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An Orthopaedic Case Contributed Substantially to the First Malpractice Crisis in the United States in the Nineteenth Century
James H. Herndon, MD1
1 Department of Orthopaedic Surgery, Massachusetts General Hospital, White 535, 55 Fruit Street, Boston, MA 02114. E-mail address: jherndon@partners.org
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Disclosure: The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Sep 05;94(17):e129 1-7. doi: 10.2106/JBJS.J.01991
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Surprisingly, the first malpractice crisis in the United States occurred in the early nineteenth century1. Recent articles commonly refer to three medical malpractice crises, occurring in the mid-1970s, 1980s, and 2002 to 2003—completely forgetting the first major crisis2,3. Even more surprisingly, the early malpractice crisis was triggered largely by an orthopaedic case, relatively unknown today, involving an irreducible dislocated hip that was first radiographed by the author almost 190 years after the patient's injury.
Before 1830, malpractice suits against physicians were rare in the United States4-6. Physicians did not feel threatened and paid little attention to the occasional suit. It is difficult to determine the actual number of suits, as records have been lost (partially because publication of all appellate court decisions did not occur until after the American Revolution). However, according to De Ville, it has been estimated that before 1830 the number of malpractice suits filed ranged from about nine to 100 cases for each appellate case6. Only two appellate malpractice decisions were published before 1830. Between 1830 and 1860, twenty-one appellate malpractice decisions (a 950% increase) and 2100 malpractice cases were reported. Between 1860 and 1890 there were 117 appellate malpractice decisions (a 457% increase). This rapid rise in malpractice cases continued until the beginning of the twentieth century, when the percentage of new appellate decisions increased by only 136%. Throughout this period, the number of medical malpractice suits far outpaced the increase in population, with the largest percentage increase in suits occurring between 1830 and 18606. As De Ville stated, “the late 1830's represented a critical turning point in the history of American medical malpractice litigation.”6
This increase in medical malpractice suits in the nineteenth century so alarmed physicians that many surgeons in the Northeast and especially in New York stopped operating. Before 1830, fractures and orthopaedic cases were rarely a cause of suits, except if they involved severe deformity or amputation; malpractice suits usually involved problems involving vaccination (smallpox), obstetrical problems, or death6. Most physicians believed that suits were rare, isolated events and that they most likely involved nonlicensed practitioners, ethical violations, or criminal abortions.
On Friday, September 7, 1821, Charles Lowell, a twenty-seven-year-old day laborer in Lubec, Maine, was thrown by his horse and landed on the ground on his back, with the horse falling on Mr. Lowell between his legs7-9. Lowell had immediate severe pain in his left hip, was unable to stand, and was carried into a friend's nearby house. A country doctor (Dr. John Faxon of Lubec) was called to see Mr. Lowell. He diagnosed a probable dislocated left hip but failed to reduce the hip despite attempting to do so for one hour. A consultant surgeon (Dr. Micajah Hawkes of Eastport) was called to help Dr. Faxon, and both men attempted to reduce Mr. Lowell's hip. They believed that they felt the hip reduce, and they then wrapped both legs together. Dr. Faxon treated Mr. Lowell with phlebotomy and administered a sedative, and the doctors recommended bed rest for four weeks. Approximately one or two weeks later, Mr. Lowell walked home. Between four and six weeks later, Dr. Hawkes revisited Mr. Lowell and found that his leg remained deformed; he told Mr. Lowell that nothing further could be done. Mr. Lowell was furious and threatened vengeance. Three months later, he traveled to Boston for treatment.
On December 3, 1821, he was examined in a local Boston inn by J. Collins Warren, MD, the first chief surgeon at Massachusetts General Hospital, which had opened only three months previously. Warren told Lowell that he could not help him, but Lowell insisted. Warren arranged for Lowell's admission to Massachusetts General Hospital the next day for a consultation with four other surgeons. Warren spent most of the night studying his cases of hip dislocation and the surgical text of the day, Sir Astley Cooper's A System of Surgery8. The next day, Warren told Lowell that he had a dislocation of the femur “downwards and backwards, in the ischiatic notch,”7 and that nothing could be done. The consulting physicians agreed. However, Lowell pleaded with them to reduce his hip. Before 125 physicians and students, Lowell was sedated with emetics, was given a hot bath, and underwent phlebotomy. A reduction was then attempted with pulleys for approximately two hours—without success. A strong band had been applied to the “middle of the thigh…to draw at right angles to the body.”7 After Lowell was discharged, he visited other physicians and a bone-setter on his way home, but many repeated reduction attempts failed. Anesthesia had not been demonstrated until October 1846, so in 1821 operative attempts to reduce dislocations of the hip had not been attempted.
Warren saw Lowell before he returned to Maine and was surprised that Lowell was planning to sue his two Maine physicians for malpractice. He tried to convince Lowell not to do so. Warren was convinced that this rare injury was not treatable, he despised malpractice suits, and he was concerned that he might have to testify against another colleague. After returning home, Lowell immediately filed suit against Faxon “for trying to do anything with a dislocation of which he knew nothing” and Hawkes “for not reducing the dislocation originally, and for neglecting it afterward.”8 The trial took place in June 1822 (nine months after the injury). Lowell was awarded $1962 (worth approximately $1.9 million in 2008 dollars). Both physicians appealed. Warren, other physicians, and a bone-setter testified with affidavits. A second trial in September 1822 resulted in a hung jury and was dismissed. A third trial in June 1824 was more contentious, with Warren being discovered to have treated only nine cases of hip dislocation and most of the consulting physicians either not having treated any or having treated only one or two patients with a dislocated hip. The defense for Dr. Faxon also argued that the great authority of the day, Sir Astley Cooper, had never seen “a dislocation into the ischiatic notch.”9 Lowell “was stripped and exhibited to the jury, his left leg being longer than the right, turned out a little from the body, and the foot turned outward also.”8 The suit ended without any award to Lowell.
During this two-year period of three trials and for years afterward, Lowell (and to a lesser extent the attorneys) wrote many angry letters to newspapers all over the United States—with horrible ad hominen attacks against the physicians involved, especially Drs. Warren, Faxon, and Hawkes. Lowell even demanded that an autopsy be done at his death to show that Faxon and Hawkes had been totally negligent in his treatment. As was the custom in this period, Dr. Warren wrote an open letter—called a pamphlet—to the Chief Justice of the Supreme Court of Massachusetts in defense of his reputation7. The pamphlet was 142 pages long, containing a detailed case history, a description of the attempted reduction with pulleys, correspondence with Lowell and other physicians, physicians' affidavits, a review of Cooper's book on dislocations, and Warren's own experience treating different types of hip dislocations (including a list of cases that he had treated at Massachusetts General Hospital). Warren emphasized two points: he had no interest in injuring the two Maine physicians; and Lowell did have an ischiatic dislocation, even if Sir Astley Cooper had never seen one.
Mr. Lowell died on Friday, October 29, 1858, at age sixty-five (thirty-seven years after his injury). His physician (Dr. Greeley) stated in his diary that he “limped on a cane, grew stout and suffered greatly for thirty-seven years.”8 Dr. Henry Oliver performed Lowell's autopsy at the request of Dr. John Mason Warren (J.C. Warren's son) and removed Lowell's pelvis and proximal femora. About fifty years later, the bones were discovered in the Warren Museum by Dr. James Spaulding of Portland, Maine, who had read Dr. Greeley's diary about the autopsy by Dr. Oliver and learned about the bones from Dr. Oliver himself. Spaulding photographed the specimens and reported his findings and those of Dr. Oliver in an address to the American Academy of Medicine in Atlantic City on June 7, 19098. It is not known how the bones found their way into the Warren Museum. Spaulding did not subject the bones to radiography, although x-rays had been discovered in 1895. Radiographs and other imaging studies, including a computed tomography scan, of Lowell's pelvis and hips were first made at the Brigham and Women's Hospital by the author with the permission of the Warren Anatomical Museum in the Francis A. Countway Library of Medicine.
The following is a brief summary of the autopsy findings by Dr. Oliver: “the left [foot] turned out an angle of 25° or 30°. The left knee was raised, so that the thigh made with the plane of the bed an angle of about 15°. The right knee being raised to the level of the left, a difference of two inches in the length of the limbs was noticeable…The movements of the left thigh were limited, and confined exclusively to flexion and extension; no motion whatever being perceived in attempts at abduction and adduction. Extension of the leg was impossible…of the left hip, all of the muscles…were found, but noticeably less full in substance, and of a less healthy color, than those of the right side…The cartilaginous, and, apparently, part of the osseous, rim of the acetabulum was absorbed…The articular cartilage of the new socket was wanting in that smooth, shining appearance, characteristic of articulating surfaces generally…That of the head of the bone was much less uneven…the thyroid foramen was found to be nearly obliterated by the rounded base of the new socket…An adventitious socket for the head of the thigh-bone is formed below, and a little in advance of the acetabulum on the left side. This socket fills up the greater portion of the thyroid foramen…The head of the left femur is much larger than its fellow of the opposite side, and its surface quite rough…The most careful scrutiny fails to detect signs of previous fracture anywhere, either in the pelvis or in the femur.”10
Dr. John Mason Warren remarks in his book, Surgical Observations with Cases and Operations, that “a dislocation did exist…that no signs of any fracture having occurred…but that the injury was what Dr. Warren supposed it to be,—a simple dislocation.”10 He goes on to describe that Sir Astley Cooper later published two cases of dislocations backwards and downwards and “at the present day, very fully acknowledged, and I have seen it in my own practice.”10 However, further on he states, “The dislocation as it now appears is not as it was described by Dr. Warren; but the socket for the head of the bone lies almost immediately under the old acetabulum, perhaps a little forward of it. The cause of the deception…lies in the fact, that the head of the bone found…almost immediately under the acetabulum, at the posterior part of the thyroid foramen, and in contact with the body of the ischium. Such a position of the head would render its detection anteriorly quite difficult, even in very thin persons.”10
It was during the reading of Warren's pamphlet in the history section of Harvard Medical School's Francis A. Countway Library of Medicine that the author was approached by the curator of the Warren Anatomical Museum (a section of Countway, donated by Warren, consisting of anatomic specimens and skeletons). He informed the author that the museum had Lowell's actual pelvis and proximal femora. Needless to say, the author was surprised and excited to see the bones and prove the type of dislocation that had remained elusive for so many years (Figs. 1-A, 1-B, and 1-C).
 
Anchor for JumpFig. 1-A

Figs. 1-A, 1-B, and 1-C Photographs of the cadaver of Charles Lowell. (Courtesy of the Warren Anatomical Museum in the Francis A. Countway Library of Medicine.) Fig. 1-A Anterior view of the pelvis and proximal femora demonstrating heterotopic bone obscuring the view of the left obturator foramen and acetabulum.

Figure Description
 
Anchor for JumpFig. 1-B

Lateral view of the left hip demonstrating the new socket below the true acetabulum.

Figure Description
 
Anchor for JumpFig. 1-C

Intrapelvic view demonstrating loss of the left obturator foramen, which is covered by bone (the dome of the false acetabulum).

Figure Description
On April 27, 2010, radiographs and a computed tomography scan of Lowell's pelvis and proximal femora were made—101 years after Spaulding's discovery, 152 years after Lowell's death, and 189 years after Lowell's injury. They demonstrate many interesting findings: the dislocation was an obturator dislocation (anterior rather than posterior and inferior); heterotopic ossification surrounds the hip, especially anteriorly; the femoral head is large and very cystic (probably secondary to osteoarthritis or osteonecrosis); there is no subchondral bone in the left acetabulum; there are no stress lines above the left true acetabulum; and the newly formed socket's dome almost completely fills the left obturator foramen (Figs. 2-A, 2-B, and 2-C).
 

Anteroposterior and oblique radiographs of the cadaver of Charles Lowell, demonstrating the new false acetabulum obliterating the obturator foramen and surrounded by heterotopic bone. Note the loss of subchondral bone in the left true acetabulum, atrophy of the iliac bone above the true acetabulum and the cystic changes in the left femoral head. (Courtesy of the Warren Anatomical Museum in the Francis A. Countway Library of Medicine.)

Fig. 2-AFig. 2-BFig. 2-C
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
 
Anchor for jumpTABLE I  Cultural Changes in the United States
Before Lowell CaseAfter Lowell Case
People lived in organic communities. Good of community above that of the individual.Individual more important than community.
Physicians were often also ministers, lawyers, or judges.Physicians worked primarily as physicians.
Misfortune thought to be because of divine providence.People looked for earthly cause of misfortune and someone to blame. Demanded compensation.
Physical imperfections tolerated.Increased intolerance of physical imperfections.
Legal tolerance of lower medical standards.Public expected higher medical standards; adopted locality rule.
Limited medical education; few books. Apprentice training.Improved medical education; increased textbooks; introduction of medical journals.
Minimal, if any, professional competition.Increased professional competition.
Public tolerance of professionsPublic sentiment was antiprofessional, antistatus.
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.
Spiegel  AD;  Kavaler  F. America's first medical malpractice crisis, 1835-1865. J Community Health.  1997 Aug;22(  4):283-308.[CrossRef]
 
Thorpe  KE. The medical malpractice ‘crisis’: recent trends and the impact of state tort reforms. Health Aff (Millwood).  2004 Jan-Jun;  Suppl Web Exclusives:W4-20-30.
 
Hyman  DA;  Silver  C. Cato Institute.  Malpractice Litigation in U.S. Health Care Reform. 2009 Aug 23. http://www.cato.org/pub_display.php?pub_id=10476. Accessed 2012 Jul 17.
 
Burns  CR. Malpractice suits in American medicine before the Civil War. Bull Hist Med.  1969 Jan-Feb;43(  1):41-56.
 
Rothstein  WG. American physicians in the nineteenth century: from sects to science. Baltimore: Johns Hopkins University Press; 1972.  p324.
 
De Ville  KA. Medical malpractice in nineteenth-century America: origins and legacy. New York: New York University Press; 1990.
 
Warren  JC. A letter to the Hon. Isaac Parker, Chief Justice of the Supreme Court of the state of Massachusetts containing remarks of the dislocation of the hip joint by the publication of a trial which took place at Machias in the state of Maine, June 1824. Cambridge: Hilliard and Metcalf; 1826.
 
Spaulding  JA. Lowell vs. Faxon and Hawkes. A celebrated malpractice suit in Maine. American Academy of Medicine  ,  Vol. XI, No. 1, February 1910.
 
Poldolsky  SH;  Bryan  CS. Oliver Wendell Holmes: physician and man of letters. Sagamore Beach: Science History Publications  ; 2009.
 
Warren  JM. Surgical observations with cases and operations. New York: William Wood and Company; 1867.  p373-5.
 
Warren  E. The life of John Collins Warren, MD. Boston: Ticknor and Fields; 1860.
 

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Anchor for JumpFig. 1-A

Figs. 1-A, 1-B, and 1-C Photographs of the cadaver of Charles Lowell. (Courtesy of the Warren Anatomical Museum in the Francis A. Countway Library of Medicine.) Fig. 1-A Anterior view of the pelvis and proximal femora demonstrating heterotopic bone obscuring the view of the left obturator foramen and acetabulum.

Figure Description
Anchor for JumpFig. 1-B

Lateral view of the left hip demonstrating the new socket below the true acetabulum.

Figure Description
Anchor for JumpFig. 1-C

Intrapelvic view demonstrating loss of the left obturator foramen, which is covered by bone (the dome of the false acetabulum).

Figure Description

Anteroposterior and oblique radiographs of the cadaver of Charles Lowell, demonstrating the new false acetabulum obliterating the obturator foramen and surrounded by heterotopic bone. Note the loss of subchondral bone in the left true acetabulum, atrophy of the iliac bone above the true acetabulum and the cystic changes in the left femoral head. (Courtesy of the Warren Anatomical Museum in the Francis A. Countway Library of Medicine.)

Fig. 2-AFig. 2-BFig. 2-C
Anchor for jumpTABLE I  Cultural Changes in the United States
Before Lowell CaseAfter Lowell Case
People lived in organic communities. Good of community above that of the individual.Individual more important than community.
Physicians were often also ministers, lawyers, or judges.Physicians worked primarily as physicians.
Misfortune thought to be because of divine providence.People looked for earthly cause of misfortune and someone to blame. Demanded compensation.
Physical imperfections tolerated.Increased intolerance of physical imperfections.
Legal tolerance of lower medical standards.Public expected higher medical standards; adopted locality rule.
Limited medical education; few books. Apprentice training.Improved medical education; increased textbooks; introduction of medical journals.
Minimal, if any, professional competition.Increased professional competition.
Public tolerance of professionsPublic sentiment was antiprofessional, antistatus.

References

Spiegel  AD;  Kavaler  F. America's first medical malpractice crisis, 1835-1865. J Community Health.  1997 Aug;22(  4):283-308.[CrossRef]
 
Thorpe  KE. The medical malpractice ‘crisis’: recent trends and the impact of state tort reforms. Health Aff (Millwood).  2004 Jan-Jun;  Suppl Web Exclusives:W4-20-30.
 
Hyman  DA;  Silver  C. Cato Institute.  Malpractice Litigation in U.S. Health Care Reform. 2009 Aug 23. http://www.cato.org/pub_display.php?pub_id=10476. Accessed 2012 Jul 17.
 
Burns  CR. Malpractice suits in American medicine before the Civil War. Bull Hist Med.  1969 Jan-Feb;43(  1):41-56.
 
Rothstein  WG. American physicians in the nineteenth century: from sects to science. Baltimore: Johns Hopkins University Press; 1972.  p324.
 
De Ville  KA. Medical malpractice in nineteenth-century America: origins and legacy. New York: New York University Press; 1990.
 
Warren  JC. A letter to the Hon. Isaac Parker, Chief Justice of the Supreme Court of the state of Massachusetts containing remarks of the dislocation of the hip joint by the publication of a trial which took place at Machias in the state of Maine, June 1824. Cambridge: Hilliard and Metcalf; 1826.
 
Spaulding  JA. Lowell vs. Faxon and Hawkes. A celebrated malpractice suit in Maine. American Academy of Medicine  ,  Vol. XI, No. 1, February 1910.
 
Poldolsky  SH;  Bryan  CS. Oliver Wendell Holmes: physician and man of letters. Sagamore Beach: Science History Publications  ; 2009.
 
Warren  JM. Surgical observations with cases and operations. New York: William Wood and Company; 1867.  p373-5.
 
Warren  E. The life of John Collins Warren, MD. Boston: Ticknor and Fields; 1860.
 
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