PAPER The History of Surgery in

James C. Hebert, MD

n 1609, while exploring the lake that now bears his name, Samuel de Champlain looked to the east and exclaimed, “Voila les vert monts.” The Green Mountain State was an inhospi- table place at that time; few dared to settle there until after the end of the French and Indian War, in 1763. By 1771, the population of Vermont was 4667 people. They led a dif- ficultI existence, and the earliest surgeons were true pioneers. Most doctors of the time practiced in widespread areas and had to endure difficult conditions to reach their patients. Many anecdotes about these individuals have survived.1-3 Dr Adam Johnson thwarted an attack by wolves by throw- ing his saddlebags at them. Dr Steven Powers of Woodstock was physically adapted to the chal- lenges of the countryside. He wore buckskin trousers for their durability and as a convenient way to sharpen his surgical instruments. Vermont’s surgical history is inextricably Dr Jonas Fay, the son of Stephen Fay (who linked to the political history of New En- owned the famous Catamount Tavern in gland, , and southern Canada. Bennington), was a surgeon to the Green Like many Vermont surgeons, Dr Powers Mountain Boys during the battle of Ticon- participated in the deroga. As early as 1774, he served as vice and was a surgeon during the Battle of Bun- president of the Council of Safety of Ver- ker Hill.1 Dr Silas Hodges of Clarendon mont and participated in all of the formal served with George Washington’s Conti- conventions leading to Vermont’s inde- nental Army. However, not all Vermont pendence and the state constitution. He surgeons were loyal to the new republic. was an agent of Vermont to the Continen- Dr Frederick Aubrey of Bradford served tal Congress. Dr Reuben Jones of Rock- as a surgeon in the British Army and was ingham signed the Vermont Declaration credited with caring for General Wolfe’s of Independence and was also a delegate wounds at . Dr Jacob Roebuck of to the . In Paul Re- Grand Isle was a surgeon for the German vere fashion, he rode to Dummerston to contingent of King George III’s army. warn its inhabitants following the West- In 1741, Vermont’s land area was minster massacre in 1775, the first blood- claimed by .4 New York shed during the American Revolution. disputed New Hampshire’s claim, and in Vermont declared itself an indepen- 1764, the English Crown decided that the dent republic in 1777 under the name of land west of the Connecticut River be- New Connecticut. Six months later, after longed to New York. The citizens of Ver- realizing that a district on the Susque- mont were upset over the rules imposed hanna River had the same name, Dr by the New York County courts against lo- Thomas Young, ’s friend and cal government. Ethan Allen, leader of the tutor, suggested “Vermont” as the state New Hampshire settlers in Vermont, or- name. Vermont was accepted as the 14th ganized the to pro- state on March 4, 1791.4 tect their interests, the same group who Following the example of the origi- fought so ardently at the battles of Ben- nal 13 colonies, the founders of Vermont nington, Ticonderoga, and Crown Point. included in its constitution provisions for an institution of higher learning, a From the University of Vermont College of Medicine, Burlington. university. The University of Vermont

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 (UVM) was established in 1800 under its first presi- surgery and received both a bachelor’s and medical de- dent, Daniel C. Sanders. The medical department was in- gree from Yale University. His father joined him in 1822 stituted in 1804. when classes began.3,5 Although he had never attended medical school, Dr It is unclear whether Pomeroy departed the faculty John Pomeroy was appointed as lecturer in surgery and when Smith arrived in deference to Smith’s national repu- anatomy and later became professor of surgery at UVM. tation or for other reasons.3,5 Pomeroy’s resignation was Born in Marlboro, Mass, in 1764, he apprenticed with accepted, and James Kemp Platt, a member of the Royal Dr James Bradish of Covington and in 1787 migrated to College of Surgeons who had graduated from Middle- Cambridge, Mass, where he had a large practice. He sub- bury College, became professor of surgery at UVM. Little sequently moved to Burlington, Vt, in 1792. At that time, is written about Pomeroy after he left the university; how- Burlington had become one of the largest lumber mar- ever, he was regarded as an excellent and resourceful sur- kets in the country, and the town’s population was 322 geon. One account describes him performing an emer- and growing rapidly. By 1800, he was taking pupils into gency tracheotomy aboard a canal boat in his home to give them a sample of “physic.” Despite his using a goose quill for a cannula.3 position as lecturer, Dr Pomeroy received no work space Dr Platt, Pomeroy’s successor, died in 1824 and was or financial support from the university; his home on Bat- succeeded by Henry S. Waterhouse. Waterhouse had only tery Street in Burlington remained his classroom and of- an honorary medical degree, which he received from the fice. Dr Pomeroy was awarded an honorary medical de- university in 1823.5 Nathan Smith, perhaps the leading gree in 1809. Only 1 of his students, Truman Powell, was medical educator at that time, gave 4 courses of lectures awarded a bachelor of medicine degree.3,5 in medicine and surgery while simultaneously teaching John Pomeroy continually worked for the advance- at Yale University and Bowdoin College.6 ment of his profession. In 1797, he organized the first Nathan Smith founded 3 medical colleges: Dart- meeting in Chittenden County to develop the Third Medi- mouth, Yale, and Bowdoin. Born in in 1762, cal Society of Vermont for all physicians. This organiza- he moved with his family to Chester, Vt. At 21 years of tion was finally established on December 29, 1803. age, Smith volunteered to assist Dr Joshua Goodhue of Pomeroy was elected president and held the office until Putney, who had come to Chester to perform an ampu- 1813. The First Medical Society of Vermont was estab- tation. Dr Goodhue was a well-known surgeon and presi- lished in Rutland and Bennington counties in 1784, and dent of the trustees of Berkshire Medical College. Fol- the Second Medical Society was incorporated in Wind- lowing a year of study, Smith returned to apprentice with ham in 1794. These societies admitted physicians who Goodhue for 3 years. He then started practicing in Cor- passed an examination and thus attempted to regulate nish, NH. A few years later, he graduated from Harvard medical practice. At that time, only a handful of indi- University and, shortly thereafter, started the medical col- viduals had received medical degrees. Surgery was lim- lege at Dartmouth. He then traveled to Europe, where ited to minor operations and amputations, all per- he broadened his medical education before returning to formed without anesthesia.2 The societies were an attempt the United States to continue his career. A resourceful to legitimize trained individuals both for the public good surgeon, Smith performed an original operation for ovari- and to decrease competition.3 otomy in 1821 with no knowledge of Ephraim McDow- Dr William Beaumont, who became famous for his ell’s operation. studies of digestion, was licensed to practice medicine Nathan Ryno Smith left Burlington for Philadel- in 1812 by the Third Medical Society.5 His diploma was phia, Pa, where he helped to establish Jefferson Medical signed by Dr John Pomeroy and his son Cassius Pomeroy. College. Later he became professor of surgery at the Uni- Dr Pomeroy had assisted Beaumont in 1806 by loaning versity of Maryland.5 In 1993, David Longcope, a seventh- him books. At the time, Beaumont was studying with Drs generation descendant of Nathan Smith, received his Benjamin Chandler and Truman Powell in St Albans. Ten medical degree from the University of Vermont.6 years later, Beaumont first treated Alexis St Martin and In the early 19th century, medical colleges were subsequently began his studies on digestion. springing up everywhere, and Vermont had 3 such insti- Following the , Pomeroy invited John tutions.3 Selah Gridley, Pomeroy’s friend and associate with LeCompte Cazier of Castleton to assist him as professor whom he started the Vermont State Medical Society, was of physiology and anatomy. This position was not pro- holding classes in Castleton with Dr Theodore Wood- vided with a stipend by the university. Pomeroy’s son John ward and others as early as 1810. The Vermont General N. Pomeroy, who was serving as professor of chemistry, Assembly granted the Castleton Medical Academy a char- was allowed a salary of $500, $300 of which was to be ter on October 29, 1818. Middlebury College, in 1810, had received from students. His father paid the remaining sum. tried to lure Dr Nathan Smith away from Dartmouth to (This may be one of the earliest examples of clinical dol- establish its medical department. Apparently, Middle- lars subsidizing basic science in a medical school.) The bury offered Dr Smith a lecture room and $200, as well as 3 were permitted to hold their classes in the newly re- the offer to hire a professor of chemistry. Dr Smith de- furbished university building.5 cided to stay at Dartmouth after the latter erected a medi- In 1822, the trustees of the university reorganized cal building (on land donated by Dr Smith) and ap- the medical department. Dr Pomeroy retained his posi- pointed a professor of anatomy. Although Middlebury tion as chair of surgery. Nathan Ryno Smith, the son of ceased its efforts to start a medical school at that time, 2 Nathan Smith, was appointed professor of anatomy. years later its trustees took control of Castleton Medical Nathan Ryno Smith had apprenticed with his father in Academy to establish an alliance with the arts and sci-

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 ences, as had other New England medical schools. This Obtaining anatomical material was always a con- tie with Middlebury lasted until 1827. By this time, Castle- cern for professors and students. It is likely that few stu- ton was the largest medical school in New England. dents chose to do their own dissections. At the Univer- Following the death of Selah Gridley, Theodore sity of Vermont, cadavers were most often procured from Woodward became the leading figure at Castleton.1,3 Born out of state, although grave robbing was not uncom- in Barre in 1788, he studied medicine with his distant mon. It was even rumored that Ethan Allen’s body was cousin, Dr Nathan Smith. Woodward was a surgeon at taken for anatomical study.3 Angry farmers from Hub- the battle of Plattsburgh in New York and later set up bardton raided Castleton Medical College to retrieve the practice in Castleton, where he enjoyed an excellent repu- body of the wife of one of the town’s citizens.1,3 During tation. He became professor of surgery and obstetrics at its early years, the school at Woodstock had to promise Castleton Medical Academy. When Woodward became not to use bodies from Vermont graves. Considering the the leading administrator there, fierce competition de- proximity of the New Hampshire border to Woodstock, veloped between Castleton and UVM. In December 1821, one need only use a bit of imagination to determine the Castleton trustees granted the title of “fellow” to 41 lead- likely source of cadavers. ing physicians who could serve as preceptors to poten- Dr Samuel White Thayer, a graduate of the medical tial students, thereby linking them to Castleton rather school at Woodstock who was practicing in Northfield, than UVM. Two years later, they voted to change the worked hard to reestablish a medical school at UVM. In school’s name to the Vermont Academy of Medicine, to 1853, trustees voted to reestablish a new medical col- capitalize on the state’s name. lege at the university.5 Dr Thayer was appointed profes- Benjamin Lincoln, a graduate of Bowdoin College sor of anatomy, physiology, and surgery. He became pro- who had studied with George C. Shattuck in Boston, Mass, fessor emeritus in 1872 and served until 1882. Together came to the University of Vermont in 1828.5 The follow- with his friend and associate Dr Walter Carpenter, who ing year, he was appointed professor of anatomy and sur- had been a physician in Randolph before moving to Bur- gery. He left for a brief period with Nathan Ryno Smith lington, Thayer built the medical school into a stable in- to lecture at the University of Maryland and returned in stitution. Enrollment grew to 55 students per year until 1830. Lincoln decided to reform the medical school by 1861 and to about 65 students during the American Civil raising admission requirements, which had previously War. Thayer held the titles professor of surgery from 1854 been only the ability to pay the admission fee. Lincoln to 1855 and professor of anatomy from 1856 to 1872. used his own money to establish a college library; Shat- He recruited Horatio Nelson of Plattsburgh, NY, as pro- tuck even loaned him money for the effort. Shattuck later fessor of medicine in 1854. Although Nelson agreed to recommended that his own son, George C. Shattuck, Jr, come if he was appointed professor of surgery, he never seek out instruction with Lincoln. A feud broke out be- served in this capacity. He was allegedly sent to New York tween Lincoln (at UVM) and Theodore Woodward (at with most of the school’s funds to procure cadavers but Castleton) when Woodward enticed 4 Canadian stu- never returned. Dr David Sloan Conant became profes- dents away from the university by admitting all 4 for the sor of surgery between 1855 and 1865 while also serv- cost of 3. Lincoln attacked Woodward in an essay about ing as professor of surgery and anatomy at Bowdoin. Un- this terrible practice, and Woodward countered with an like Thayer and Carpenter, he was a professional educator attack on Lincoln for poor business practices that would and did not do clinical practice in Burlington. certainly doom the medical school. Indeed, when the pro- More than 34000 Vermont men, or approximately spective students learned that they would be expected 10% of Vermont’s population, served during the Ameri- to study and take examinations, enrollment at UVM de- can Civil War.7 Dr Edward E. Phelps, professor of anatomy creased from more than 40 students to only 14 in 1832. and surgery at UVM from 1835 to 1837 before going to Woodward died in 1837, and Castleton closed its doors Dartmouth, served on the staff of the commander of the between 1838 and 1840, at which time it reopened until First Brigade, Vermont Volunteers, between 1861 and its final demise in 1861. Likewise, Lincoln became ill 1862. He was subsequently in charge of the camp and and died of tuberculosis at his father’s home in Maine in military hospital at Brattleboro. Under his watch, the hos- 1835. Edward Elisha Phelps succeeded him as professor pital was credited with the largest percentage of cures of of anatomy and surgery; however, because of poor en- any US military hospital at the time.1,7 rollment, the college ceased its operations after award- In the spring and summer of 1864, the Vermont Bri- ing a single medical degree in 1836. It was not to reopen gade suffered many casualties. More than 1000 Ver- until 1853. mont soldiers lay wounded in Fredericksburg, Va, un- Dr Joseph A. Gallup started the Clinical School of der terrible conditions. Dr Samuel Thayer, appointed state Medicine in Woodstock in 1827. Dr Gallup had been a surgeon general by Governor Smith, and 20 other Ver- lecturer at UVM and a professor and president of the mont physicians went to Fredericksburg with a number Castleton Medical School. The Woodstock Infirmary be- of volunteers (wives and mothers of the wounded) to as- came a site for bedside teaching, a concept stressed by sist with care.7 He established the 3 Vermont military hos- the school and unique for its time. The infirmary be- pitals: Brattleboro, Montpelier, and Burlington. came affiliated with Colby College in Waterville, Me, Dr Milton Goldsmith, born in Maryland in 1818, which granted medical degrees until 1832. Between 1833 graduated from the New York College of Physicians and and 1837, the school was affiliated with Middlebury Col- Surgeons in 1840.1,7 A professor of surgery at Castleton lege, after which it was chartered as the Vermont Medi- in 1845, he subsequently became professor of surgery at cal College and could confer its own degrees. the Kentucky School of Medicine. Appointed by Presi-

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 dent Lincoln as brigade surgeon of the volunteers, he had John Brooks Wheeler graduated from UVM in 1875 charge of all the military hospitals in Kentucky and was and the Harvard Medical School in 1879. After his third the inspector of hospitals for Grant’s army. He demon- year, he was appointed as a surgical intern or house pu- strated the usefulness of bromine in the treatment of in- pil, also known as a “house pup,” at the Massachusetts fections, which led to his recognition throughout the army. General Hospital in Boston. Wheeler graduated in 1879 After the war, he returned to Vermont and continued his and traveled to Europe, where he studied in the clinics practice of surgery in Rutland. of Bamberger and Billroth in Vienna, Austria.8 In Vi- Dr Henry Janes, a physician in his hometown of enna, Wheeler realized the benefits of antisepsis and asep- Waterbury, became a surgeon of the Third Vermont tic technique. He then went to Berlin, Germany, where Regiment.7 Rising to the rank of major, he supervised he studied operative surgery with Langenbeck. Before re- 250 surgeons after setting up a special 2000-bed hospi- turning home, he traveled to Edinburgh, Scotland, where tal at Gettysburg, Va. He instructed his surgeons on the he met Dr Joseph Bell, the original Sherlock Holmes. proper care of the wounded and to resort to amputation In 1881, Wheeler returned to Vermont, where he only as a last resort. Because of his directives, many settled and practiced in Burlington. He joined the then lives and limbs were saved. Dr Janes was onstage at the proprietary faculty of UVM, giving his first course of lec- cemetery when Lincoln presented his now famous ad- tures in the winter of 1881-1882. In 1885, Dr Laurence dress. Janes then returned to Waterbury and practiced Little, professor of surgery at the university, died of ap- there until his death, in 1913. Dr John Brooks Wheeler pendicitis—just 1 year before Reginald Fitz wrote his fa- remembered him as an excellent surgeon with superior mous paper on the topic.3 Little was succeeded by Dr J. judgment, particularly concerning infections of the ex- Williston Wright of New York, who resigned in 1889. tremities and amputations. Wheeler praised Janes’ skill He was succeeded by Dr A. M. Phelps, also of New York. in administering chloroform anesthesia.8 Dr Wheeler Famous for his operation to repair clubfoot, Dr Phelps preferred to use ether, which he felt was safer. Wheeler was praised by Wheeler for his use of antisepsis and asep- also praised Janes for knowing his limitations, particu- tic technique, as well as his ability to apply bandages and larly in regard to the new practice of abdominal surgery, casts. Phelps remained professor of surgery until he re- in which he was untrained and had little interest. signed in 1900 following a major reorganization of the Wheeler noted that Janes was quick to refer patients in medical department by the trustees. This occurred be- need of abdominal surgery. cause of new standards set by the recently established As- By the latter half of the 19th century, many Ver- sociation of American Medical Colleges (AAMC).5 mont physicians and surgeons were graduates of the lo- Wheeler was named professor of surgery, and his friend cal medical schools. Because not even a high school di- and former student, Henry Crain Tinkham, became pro- ploma was required for admission, most doctors had little fessor of clinical surgery and dean of the medical school. formal education.5 With the introduction of anesthesia Tinkham started as a demonstrator of anatomy. He rose and in particular antisepsis and sterile technique, opera- to the rank of professor in 1884 and was dean from 1900 tions on the abdomen and thorax were developed and to 1925. Shortly after his appointment as dean, a fire de- practiced, first in the large centers in Europe and later stroyed the medical building; this event threatened the sur- in America. By the end of the 19th century, most sur- vival of the medical school. Through his leadership, a new gery in Vermont was still performed in patients’ homes. building was constructed that contained a new library, to After traveling many miles, the surgeon, his assistant, and which Tinkham donated his personal collection.3,5 sometimes a nurse generally used the kitchen table for The American Medical Association (AMA) estab- the operation.8 The assistant, often an apprentice or stu- lished a Council on Medical Education in 1904. Tinkham dent, would administer the anesthetic while the sur- and the faculty worked hard to bring UVM up to the new geon operated. standards. In 1906, the school received an “A” rating by Several military hospitals and “pest houses” existed the AMA after its first survey.3,5 The Flexner report of at various times in Vermont, but general hospitals in this 1910, however, severely criticized the school and rec- state were a product of the last quarter of the 19th cen- ommended its closure. The UVM physicians, lead by tury.1 Established to provide care for the needy and to in- Tinkham in the spirit of Ethan Allen, rallied support from crease the efficiency of physicians and surgeons, general the entire medical profession in the state, as well as alumni hospitals also provided a ready supply of clinical material throughout the country.3,5 The state legislature contin- to use in the instruction of students and apprentices. ued support despite Flexner’s recommendations. Tinkham The Mary Fletcher Hospital in Burlington was a clini- continued to argue UVM’s case before the councils of the cal site for the UVM faculty. According to the accounts AMA and the AAMC. In 1915, the school was classified of Dr Charles Downey, who graduated from UVM in 1894, as grade “A.” the first abdominal operation was performed there by Dr Tinkham’s health declined, and he died in 1925. In A. M. Phelps, professor of surgery, who operated on a addition to his brilliant career as an administrator, drug store clerk in 1894.3 Downey assisted and de- Tinkham was described by John Brooks Wheeler as a scribed scrubbing his hands in bichloride solution and “beautiful operator” and likened to Wheeler’s former in- wearing a sterile gown, though no gloves were worn. Her- structor at Harvard, Dr Charles B. Porter, who was origi- nia surgery was performed, but not at the Mary Fletcher nally from Rutland and was descended from a long line Hospital. There, students observed mostly amputations of Vermont doctors.8 and removal of superficial tumors. Appendixes were al- In 1916 at the behest of Dr Peer P. Johnson, who lowed to abscess and then drained. had graduated from UVM in 1900, Wheeler, Tinkham,

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 and Lyman Allen, who had received his medical degree During the 1940s and 1950s, the trustees at UVM from UVM in 1896 and was on faculty as professor of pushed to increase the research abilities of the medical surgery, became founding members of the New En- college to be eligible for newly available grant funding.5 gland Surgical Society (NESS).9 Wheeler served as the first A national search was undertaken for new chairs of medi- vice president and was the second president following cine and surgery to lead new research and academic ef- Samuel Mixter. Lyman Allen served as vice president forts. Dr John H. Davis was recruited in 1969 as chair of in 1924 and president in 1933. Peer P. Johnson, of Bev- surgery. A graduate of Allegheny College in Pennsylva- erly, Mass, served as treasurer from 1921 to 1934 and nia, he obtained his medical degree from Case Western president in 1935. Reserve University in Cleveland, Ohio, in 1948 after serv- In 1923, Lyman Allen followed Wheeler as chair of ing in World War II. During the Korean conflict, he was surgery at UVM and kept that position until 1942. He a member of the surgical research team, which was the continued the modernization of surgery started by first to use artificial kidneys in the treatment of wounded Tinkham and Wheeler. A respected surgeon, he served soldiers in combat. as president of the Vermont State Medical Society. He was When Davis arrived in Burlington, he recruited a a founding member of the American College of Sur- top-notch faculty and built excellent clinical, research, geons and the American Board of Surgery. and educational programs in the Department of Surgery During this time, other Vermont surgeons enjoyed at UVM. Dr Jerome S. Abrams was recruited as vice excellent reputations, including Dr William Townsend, chair and developed colorectal surgery and endoscopy. vice president of the NESS in 1928 and again in 1936; Dr Laurence Coffin was recruited to develop the open Dr George M. Sabin, vice president of the NESS in 1941; heart program. Despite opposition and 2 previous failed and Dr Herbert A. Durfee, vice president of the NESS in attempts by others at UVM, Dr Coffin succeeded in 1949—all from Burlington. Dr John H. Woodruff of Barre building an excellent program, eventually adding 3 served as vice president of the NESS from 1945 to 1946. more surgeons to his team. Dr Roger S. Foster was re- Dr Charles P. Chandler of Montpelier was president of cruited as a breast and endocrine surgeon. Principal in- the NESS in 1952. vestigator for the National Surgical Adjuvant Breast Dr Albert George Mackay succeeded Dr Allen as chair Project in Vermont in the 1970s and 1980s, he was in- of surgery at UVM from 1942 to 1969. Dr Mackay was strumental in educating Vermont surgeons on modern an outstanding clinical surgeon, and the department at diagnosis and management of patients with breast can- UVM continued to provide excellent clinical instruc- cer. In addition, he developed the renal transplant pro- tion to students and residents. He served as president of gram at UVM. He served as treasurer of the NESS from the NESS in 1964. 1987 to 1989 and is now president-elect of the NESS In the 1960s and 1970s, Vermont was leading the and a member of the Board of Regents of the American development of microvascular surgery. The pioneering College of Surgeons. Dr David B. Pilcher joined Dr work of Dr Julius Jacobson along with Suarez10 in the mi- Davis in 1969 as a vascular and trauma surgeon. He was crovascular anastomosis of small blood vessels led instrumental in developing a statewide emergency to advances in all fields of surgery. Dr Jacobson subse- medical technician program in Vermont. Dr Pilcher was quently moved to New York. Microvascular neurosur- vice president of the NESS in 1994. gery developed under the direction of Dr R. M. Peardon In 1986, Dr Davis contracted a viral transverse my- “Pete” Donaghy. Born in Quebec, his family moved to elitis that left him paralyzed from the chest down. He was Vermont in 1922. After graduating from Northfield High forced to step down as chair. Although officially retired, School, UVM, and UVM College of Medicine, he did his he remains an active teacher to this day, and surgery stu- postgraduate work at Montreal General Hospital and the dents go to his home for seminars. Even on occasions Childrens’ Hospital in Montreal, Quebec. Donaghy ob- when he has been hospitalized, students have crowded tained further training in neurosurgery, neuropathol- around his bed for teaching sessions. ogy, and psychiatry in London, at the Lahey Clinic in Bur- Dr Davis served as editor of the Journal of Trauma lington, Mass, and at Massachusetts General Hospital. In from 1975 to 1995. He was president of the NESS in 1992 1946, he returned to UVM as chair of neurosurgery. In and received the society’s Nathan Smith Award for dis- 1948, he started his research in a Quonset hut behind tinguished service in 1997. He has also served as presi- the medical college. His research budget that year was dent of the Eastern Surgical Association and the Ameri- $25, which he provided, to study peripheral nerve re- can Association for the Surgery of Trauma. He received pair. His interests turned to cerebrovascular disease and the Surgeon of the Year Award from the National Safety novel ways to revascularize the cerebral circulation us- Council, and in 1991 he received the Distinguished Ser- ing the operating microscope. Perhaps more than any- vice Award from the American College of Surgeons. Per- one, Dr Donaghy made microsurgical management of haps his greatest legacy is the many students and resi- many complex neurosurgical problems possible. Dr Gazi dents he has trained who are now leaders in the field of Yasargil from Zurich, Switzerland, learned from and surgery throughout the country. worked with Dr Donaghy. Together they developed a su- Dr Steven R. Shackford succeeded Dr Davis in 1989 perficial temporal artery to middle cerebral artery anas- as professor and chair at UVM. After receiving his medi- tomosis. The first 2 cases were performed 2 days apart, cal degree from St Louis University in Missouri in 1973, in Zurich and Burlington in 1967. Both cases were he did his residency training and vascular fellowship at successful.11 Dr Donaghy was vice president of the NESS the Naval Regional Medical Center in San Diego, Calif. in 1970. A vascular and trauma surgeon, he became nationally

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 known for developing a model trauma system at Naval surrounding communities. The history of surgery in Regional, where he was director of trauma and the sur- Vermont is filled with many more stories and vignettes gical intensive care unit. When he arrived in Burling- that are not possible to relate in a document of this ton, he quickly worked to build on the foundation laid length. I apologize for any misstatements or misinter- by Dr Davis and his predecessors. The American Col- pretations of events, and welcome any clarification or lege of Surgeons certified UVM as a Level I Adult and Pe- additional information. diatric Trauma Center. Internationally known as a leader in the use of ultrasonography by surgeons, Dr Shack- Presented at the 81st Annual Meeting of the New England ford organized courses for training residents and prac- Surgical Society, Boston, Mass, October 6, 2000. ticing surgeons to perform ultrasonography. Currently, I would like to gratefully acknowledge Dr Lester Wall- the Department of Surgery at UVM continues to grow, man for his contributions to the paper; Lori Shatney- with new faculty members adding their expertise to build Leach, Bunny Barry, and Deanna Nelson for researching and expand programs. and collecting data; and Jody Ciano for editorial assistance Vermont remains a beautiful place to live and prac- in the preparation of the manuscript. tice. Vermont surgeons, like the people they treat, con- Corresponding author and reprints: James C. Hebert, tinue to be innovative, independent, and caring neigh- MD, University of Vermont, Fletcher House, 111 Col- bors. Primary and secondary surgical services are provided chester Ave, Burlington, VT 05401 (e-mail: James.Hebert by well-trained surgeons in communities throughout the @vtmednet.org). state. To this day, the Green Mountains are a significant barrier to east-west travel in the state, especially during REFERENCES the winter months. Referral patterns are dictated, in part, by the geography of the area. Together with Burlington 1. Caverly CS. Twentieth century history of Vermont: medicine and surgery. The hospitals, UVM has developed into a major referral cen- Vermonter. 1903;8:311-336. ter for northern Vermont, northern New York, and parts 2. Allen L. A sketch of Vermont’s early medical history. N Engl J Med. 1933;209: of northern New Hampshire. Dartmouth and the Mary 792-798. Hitchcock Hospital developed into a referral center for 3. Chapin WA, Lyman A, eds. History: University of Vermont College of Medicine. Hanover, NH: Dartmouth Printing Co; 1951. southern Vermont, the towns along the Connecticut River 4. Doyle W. The Vermont Political Tradition: And Those Who Helped Make It. Barre, Valley, and the north-south interstate highway system. Vt: Northlight Studio Press; 1984. A Department of Veterans Affairs hospital was estab- 5. Kaufman M. The University of Vermont College of Medicine. Hanover, NH: Uni- lished in White River Junction, just across the river from versity Press of New England; 1979. 6. Hayward OS, Putman CE. Improve, Perfect & Perpetuate. Hanover, NH: Univer- Hanover, NH. It is staffed by physicians and surgeons sity Press of New England; 1998. closely affiliated with Dartmouth. An excellent surgical 7. Coffin H. Full Duty. Woodstock, Vt: Countryman Press, Inc; 1993. department was built there under the guidance of Dr Wal- 8. Wheeler JB. Memoirs of a Small-Town Surgeon. New York, NY: Frederick A. Stokes ter B. Crandell, who served as vice president of the NESS Co; 1935. in 1973 and president in 1982. 9. Crombie HD. The beginnings of the New England Surgical Society [commen- tary]. Arch Surg. 1998;133:352-353. This report has commented on only a few of the many 10. Jacobson JH, Suarez EL. Microsurgery in the anastomosis of small vessels. Surg capable surgeons who have provided and continue to Forum. 1960;11:243-245. provide excellent care to the citizens of Vermont and 11. Wallman LJ. Raymond Madiford Peardon Donaghy. Surg Neurol. 1978;9:73-75.

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ARCHIVES OF INTERNAL MEDICINE An Overview of Acute Stroke Therapy: Past, Present, and Future Marc Fisher, MD; Wolf Schaebitz, MD The effort to develop effective therapies for acute ischemic stroke achieved several important successes during the past decade, but also many disappointing failures. The 2 primary successes were related to thrombolysis. The first was the NINDS rt-PA (Na- tional Institute of Neurological Disorders and Stroke Recombinant Tissue-Type Plasminogen Activator) trial reported in 1995. This study demonstrated that initiation of intravenous (IV) rt-PA within 3 hours after the onset of acute ischemic stroke signifi- cantly improved outcome at 3 months.1 This study led to the approval of rt-PA initiated within 3 hours of stroke onset as the only currently available acute stroke therapy. The second major success was the demonstration that intra-arterial prourokinase initi- ated within 6 hours of stroke onset in patients with angiographically documented proximal middle cerebral artery (MCA) oc- clusion also improved outcome at 3 months.2 A third marginally positive acute stroke trial used ancrod, a defibrinogenating agent derived from Malaysian pit vipers.3 Ancrod initiated within 3 hours after stroke onset also improved 3-month outcome but to a lesser degree than either rt-PA initiated within 3 hours or prourokinase initiated within 6 hours. These successful acute stroke therapy trials were outweighed by a large number of neuroprotective trial failures. Currently, not one of many purported neu- roprotective therapies assessed in pivotal clinical trials has demonstrated unequivocal, statistically significant improvement in clinical outcome.4 The neuroprotective trials all included patients who presented with a stroke 3 hours after onset, and the thera- pies used for each patient failed for myriad reasons that will be explored in detail. (2000;160:3196-3206) Reprints: Marc Fisher, MD, 119 Belmont St, Worcester, MA 01605.

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