and year one in stone thirtycut I ye of all died they and cut four afterwards Generous donations were received from Western Western from received donations were Generous amounting to in Canton, missionaries and merchants the end of the first year, $1,800 by evolution of lithotomy is mired with intrigue, jealousy, jealousy, with intrigue, is mired lithotomy of evolution or quacks – lithotomists between dealings dishonest and their patients. qualified – and Parker’s aims were firstly to ‘enlighten’ China in the the in China ‘enlighten’ to firstly were aims Parker’s to secondly, and surgery, and medicine of science population. Christianity among the vast spread he patients, treating successfully Through value of the Chinese the great demonstrated to science and its the advances of medical hospitals, service and generous This unselfish practical benefits. Chinese hearts and minds, also helped win over of introduction the for way the paving thereby Christianity. $454.84. Parker himself received no remuneration. himself received Parker $454.84. Ai I-yuan, Pu in Chinese as The hospital was known Love.’ ‘Hospital of Universal literally J R Coll Physicians Edinb Coll Physicians J R Until the twentieth century, bladder stone was one of stone bladder century, Until the twentieth among especially in males, disorders the most prevalent © 2011 RCPE Y LUTION OF LITHOTOM THE EVO On the ground floor there were a few rooms for rooms there were a few floor On the ground hallway. paved stone large a and purposes domestic surgery before and after of patients Colour portraits One small floor. first the on walls the decorated as the consultation room, while apartment served The operating the dispensary. out as was fitted another for inpatients were rooms three other and room floor. the top on housed between China and the West, the hospital played an played the hospital West, the and China between understanding mutual improving in important role was Parker and the Chinese people. foreigners between the patients Chinese upon perform to surgeon first the extraction of operations of amputation of limbs, He also and lithotomy. excision of tumours, cataracts, This in 1847. China into anesthesia ether introduced of operation with the experience his documents paper stone. bladder for lithotomy Of the three oldest elective surgical operations in operations surgical elective oldest three Of the and cutting for trepanation, civilisation – circumcision, ancient most the considered be may latter the stone, the of a specific condition. the cure for procedure patients, from beggars to members of the Imperial the of members to beggars from patients, Parker all parts Canton. of to it from flocked household Chinese society of all sections by to be admired came and the initially including the haughty official class sceptical gentry. L Fu

3. Lithotrity The extraction of moderate-sized bladder stones via the urethra after crushing them into small fragments was said to have been practiced by the ancient Egyptians. They forcibly dilated the urethra with a hollow wooden tube which was pushed against the stone before it was sucked out.28

In 1817 the French surgeon Jean Civiale invented the lithotriteur for drilling and fragmenting the stone.30 Over the next 150 years, new instruments were developed until lithotrity became obsolete in the late 20th century.

Figure 3 Technique of ‘sounding’ for stone. A metal sound passed into the urethra was used to localise the stone in the bladder, the diagnosis confirmed by the click heard on abdominal auscultation when the sound touched the stone. (Image from Charles Bell’s Great Operations of Surgery 182155 courtesy of The Royal College of Surgeons of Edinburgh.)

urinary calculus among 4,575 patients34 and for the two years, 1838 and 1839, there were only three cases.35,36

The following reports marked a new era in the Ophthalmic Hospital as well as in Chinese medical history. Parker’s thirteenth report of the hospital from 1 January to 1 July 1845 is worthy of extensive quotation:37

Figure 2 Technique of localising bladder stone as a prelude During the period now under consideration 6,209 to perineal lithotomy. The finger in the rectum was used to patients have been received, and an aggregate of press the stone against the perineum, which was then incised. 18,257 since the commencement of the institution in (Image from Charles Bell’s Great Operations of Surgery 182155 October 1835… from the beggar to the highest courtesy of The Royal College of Surgeons of Edinburgh. ) functionary under the imperial government… a number of successful cases of lithotomy are given in full. The more interesting as they are probably the first BLADDER STONES IN PRE-MODERN CHINA instance, so far as is known, since the foundation of the empire. When the missionary aim of these labors There are three sorts of diseases to escape any of is borne in mind, neither the profession nor others which a man has good title to destroy himself; the will deem misplaced the moral treatment, in worse of these is stone in the bladder.31 connection with the physical and surgical… The stone Pliny the Elder, Historia Naturalis that has caused pain for years, not less distressing than the rack, has been in as many minutes extracted and There is no obvious explanation for the preponderance in an equal number of days followed with perfect of urinary stones in the people of Canton (provincial recovery, yet all these are but subordinate to the aim, capital of the southern coastal Kwang-tung) compared instrumentally to improve spiritual blessings, that run to the rest of China.32 Western-style missionary hospitals parallel and commensurate with man’s immoral had been established in the five ‘Treaty Ports’ (Shanghai, existence... While rejoicing that these labors are Canton, Ningpo, Fuchow and Amoy) after the First Sino- appreciated and approved by the most enlightened, British War (Opium War) of 1839–1842. devoted and Christian communities, and by the highest personages civil and ecclesiastical of the age, During the time Parker was in charge of the Canton the deepest consolation is in the humble hope of the history hospital, he performed thirty two lithotomies, the last in approbation and blessing now, and the future reward February 1852.33 In his seventh quarterly report for the of that Saviour whose kingdom we devoutly desire to term ended December 1837, there were three cases of see established in China.

40 267 Parker Parker 3 39 Crossing the Crossing 38 Dr Abercrombie 5 Two stones were also also were stones Two

Lithotomy in nineteenth century nineteenth in Lithotomy China 5,33 Other members of the committee included 38 He obtained a supply of sulphuric ether from from ether sulphuric of supply a obtained He 10 On 24 November 1849, lithotomy was performed was performed lithotomy 1849, On 24 November 5 extracted from him… since his convalescence he has he convalescence his since him… from extracted from Bridgman, Dr Rev. the of employ the in been in the knowledge instruction whom he still receives the Gospel. of cases of complete fistula… The patient became for a for became patient The fistula… complete of cases health again, robust enjoys but now time emaciated, very a in the small fistula by inconvenienced only urethra. membranous Nowhere more than in Edinburgh was a sincere was a sincere than in Edinburgh more Nowhere meetingA public in this cause manifested… interest the of the chief citizens by attended was held there, to carry and an efficient committee appointed place, has beenout the designs of the meeting… Intelligence of the organization of a society auxiliary to received has been issued and which a circular by that in China, ofChristians the to appealing circulated, widely Scotland and England in behalf of our object. returned to China in October 1842, and soon after to China in October 1842, returned there. hospital the reopened and Canton to proceeded Boston, the apparatus of Dr Charles Thomas Jackson (a of Dr Charles the apparatus Boston, ether’s discovered have to claimed who chemist a letter of instruction from and anaesthetic properties), him. William Alison, Professor of Physic, James Syme, Professor Professor James Syme, of Physic, Professor Alison, William ofBank Royal the of the President and Surgery, of who was treasurer. Thompson, John Scotland, The ordinary Chinese person knew little The ordinaryof the outside knew Chinese person ability of The surgery. modern about nothing and world, Parker wanted to stir up interest among friends of the among wanted to stir up interest Parker aid to carry for out He first applied Christian missions. of President (Vice Abercrombie John Dr from plans his physician). prominent a and Edinburgh of Society Royal the Hotel in Edinburgh was Waterloo A meeting at the Provost. the Lord by over presided ANAESTHESIA in Parker by China into introduced was anaesthesia Ether 1847. under chloroform anaesthesia, the first time this had anaesthesia, under chloroform with York, New The drug came from been used in China. thisabout Simpson Young James Professor by pamphlet a anaesthetic agent. new was appointed President of the Edinburgh Association for Association for of the Edinburgh President was appointed which two Countries, Aid to Foreign Sending Medical later became the Edinburgh Medical Missionaryyears Society. In June 1840, due to open war between the British and due to open war between 1840, In June He furlough. on America left for Parker Chinese, the in medical schools, lectured the US Congess, addressed pleading public meetings, at and seminaries, theological donations. for asking and his cause Atlantic to the UK in April 1841, he was welcomed as a he was welcomed April 1841, Atlantic to the UK in words: In Parker’s celebrity. All was favorable… All was favorable… Aged 30 had suffered from from suffered had 30 Aged

2011; 41:264–9 2011; 37 Number 16564. May 13th 1845. Urinaryof calculus 13th 1845. May 16564. Number character. peculiar been Having years! urinary twenty-three calculus for assisted time, some for under preparatory treatment extracted stone was this day the pupils, my by…and 5½ by 4½ It measured the lateral operation. by 2½ ounces… weighed and circumference, in inches fortitude, with heroic operation the bore patient the and remarked not seeming to notice the incisions, ‘I feel much. shortlynot suffered after that he had him Reminding grateful. truly appeared He liberated’. his render to urged was he goodness, divine the of thanks to the ‘many He replied thanks to God. he was again the object, But this was not doctor’… seemed him he of God, to thanks render to desired remarked was It conceptions. very imperfect have to comparatively was the calculus extract to him that to the heart heartgive and extirpate the stony to easy, Almighty God. the the spirit of of is the work flesh, of the and healed, perfectly was the wound 6th, June and had loss very little patient in excellent spirits, completely he was days in twenty-three Thus flesh. twenty-three calamity of his distressing of relieved ever have in this hospital operations No years… partthe on surprise and attention much so excited of intelligent Chinese and officers of the Government. in the Stones 1845. December 15161. Number this distressing by been afflicted Had 21. aged bladder, he had During this period fourteen years! for disease and posture, not been able to sleep in a recumbent a like more he appeared paroxysms, in severe often were stones Two person. delirious than a sane it after the operation day The second extracted… been wounded… had that the rectum was discovered in as divided immediately were the sphincter muscles Number 11205. July 17th 1844. Lithotomy. Aged 35, Aged 35, Lithotomy. 1844. 17th July Number 11205. A notice. under been long had with stone afflicted when of the hospital, he was an inmate previous year by into two and broken the stone was grasped down… broken be to hard too but lithotrity, he previously weeks For to. resorted was Lithotomy the for preparation physical and moral under was with the Gospels and being supplied operation, that he with the desire in Chinese, Christian books and their contents acquaint himself with would reveal…The God they of the become a worshipper 5½ and 3½ inches measured pieces two in stone was and drachm, one and ounce one weighed inches, the lateral operation. extracted by flow to entirely ceased water the in nine days he was in eighteen days and the wound, through well. perfectly J R Coll Physicians Edinb Coll Physicians J R © 2011 RCPE The following year operations of a similar nature were were of a similar nature operations year The following performed: L Fu

foreign surgeons to cure painful diseases, restore sight From 1888, Dr John Myers Swan MD (1860–1919) of to the blind and remove large tumours by methods Glasgow, Ohio became Kerr’s assistant.43 and they unknown to indigenous physicians, soon became known performed 963 perineal and 50 suprapubic lithotomies, throughout the nation. As xenophobia and hostilities to together with 120 lithotrities. Age, physical condition of foreigners decreased, more patients applied for the patient, size and density of the stone, and the treatment. Parker’s connection with the American Board condition of the urinary tract influenced the choice of was severed in 1847, though he continued to work at operation.44 Thirty per cent of the patients were children the hospital until 1855, when diplomatic duties with the under ten years old. The procedures had a combined United States Legation engaged his full attention.2,3 mortality rate of 9.5%.

DR JOHN GLASGOW KERR From infancy to puberty, perineal lithotomy gave the best results. The operation time was from three to ten Dr John Glasgow Kerr MD (1824–1901) of Duncansville, minutes, recovery was generally uneventful, the wound Ohio, a graduate of Jefferson Medical College, was sent closing in one to two weeks and fistula, stricture and to China by the American Presbyterian Mission (Figure sterility were almost unknown.45 4).41,42, In May 1855 he was asked to take charge of the hospital.5,42 Kerr performed the first successful lithotrity LEGACY OF THE MEDICAL MISSIONS in China in 1855, but he considered lithotomy safer because of the pain and sometimes fatal bacteraemia With the Canton Hospital already a going concern, associated with lithotrity.32 medical missionaries began work in Hong Kong, Shanghai, Amoy, Foochow and Ningpo. From such humble In December 1856, the hospital was burned down due beginnings, medical schools, large well-equipped hospitals, to hostilities that eventually led to the Second Sino- and various auxiliary organisations have sprung up British War of 1856–1858. The practice was throughout China.46 The efforts of these pioneers were re-established in a new building, and the hospital’s name augmented by successive generations of farseeing men was changed to Pok Tsai (literally ‘Diffusive Benevolence’) and women, who devoted their lives to the spread of in January 1859.5 their religion, and to the development of the highest standards of medicine, all motivated by Christian ideals with little thought of personal gain.47,48

Some Chinese historians, especially Marxists, have viewed the introduction of Western medicine into China as one of the means of ‘invasion by Anglo-American Imperialism under the banner of medicine’.49 Scathing attacks were made against the American missions in general, and Parker in particular as ‘wolves in sheep’s clothing’.50,51 The pendulum has swung the other way with the passage of time. Most contemporary observers now agree that Western medicine as a scientific discipline has been of undisputed benefit to the advancement of knowledge in China.52,53 Objective reappraisal of the role of the medical missionaries suggests that their contribution was a valuable one for the development of medicine in China.54

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1 Balme H. China and modern medicine, a study in medical mission development. London: United Council for Missionary Education; 1921. 2 Stevens GB, Marwick WF. The life, letters and journals of the Rev. and Hon. Peter Parker, M. D., missionary, physician and diplomatist, the father of medical missions and founder of the Ophthalmic Hospital in Canton. Boston: Congregational Sunday-School and Publishing Society; 1896. 3 Gulick EV. Peter Parker and the opening of China. Cambridge: Harvard University Press; 1973. Figure 4 Dr John Glasgow Kerr. (From the author’s own 4 Bartlett CJ. Peter Parker, the founder of modern medical missions. history collection.) JAMA 1916; 67: 407–11. 5 Cadbury WW, Jones MH. At the point of a lancet: one hundred years of the Canton Hospital, 1835–1935. Shanghai: Kelly and Walsh; 1935.

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