RESEARCH • RECHERCHE

A surgical review of the priority claims attributed to Abraham Groves (1847–1935)

Christopher R. Geddes, MD* Background: The practice of surgery had changed little over millennia when Vivian C. McAlister, MB† Abraham Groves and William Osler attended medical school together in Toronto, Ontario. The invention of anesthesia sparked such rapid development that by the time of Groves’ and Osler’s deaths, surgical practice resembled the current model. Several From the Departments of Surgery, priority claims have been attributed to Groves’ life in surgery, including aseptic *University of Toronto, Toronto, and surgery (1874), suprapubic lithotomy (1878), appendectomy (1883), surgical gloves †University of Western Ontario, London, (1885) and cancer radiotherapy (1903). These claims arise from an autobiography Ont. written by Groves at the age of 87 years in 1934.

Presented in part to the American Osler Methods: The purpose of this paper is to assess these priority claims from a modern Society, May 2006, in Halifax, NS surgical perspective. We did a systematic search of contemporary (1873–1934) and modern journals for articles by or about Groves. We searched relevant archives and Accepted for publication museums. We reviewed the 1934 autobiography, notes held by descendants, reminis- Aug. 1, 2008 cences by contemporaries and collateral information. We assessed the information not only for priority but also for the development of organized surgical thought. Correspondence to: Results: Groves published frequently throughout his career; thus far we have located Dr. V.C. McAlister 36 papers, almost all of which were published in Canadian journals. He spoke regu- C4-212 University Hospital larly at regional meetings in Ontario. Many medical students apprenticed with him London ON N6A 5A5 (including his brother, son and grandson), he established a hospital and he founded a [email protected] school of nursing. His contemporaries published complimentary reminiscences, but no correspondence with his classmate, William Osler, is known. Groves’ priority claims for aseptic surgery, suprapubic lithotomy and radiotherapy are supported by contemporary publications. Groves independently developed an organized surgical system that remains valid today. Priority claims for appendectomy and the use of sur- gical gloves are entirely consistent with that system. Conclusion: Although Groves’ impact was reduced by his location and the limited circulation of the journals in which he wrote, he demonstrated a systematic under- standing of modern surgery well ahead of his contemporaries.

Contexte : La pratique de la chirurgie avait peu changé au fil des millénaires lorsque Abraham Groves et William Osler ont fréquenté ensemble la Faculté de médecine à Toronto (Ontario). L’invention de l’anesthésie a déclenché un progrès tellement rapide qu’au moment de la mort des Drs Groves et Osler, la pratique de la chirurgie ressemblait déjà au modèle actuel. On a attribué plusieurs premières en chirurgie au Dr Groves, y compris la chirurgie en condition d’asepsie (1874), la lithotomie sus- pubienne (1878), l’appendicectomie (1883), les gants chirurgicaux (1885) et la radio- thérapie contre le cancer (1903). Ces premières sont mentionnées dans une autobi- ographie rédigée par le Dr Groves à l’âge de 87 ans, en 1934. Méthodes : Ce document vise à évaluer ces premières dans l’optique de la chirurgie moderne. Nous avons procédé à une recherche systématique, dans des journaux de l’époque (1873–1934) et modernes, d’articles écrits par le Dr Groves ou à son sujet. Nous avons effectué des recherches dans des archives et des musées pertinents. Nous avons revu l’autobiographie de 1934, des notes détenues par ses descendants, des sou- venirs de contemporains et des renseignements collatéraux. Nous avons évalué l’infor- mation sur le plan non seulement de la priorité, mais aussi de l’évolution de la réflex- ion chirurgicale structurée. Résultats : Le Dr Groves a publié fréquemment tout au long de sa carrière : jusqu’à maintenant, nous avons trouvé 36 communications, presque toutes publiées dans des journaux canadiens. Il a pris régulièrement la parole au cours de rencontres régionales en Ontario. Beaucoup d’étudiants en médecine ont reçu leur formation à ses côtés (y compris son frère, son fils et son petit-fils), il a créé un hôpital et fondé une école de soins infirmiers. Ses contemporains ont publié des souvenirs élogieux, mais on ne

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connaît pas de correspondance échangée avec son confrère de classe, William Osler. Les publications de l’époque confirment les premières revendiquées par le Dr Groves en ce qui a trait à la chirurgie en condition d’asepsie, à la lithotomie sus-pubienne et à la radiothérapie. Le Dr Groves a mis au point indépendamment un système chirurgi- cal organisé qui demeure valide encore aujourd’hui. Les premières revendiquées au sujet de l’appendicectomie et de l’utilisation des gants chirurgicaux concordent entièrement avec ce système. Conclusion : Même si le lieu où il vivait et la diffusion limitée des journaux dans lesquels il a publié ont réduit son impact, le Dr Groves a fait preuve d’une compréhen- sion systématique de la chirurgie moderne bien avant ses contemporains.

n an article published in this jour- consistently applied. On May 10, nal in 1961,1 C.W. Harris asked if 1883, he performed an appendec- I Abraham Groves (1847–1935), a tomy on a 12-year-old boy with physician practising in the village of acute appendicitis; this would be the Fergus, Ont., was the first to per- first such operation performed in form an appendectomy for previ- North America. In November 1885, ously diagnosed appendicitis. The he used sterilized rubber gloves to article was the first of 3 written by perform an appendectomy in a Harris on important late 19th–century patient with purulent peritonitis to Canadian surgeons, the other 2 prevent transfer of infection to being W.T. Aikins (1827–1897)2 and other surgical patients. This would I.W. Cameron (1855–1933),3 both be first use of surgical gloves for professors of surgery in Toronto, infection control, 5 years before Ont. Together, these well research ed Halsted’s use of gloves to protect and finely written articles provide a against the corrosive effect of car- vivid glimpse of Victorian surgery in bolic scrub. The autobiography Canada. The article on Groves is fas- detailed several operations that cinating in another respect: Harris might represent North American or wrote that the actual appendix Canadian priority including vaginal removed by Groves still existed and hysterectomy (Sep. 10, 1875), supra- that modern histologists had exam- pubic lithotomy (Apr. 20, 1878), ined it. prostatectomy (not dated) and At the age of 87 in 1934, Abraham radiotherapy (1903). Groves’ auto- Groves (Fig. 1) published a memoir biography was an author-paid publi- of an exceptionally long career as a cation of 500 copies in 1 edition surgeon in Canada. His purpose was and, as such, had a very limited cir- Fig. 1. Abraham Groves in the 1870s at the “to preserve records of some of the time he commenced a program of modern culation, despite positive reviews earliest operations” that he believed surgery. (Wellington County Museum and from the Lancet and the British had not been performed before and Archives, ph 9097) Medical Journal. “to set forth important theories Twenty years after Harris’ article,1 which [he thought] would improve a historical review of appendicitis by some of even the modern methods in present-day medical Andrew Seal,5 also in this journal, suggested that Groves practice.”4 Detailed information regarding the time, place should be remembered for the first appendectomy in North and presence of witnesses was included in his report of the America. Both authors issued a note of caution because events. In May 1874, before his first laparotomy, both Groves’ autobiography was written 60 years after some of Groves and his assistant, John Wishart, thoroughly the events it described. Despite the cautious approach to val- scrubbed their hands with previously boiled water and used idation taken by these and subsequent authors,6,7 the claims only instruments and sea-sponges that had been boiled in have gained currency through repetition. water. Groves continued to employ these precautions throughout his career as well as developing systems to METHODS wash the patient’s skin preoperatively and to irrigate the bladder for urological procedures. Laparotomy was com- The purpose of this paper is to assess priority claims pleted by copious irrigation with sterile water. This would attributed to Abraham Groves from a modern surgical be the first time that the aseptic surgical technique was perspective.

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We did a systematic search of contemporary journals Fergus. His widow donated the appendix in 1961, and her (1871–1935) for articles by or about Groves. We searched estate gave the stones in 1965 to the Toronto Academy of the collections of the Wellington County Museum, Medicine. Curator Felicity Pope told us that the appendix Archives of Ontario, University of Toronto, University of was contained in an authentic 19th-century container, the Western Ontario, the Museum of Healthcare at Kingston, contents of which were almost invisible because the wine- the Osler Library at McGill and the Osler Collection at spirit preservative had become cloudy. The academy con- Johns Hopkins University, as well as contemporary news- sidered sending the specimen to the Hunter Museum in papers from Fergus and Toronto. We reviewed the 1934 England because it had the only experience of restoring autobiography, notes held by descendants, reminiscences 19th-century specimens. Mr. Penz, a technician with the by contemporaries and collateral information. We assessed William Boyd Museum at the Banting Institute, thought the information not only for evidence of priority but also he could clean the specimen, but the glass container was for the development of organized surgical thought. damaged and could not be saved. The opportunity was taken to make a paraffin-fixed section of the base of the RESULTS appendix, which was then placed in a modern bottle. With the divestment of the Toronto Academy of Medicine’s We found Index Medicus and journal indices to be incom- assets in 1999, the appendix was transferred to the History plete. Thus far we have located 36 articles published by of Medicine collection at the Toronto General Hospital. Groves, of which 5 are duplicates.8–43 These publications, Following the closure of this collection in 2002, we can which cover a very wide range of surgery, are mostly sum- find no trace of Groves’ appendix or stones. One explana- maries of lectures given to medical societies, frequently tion given was that the material was destroyed because no the Ontario Medical Association. Most of his papers were patient consent for storage was available. published in the Canada Lancet and the Dominion Medical Monthly from Toronto, and in the Montreal Medical DISCUSSION Journal. Groves also appeared in short-lived Canadian journals such as the Canadian Practitioner, Canadian Abraham Groves was born on Sep. 8, 1847, to an Irish Medical and Surgical Journal and Canadian Practice and family in Peterborough, Ont., 35 miles from the birth- Review. These journals often duplicated each other’s arti- place of William Osler (1849–1919). When Groves was cles for their respective audiences until they were super- 5 years old, the family moved to a farm beside the small seded by the Canadian Medical Association Journal (CMAJ) Ontario town of Fergus. Groves attended the Toronto in 1911. Groves, who was 64 years old at the time, disap- School of Medicine from 1867 to 1871, where he regis- peared from view. In 1921, he spoke at the Ontario Hos- tered 1 year ahead of Osler. Records for the 1869/70 ses- pital Association annual meeting. Toronto Star reporter sion were rediscovered in the 1940s and studied because of Frederick Griffin was taken by the quick-footed 75-year- the fame later achieved by Osler.45 Although there were old, who he heard was still an operating surgeon. A por- weaknesses in the clinical training available in Toronto, trait that appeared in the newspaper lead to an invitation teaching in anatomy by J.H. Richardson was said to be from the CMAJ to write a review of his career.41 The superb.45 Both Groves and Osler admired and were in- review formed the basis of his memoir 12 years later. fluenced by James Bovell, lecturer in physiology, and Another 2 original case reports to CMAJ complete Groves’ William Thomas Aikins, who taught surgery. Bovell writing career, which spanned a remarkable 60 years. inspired his students to imagine future developments in The largest collection of materials and artifacts from medicine; the vision that laparotomy might help diagnosis Groves’ career are held by the Wellington County was the thought that struck Groves most forcefully.4 Museum. A common book kept by Groves throughout his Despite this, no abdomen was ever opened while Groves life, autobiographical notes and Ontario public health was in Toronto. Aikins, who was particularly adept at materials used by him are in the Archives of Ontario. orthopedic and soft-tissue surgery, was an early proponent Although a 1926 edition of Osler’s Principles and Practice of of listerism, but he was not above using his mouth to hold Medicine inscribed by Groves is among books held by the instruments that might be needed later in an operation.2 Wellington County Museum, no record of correspondence Feuding between different schools of medicine in between the two Toronto School of Medicine classmates Toronto, and a funding crisis that caused the closure of has been located. An amputation knife with evidence of the Toronto General Hospital for the year in 1868 frequent boiling is in the collection of the Dittrick induced Osler to leave for Montréal, Que., and Groves to Museum in Cleveland, Ohio. The museum has verified hastily complete his apprenticeship. Osler and Groves that the knife was manufactured in England in 1870, which took their Ontario licensing examinations in 1871, 1 year is consistent with Groves’ claim regarding aseptic surgery.44 after a profound change had occurred in the examina- Groves kept the appendix and stones from his first opera- tion.45 Chief examiner Michael Sullivan from Kingston, tions as trophies that were displayed in his hospital in Ont., had ordered all students to be examined at the

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anatomy table, lessening the emphasis on theoretical med- 1934 memoir, Groves published a letter from Dr. E. Flath icine in favour of standard core knowledge. We believe to support his use of sterile rubber gloves in 1885, but the this emphasis on anatomy and physiology created an envi- dates are included in Groves’ account and not in Flath’s. ronment that permitted innovators like Osler and Groves Although Groves’ claims are entirely consistent with the to thrive. system of surgery that he had developed, we cannot verify The claim that in 1874 Groves was the first to consis- the year when he first started to use these procedures. tently use aseptic surgical technique is strong. It is sup- In 1948, Dr. G.D. Stanley, who knew Groves as a ported by his contemporary account,8 has a sound theore - Toronto Medical School classmate of his son William and tical basis and became his consistent practice. Groves had confidence in the 1883 date of the appendectomy, reasoned that since typhoid was carried by water, infections wrote that Groves reported the operation soon after to a after surgery might arise from infected fluids of the patient, meeting of the Toronto Medical Society.47 He was con- the surgeon’s hands, the instruments or the sponges. He demned as a “backwoods doctor” who must be stopped. A boiled the instruments and sponges, and he thoroughly written record of this meeting would verify the year of washed the patient’s skin and his hands in sterilized water.8 Groves’ claim. In 1907, the Toronto Medical Society was Later on, he added small amounts of antiseptic solution to amalgamated with 3 other Toronto societies to form the the water which had been sterilized by boiling.41 His prac- Toronto Academy of Medicine. Unfortunately, records of tice is more like that of today than Lister’s, which empha- the Toronto Medical Society, if they had survived the sized airborne infection. Groves undoubtedly heard about transfer to the academy, did not survive its closure. It may Lister in Toronto, but Lister’s student, Archibald Malloch be that, like modern surgeons, Groves did not consider of Hamilton, Ont., did not introduce the carbolic spray to appendectomy or the use of gloves as surgical milestones Canada until 2 years after Groves’ graduation and 1 year until they achieved recognition later. We believe Abraham before his landmark operation.44 Groves should be remembered for the development of a The breadth of Groves’ practice as measured by his comprehensive, logical system of surgery that remains valid publications is astounding. Claims that he is a pioneer in today, 130 years after its inception. Canada of what today are classified as general surgery, urology, gynecology and radiotherapy are supported by Acknowledgements: This paper is dedicated to the memory of Mel contemporary reports, valid developmental logic and per- Muir of Elora, Ont. We are very grateful to the librarians and archivists of the collections consulted for this paper, in particular to Felicity Pope, sistent practice. His priority may extend to North America curator of the History of Medicine Museum at the Toronto Academy of in areas such as urology.46 This record alone puts Abraham Medicine. Groves far ahead of his distinguished contemporaries Competing interests: None declared. Aikins and Cameron.2,3 The theory behind Groves’ practice Contributors: Both authors contributed to every aspect of this article. is entirely consistent with that outlined by Koch at the Tenth International Medical Congress in 1890. At this widely reported meeting, Lister issued a courageous retrac- References tion regarding the use of carbolic spray with the result that aseptic technique replaced antisepsis in surgery. In con- 1. Harris CW. Abraham Groves of Fergus: The first elective appendec- trast, I.W. Cameron clung to listerism and remained reluc- tomy? Can J Surg 1961;4:405-10. tant to perform laparotomy.3 2. Harris CW. William Thomas Aikins. Can J Surg 1962;5:131-7. We did not find contemporary reports to support 3. Harris CW. Irving Heward Cameron (1855–1933), Professor of Groves’ claims regarding the first appendectomy and the Surgery, University of Toronto (1897–1920). Can J Surg 1965;8:131-6. use of surgical gloves. Family records held by the Welling- 4. Groves A. All in the day’s work. Toronto (ON): McMillan Publishing ton County Museum suggest that John Wishart, Groves’ Company; 1932. student in 1873 who became professor of surgery at the 5. Seal A. Appendicitis: a historical review. Can J Surg 1981;24:427-33. Western University of London, Ontario, also claimed to 6. Sanders P. Abraham Groves. Surg Gynecol Obstet 1987;164:179-84. have performed the first appendectomy in 1885, 2 years 7. Spaulding WB. Abraham Groves (1847-1935): a pioneer Ontario after Groves’ claim. A self-written entry for Abraham surgeon, sufficient unto himself. Can Bull Med Hist 1991;8:249-62. Groves in the 1886 edition of Canadian Biography claims 8. Groves A. Case of ovariotomy. Canada Lancet 1874;6:345-7. the first Canadian suprapubic lithotomy but does not men- 9. Groves A. Case of ovariotomy. Canada Lancet 1875;7:192-3. tion appendectomy. In a report of 17 patients with appen- 10. Groves A. A case of double ovariotomy. Canada Lancet 1878;10:195. dix (perityphlitic) abscess in 1890, Groves was able to dis- 11. Groves A. Supra-pubic lithotomy. Can J Med Sci 1881;4:354. tinguish cases that would resolve spontaneously from those 12. Groves A. Puerperal septicaemia. Northwest Lancet 1883;13:372-4. that required drainage, for which he recommended the 13. Groves A. Empyema. Canadian Medical and Surgical Journal posterior extraperitoneal route.21 He wrote a comprehen- 1884;12:696. sive review of appendicitis in 1903, in which we found the 14. Groves A. The operative treatment of fluid effusions of the chest. earliest reference to his appendectomy of 1883.32 In his Canadian Practitioner 1884;9:233-6.

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15. Groves A. Removal of firmly adherent solid tumour ovary. Canadian 32. Groves A. Appendiceal diseases. Dominion Medical Monthly 1903; Practitioner 1884;7:323. 20:311-8. 16. Groves A. Renal calculi. Canada Lancet 1885;16:360-2. 33. Groves A. Radical cure of hernia. Canadian Practitioner 1904;29:68. 17. Groves A. Prostatotomy. Canada Lancet 1887;12:240-1. 34. Groves A. The radical cure of hernia. Canadian Practice and Review 18. Groves A. Prostatotomy. Canadian Practitioner 1887;12:240. 1904;29:68-71. 19. Groves A. Prostatectomy. Canadian Medical and Surgical Journal 35. Groves A. Intra-abdominal anastomosis. Canada Lancet 1904;38:407-9. 1887;15:715. 36. Groves A. Case of acute uraemia in which decapsulation of the kid- 20. Groves A. Vaginal hysterectomy with abdominal ovariotomy. Canada neys was performed. Canada Lancet 1905;39:609-10. Lancet 1889;22:6. 37. Groves A. Intra-abdominal anastomosis. American Medicine 1905; 21. Groves A. Peri-typhlitic abscess. Montr Med J 1890;19:11. 9:697-700. 22. Groves A. Immediate closure of the wound after supra-pubic cystotomy. 38. Groves A. Thyroidectomy. Canada Lancet 1905;41:524-9. Canada Lancet 1892;25:44-5. 39. Groves A. Pyloroplasty. Canada Lancet 1909;43:341. 23. Groves A. Laparo-elytrotomy. Dominion Medical Monthly 1893;10:73-4. 40. Groves A. Prostatectomy. Canada Lancet 1911;45:572. 24. Groves A. Extrauterine pregnancy. Eclectic Medical Journal 1895;4:509-11. 41. Groves A. Evolution of surgery. CMAJ 1922;12:527-31. 25. Groves A. The local treatment of intrauterine sepsis. Montr Med J 42. Groves A. Rupture of the bladder. CMAJ 1923;13:319-20. 1899;28:208-10. 43. Groves A. Fracture of the clavicle, acromium process and surgical 26. Groves A. Operative treatment of the ruptured urethra. American neck of the scapula. CMAJ 1924;14:318. Medicine 1903;5:410. 44. Edmonson JM. Groves’ amputation knife. Can Bull Med Hist 1991;8: 27. Groves A. The action of X-rays in diseased structures. Canada Lancet 289-91. 1903;36:463-4. 45. Elliott JH. Osler’s class at the Toronto School of Medicine. CMAJ 28. Groves A. Estlanders operations — 3 cases. Canada Lancet 1903;37:408. 1942;47:161-5. 29. Groves A. Diagnosis and treatment of tuberculous peritonitis. Canada 46. Caumartin Y, McAlister VC, Luke PPW. A pioneer of urologic Lancet 1903;38:526. surgery from a small town in Ontario, Canada: Abraham Groves 30. Groves A. Intestine ruptures by kick of a horse. Dominion Medical (1847-1935). J Urol 2007;177 (Suppl):S353-4. Monthly 1903;20:201. 47. Stanley GD. Physicians in Canadian history IX — Abraham Groves 31. Groves A. Operation for traumatic epilepsy. Dominion Medical Monthly (1847-1935), a great crusader of Canadian medicine. Historical Bul- 1903;20:200. letin. Calgary Associate Clinic 1948;13:4-10.

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