Interestingly, no one had correctly diagnosed Mr. Lowell's dislocation as an obturator (anterior) dislocation. At the end of the last trial, the judge, Justice Nathan Weston, stated, “I believe that the head of the bone is in the foramen ovale…not…the ischiatic notch.”8 Later, Lowell bitterly attacked Judge Weston and called for his impeachment because of the judge's statement at the trial.
During the trials and for years afterward, Lowell and some of the attorneys wrote many letters and reports to newspapers around the country attacking the two treating physicians, Dr. Warren, and Massachusetts General Hospital. Lowell was very articulate, eventually becoming a lawyer himself. The following are a few examples of the public accusations by Lowell: “Those two assassins and quacks [Faxon and Hawkes]…ought to maintain me and my family for life.”8 What right did the judge have “to tell the jury that he thought the bone was in the foramen ovale”8? He accused Warren of “ignorance of anatomy and surgery.”8 In some violent political pamphlets, Lowell called his doctors “ignorant quacks poisoning suffering humanity.”8 His life had been ruined by “ignorance, stupidity, and unpardonable neglect.”6 Lawyers wrote that Boston physicians were “adventurous and used torture”6 (pulleys); “treatment was experimental and unproven.”6 Newspapers followed with allegations that “Warren must take a high rank among the detestable class of men who pretend to[o] much and know but little.”6 They rapidly spread news around the country. During the remainder of his life, Lowell commanded that at his death necropsy should be made to prove that “those villains, Faxon and Hawkes, were crassly ignorant and culpably negligent of my case from beginning to end.”8 No other case engendered the publicity that this case had—largely through the repeated articles and letters that Lowell published in papers throughout the United States as well as those of the attorneys and journalists.
In 1826, Warren wrote his pamphlet (A Letter to the Hon. Isaac Parker, Chief Justice of the Supreme Court of the State of Massachusetts: Containing Remarks on the Dislocation of the Hip Joint, Occasioned by the Publication of a Trial which Took Place at Machias, in the State of Maine, June, 1824) in his defense7. The volume of letters, stories, reports, and pamphlets regarding Lowell's case exceeded that of any other suit in the nineteenth century. This case brought unwanted attention to the physicians, especially Dr. Warren and Massachusetts General Hospital. It also had a substantial influence on the increase in malpractices suits in the next thirty years. As previously stated, the number of appellate malpractice decisions increased by 950% and 2100 malpractice cases were reported between 1830 and 1860—far more than the increase in population (144% during the same period). The first United States malpractice crisis had begun and continued for the rest of the nineteenth century, resulting in the first appearance of professional liability insurance companies and of legal defense associations sponsored by medical societies in the first decade of the twentieth century.
De Ville presented many social and economic reasons for this crisis, which he stated “represented a critical turning point in the history of American medical malpractice litigation”6 (Table I). Competition among physicians was particularly troublesome for Dr. Warren as physicians often criticized and denigrated other physicians. During the third trial, Dr. Nathan Smith—who believed that Lowell had a fracture, not a dislocation—was reported to testify that pulleys were not helpful and that the staff of Massachusetts General Hospital were a “pack of old grannies following the lead of Dr. Warren.”8 Dr. Warren, fully aware of the misbehavior in the profession, which probably worsened during his lifetime, noted his concerns in his last lecture to Harvard medical students on March 2, 1847. After a brief history of the school, he gave the following advice to his students: “avoiding every thing that may be to the prejudice of a rival practitioner…Prosecutions for mal-practice, which have become so frequent, have almost always been traced to the private hostility of a rival in the professional career.”11
During this period of increasing malpractice suits, doctors became angry, confused, and panicky, with suits becoming “public prosecution[s].”6 There was also a substantial change in the reasons for the suits—most were orthopaedic cases involving a short leg after a fracture, angular and rotational deformity after a fracture, and stiff joints after an injury. Late in the nineteenth century, 90% of all malpractice cases were because of amputations, fractures, or dislocations. The damage awards also climbed—from $200-$800 before 1865 to an average of $2492 after 18706.
In summary, the widespread publicity involving this interesting case at a time of great social, economic, and competitive changes in the United States resulted in a large increase in malpractice suits against physicians during the mid-nineteenth century. It occurred at a time when orthopaedic-related malpractice cases were rare, and the Lowell case was extremely well documented at the time. In addition to acting as a spark for the first United States malpractice crisis, this case provides us with an example of a hip that was chronically dislocated (for thirty-seven years) after unsuccessful treatment; recent radiographs demonstrate remarkable biologic responses, with the development of a new hip socket, and demonstrate Wolff's law, with acetabular atrophy and lack of normal pelvic osseous trabeculae.
Note: The author thanks Kenny Gundle, MD (former Harvard Medical School student); John J. Pam, MD, Fellowship Director, Musculoskeletal Imaging and Intervention Fellowship Program, Brigham and Women's Hospital; and Dominic Hall, Curator, the Warren Anatomical Museum in the Francis A. Countway Library of Medicine, for their assistance in transporting Mr. Lowell's pelvis and proximal femora and obtaining the imaging studies.