Chirurgery in 1740

Osborn began his practice of practice in 1744.  During the years of his apprenticeship (ca. 1737/8-1743/4, usually for 6 years, but possibly less), the popular notion for the late 1720 and 1730s was that there were two types of medicine, the kind of medicine that was practiced from the skin outwards, and the kind of medicine that included knowledge of the physiology and anatomy of the body underneath the skin.  By the 1740s this issue about whether the physician was a simple physician or an educated physician familiar with anatomy became less of an issue to Osborn’s teachers or preceptor, and so it is assumed that Osborn did have some understanding of the inner makings of his patients’ bodies, be they male or female.

It is also possible that this understanding of human anatomy seemed not as important to Osborn as his understanding of the patient at bedside.  A number of physicians were trained to know their patients from the skin out, as one of his authors Daniel Turner used to state in his essays on mountebanks and “quacksalvers” (“quacks” as they were later called and defined for the time).  But Turner was respected by Osborn, so Osborn did not feel this attitude about quacksalvers had anything to do with him, otherwise he would not have referred to Turner in one of his reviews of his most respected authors. 

Is is safe to assume that at least to some extent, Osborn had some if not most of the understanding of the human body required of a surgeon.  The most convincing evidence of this knowledge is found in his recipe for the “Barring Down of the Matrix” or protuding uterus, in which he notes the potential use of a device that, although it did not require a knife to be put in place, required the knowledge and manual dexterity and visual memory skills of a surgeon for this time.  In addition, he needed to have the humility and respect required for any physician to be able insert a device into a lady designed to keep her uterus from moving forward and downward, preventing unnecessary movement and the continuing pain and distress faced by an already “weakened lady”. 

As part of his final discussion of the Piles (hemorrhoids), Osborn mentions the need for an operation should a fistula result from the patient’s history.  This surgery would be considerably more aggressive that whatever conservative clinical actions had already been taken on the patient.    For this reason, Doctor felt he was fairly familiar with how to deal with such problems and was probably familiar with a number of other procedures he has had to perform as a surgeon.  For this reason, at the end of his Piles discussion, he states to the reader his plans to include his comments about surgery in another booklet.

Revolutionary War Surgery

Much more of Osborn’s surgery training and history can be surmised based on his meeting with Samuel Bard and the State Committee just prior to the initiation of full operations at the Fishkill.  It was then that he would have been a surgeon first, and a physician second.  Were any wartime injuries to occur during his hours and days of service, Osborn had to bandage limbs, splint fractures, replace extruding broken bones, treat injured eyes, and surgically deal with any objects extruding from any part of the body of his patients.  He would have to be able to handle the typical accoutrements requirement for the repair of a severely maimed and nearly amputed limb–the saw and surgical knife.  In the hospital setting, he may not have been as skillful as the primary hospital surgeons working there for the time, but in the field and at home Osborn had to be the recruitable doctor and surgeon the officers overseeing his services expected him to be.

One of the authors Osborn referenced in 1768 is a surgeon, Samuel Sharp.   Samuel Sharp must have been the most important Surgeon to refer to for the time, and he must have been able to provide Osborn with some knowledge that was directly applicable to the time and place of Osborn’s medical career and service.  We find Samuel Sharp mentioned by another physician in direct communication with Osborn durign the war, but holding a higher position than him be serving as a Field Surgeon assocaited with the Medical Hospital and University in New York, John Jones.  Jones was a fully-trained surgeon, apprenticed in London by his father and two of his father’s close friends, and then trained still more in Edinburgh followed by Paris, he received an actual MD degree in 1751, and became an army surgeon by 1755 serving during the French and English War, including the Battle of Lake George.

By the dawn of the revolution, Jones produced a pamphlet-like writing summarizing his recommendations for the applications of surgical skills and knowledge to the military hospital and possibly the battlefield.  In his discussion of treating wounds, he wrote:

“Mr. Sharp in his Operations of Surgery, recommends nothing but dry, soft lint to recent wounds; which is generally the best applications through the whole course of the cure.” 

Jones then goes on the discuss his understanding of Sharp’s lessons about treating the complications of wounds, such as the repair of severe hemorrhages, the onset of wet and dry gangrene, and the ways to recognize and treat an ulcerating wound.   

Examples of Osborn’s Surgical Skills from his Vade Mecum

Osborn’s mention of Sharp is in during his discussion of Consumption in the vade mecum.  This complication of consumption he is referring to in his writing Osborn believed was the development of dropsy, due to a serious build up of humours in the body adjacent to, but not in, the hollow intestinal organ system.  In terms of the four humours philosophy, these humours may have simply been clear fluids, in which case they would be phlegm, exuding from the lungs due to excess amounts of build up in the chest cavity, in turn enabling an overflow or seepage of these humours to occur within the abdominal cavity.  However, the consumption also has it other stages that are indirectly humoural based.   In the case of spitting of blood, which Osborn also discusses, the display of dropsy as a result of consumption is not required to take place for all cases.  In the case of a build up of black bile in the coughed up consumption tissue, this represents a serious complication of the disease. (In modern terms, this would indicate that the organism responsible for consumption, mycobacterium, is taking a hefty toll on the lungs; consumption was usually a term reserved for tuberculosis patients during this time, but at times could also simply be a reference to severe and chronic lung condition resembling some of the signs and symptoms of tuberculosis, such as a chronic cough, increased weakness throughout the body, and waves of fatigue followed be periods of remission.)

An important bit of historical sequencing to make note of at this time is Osborn’s mention of the value of Sharp’s writings approximately 6 years before he began his service in the Revolutionary War.  So even though Osborn and Dr. John Jones cite an identical author and practitioner of surgery, Osborn already knew about Sharp and his surgery writings well before he began his work as Field Surgeon, so this knowledge is not simply a result of learning this information while serving as part of the local militia.  This supports Osborn’s ability to pass the tests needed for placement as Field Surgeon within the local militia, and it further supports any doubt that Osborn was not a surgeon prior to the war, due to a lack of much writing on the topic of surgery in the vade mecum. 

Tapping the Dropsy.  Making reference to a need for some special, additional forms of treatment in some cases for the dropsy, Osborn then refers his reader to Sharp’s writings in which additional recommendations can be obtained for inforamtion of appropriately tapping the body of its excess fluids.  Osborn’s mention of tapping may have referred to bloodletting, for which tapping is sometimes used colloquially when referrign to this part of the practice.  However, it is more likely that Osborn was referring to a form of tapping the abdominal cavity which was commonly done in order to release the build up of fluids that has occurred due any number of common illnesses for the time.  Unlike bloodletting, this type of tapping requires Sharp’s written instructions and advice, for it involved carefully incising the abdominal flesh in the front or on its side in order to evacuate the excessive humours that have built up inside.  It is therefore most likely that Osborn is referring to this traditional way of ridding the abdominal cavity of its excess humours due to dropsy, a fairly common form of treatment for dropsy during this time. 

Cleaning the Fistula.  Osborn also mentions the need for surgery to treat Piles if all other treatments fail, allowing them to proceed to form a fistula.  In the case of a fistula, there is an infection that has produced a tunnel enabling material inside the colon or large intestine to find an alternative route to the outside of the body.  Such a process develops due to decaying tissue inside due to an old hemorrhoid that has finally sloughed off, or due to an external hemorrhoid that has died and resulted in the decay of its udnerlying flesh.  This decaying process proceeds along the paths of least resitance, which is usually along tissue layers passing from inside out or vice versa.  As an 18th physician and surgeon, just how much Osborn knew about this development and growth process for the fistula is uncertain.  What is certain is that Osborn knew a channel would form that would essentially ulcerate with time, remain open and be very difficult to resolve without undergoing the right form of surgery.  (Treatment: the channel is cut open and the tissues allowed to heal from the inside out, requiring frequent sitz-bath types of soaks.) 

Due to this reasoning, we can deduce that Osborn was definitely trained in surgery to some extent.  He knew how to make best use of both the  lancet and the scapula.  It help to note that when Osborn referred his reader to Samuel Sharp, he also mentioned another manuscript that he intended to write on how to perform the surgery required for the “separation” of the skin needed to heal this problem [MS p 45]:

“[O]ften from the Piles their will Proceed a fistolow by all means try to Scater with poltice before observed and that if it Should fail and will Come to Seperation which I Shant Speek of now as that is a branch of Shurg and Shall Speek of in another place when I Come to Treat on that head.”

To date, such a writing by Osborn has never been found.

Impostumes, or Abcesses.  It seems unlikely that Osborn would have performed much surgery during his life, especially any processes that extended much beyond the level and depth of the skin and it immediate underlying flesh.  The exception to this assumption was the probability that quite often, Osborn would have had to treat the serious abcesses that can erupt following an injury or followign a prolonged bout with an internal organ disease.  the term osborn uses to refer to these unique humoral rich components of the body is “impostumes.”   “Impostume” is an anglican term, not unusual to early 17th C literature, that was derived from the Old French word “empostume,” a term used to refer to an exceptionally large apostume or abcess; “apostume” in turn is a derivation of a Greek word of similar sounds used to refer to “the separation of pus into an abscess”. 

In  Osborn’s opening line to his thoughts about the “impostume” he is discussing the treatment of  severe cases of Pleurisy in which fluids have build up in the lungs, and the heat and fluids have begun to build up in the chest cavity or lungs.  With regard to treating this, Osborn writes:

“and by having the Impost or Such Like / Tumors Very often Will bring on a / Consumption and then must be treated / after the manner Spoken of under that / Subjact and manney Times it brings / them Drapsical I if So the Chlebates /mention und the head of the Jandeis and / Decoct mention undr  the Clas of the Draps / and the purges Likewise to be made use of / and Delt with Lik a rail Drapsie as / farther Expearence will Teach by Constant / use of the practice” 

In this case, we expect Osborn to mention the possible use of surgery, in order to remove the unhealthy part(s) and then assist the body through the remaining healing processes.    Osborn does not mention to use of surgery for treating the Impostume brought on by Pleurisy.  This is because this fluidous for of the disease is perhaps too deep within the chest cavity to warrant the practice of surgery.   Instead Osborn mentions the use of various remedies meant to tonify and reduce certain humours or fluids in the body.   According to this section of the vade mecum, Osborn’s understanding of “Tumors” is that they are similar to impostumes, and so require similar forms of treatment, such as the use of diuretics, diaphoretics (sweat-inducers), emetics, laxatives, drastics and purgatives.    Referring to the complication of such a disease as a tumor is very much in line with many iof the same mistakes made by physicians in reference to treating the canker or what the least trained physicians like to consider a form of “cancer.” 

One of the most common surgical processes for much of the time in pre-20th century history was probably for the development of abcesses and other infectious conditions involving the skin and its adjacent structures.  Since the different types of infections in the skin could not be differentiated without and knowledge of the organism involved, these different forms of “canker” and “cancer” were often treated in much the same way.  The way to treat such a growth was to extricate it from the neighboring flesh, which was typically done using caustics or toxic materials laid upon the canker growth until it could be completely scraped out of the tissues it was occupying.   To some physicians, this surgical treatment was very similar to the treatments used to treat the expurgence of  of viscous humours of various forms, shapes and colours extracted from the abscess (a seriously swollen sore or infection).  There were distinct differences between the expression of humours by the abcess or sore, the canker or cancer, and the consumptive lung coughing up its black bilious sputum.  How much Osborn knew about the differences between these different expressions of a similarly appearing sickness at times are for now mostly speculative.  Osborn makes no mention of treating other forms of impostumes, referring only to Pleurisy and its complications due to codependent or sequential disease patterns such as Jaundice and Dropsy.

With the possible exception of injury-related needs when the tissues are highly exposed, the need for closure and suturing of severe wounds, growth or abcesses, or the case of the occasional “barring down of the matrix,”  few other surgical actions can only be speculated on without much certainty.   The primary premise many of Osborn’s theories for disease begin with seem to be acting upon his assumption that a disease can at first manifest itself in one section of the body and then move and be converted to another form of disease or malady manifesting in another part of the body.   Like the migration of true cancer from one part of the body to the next, so too can a new tumor-forming site be formed due to an infectious problem which was spread and displayin the form of an abscess or other form of impostume.   Osborn is referring to this concept of disease  only in a humoral sense.  Like other physicians for his time, he essentially had no idea of the notion of infection or small organisms and disease.  Osborn’s surgery might very well be more like Turner’s description of old and new medicine for the time, with operations performed most from just beneath the skin and outward.