Dr. McDowell’s Other Patient
John F. Rice, MD, FACR
November 10, 2009
In just a few weeks we will mark the 200th anniversary of one of the signal events in American medical and surgical history: the successful removal of a large intra-abdominal and pelvic tumor by Ephraim McDowell, in Danville, Kentucky on December 25, 1809. Dr. McDowell’s famous patient, Jane Todd Crawford, not only survived the ground breaking surgery, but outlived her surgeon, dying in 1842, at age 78.
McDowell had the reputation as the first surgeon west of the Allegheny Mountains. He operated in his home, or, if necessary, days away in his patients’ own homes.Hernias, abscesses,amputations, tracheostomy, superficial masses and assorted repairs of early 19th century mayhem were common procedures for him.
Another procedure common in this era was lithotomy for bladder stone. McDowell was an accomplished lithotomist, eventually performing a total of 32 lithotomies for bladder stone in his career, without mortality. His prowess in this operation led his other famous patient to his door in 1812, 17 year old James Knox Polk, of Columbia, Tennessee, later to become the eleventh President of the United States.
Ephraim McDowell was born November 11, 1771 in AugustaCountyVirginia, to Samuel and Mary McClung McDowell (tomorrow would be his 238th birthday). This area is now known as RockbridgeCounty, and contains Virginia’s famous NaturalBridge. By coincidence, Jane Todd Crawford was born in the same county, just a few miles away, in 1762.
Samuel McDowell was politically active-a captain of militia, justice of the peace, Revolutionary War Colonel, and Burgess in the Virginia assembly. In 1783 Samuel was appointed Judge in LincolnCounty, one of three counties then making up what we know as Kentucky. The District Court was established in Danville in 1784, and there the McDowells established themselves. Danville was an important stop on the Wilderness Road, and ultimately became Kentucky’s first capital.
Young Ephraim attended school in Virginia (LibertyHallAcademy), and in Kentucky at seminaries in Georgetown and Bardstown. At the age of 19 years he decided to study medicine. Most frontier doctors were prepared for their trade by becoming apprentices to practicing physicians. Ephraim arranged to study with Dr. Alexander Humphreys in Staunton, Virginia, not far from his birthplace. There he remained for about two years.
Dr. Humphreys had studied medicine at Edinburgh, and encouraged Ephraim to further his education in Scotland. After much deliberation the young Kentuckian embarked for Scotland, arriving in December 1792.
At that time Edinburgh offered a six month Winter session, and a three month Summer session. Although he was late, McDowell managed to enroll in the Chemistry class of Dr. Joseph Black (discoverer of CO2) as well as extra academic (outside the University) lectures by Dr. John Bell, anatomist and surgeon. The University anatomist was Alexander Monro secundus, who had described the eponymous intraventricular foramen. His were the most popular lectures of the Faculty.
Summer of 1793 offered Clinical Medicine and Botany only, and left Ephraim two months to wander the Scottish countryside. The Winter 93/94 session was his busiest, including the Practice of Clinical Medicine, Anatomy and Chirurgie, and a repeat of Black’s Chemistry. At the end of March 1794 Samuel McDowell determined that he could not finance Ephraim’s Caledonian rhapsody any longer, so the young physician returned home.
McDowell did not earn a degree from Edinburgh. That would have required completing the curriculum, including Chemistry, Botany, Materia Medica and Pharmacy, Theory and Practice of Medicine, and Anatomy. This was followed by oral examinations (2) in Latin, and acceptance and defense, also in Latin, of a dissertation on a subject in Medicine.
Nevertheless, McDowell was well prepared for medicine and surgery on the western frontier,and in 1795 he set up his practice in Danville, in the new Common-wealth of Kentucky.
Much has been written about the case of Jane Todd Crawford. McDowell had visited her in Greensburg, after local midwives had no explanation for the excessive duration of what they thought were twin pregnancies. Upon examination it was apparent to the young doctor that this was a mass, not a gravid uterus. He proposed an “experiment” to the young woman, to relieve her of the mass. A trek of several days on horseback brought her to Danville.
On December 25, 1809, McDowell removed the 22 pound cystic mass, probably a mucinous cystadenoma, in a twenty-five minute procedure with the help of his nephew and new partner, Dr. James McDowell. Also in attendance were McDowell’s pupil, Charles McKinny, and Mrs. Baker, attendant to Mrs. Crawford. Brandy was the only relaxant available. McDowell incised parallel to the rectus muscles on the left, and first ligated the vascular pedicle and fallopian tube. He drained the large cystic component, and then removed the 7 pound solid tumor. He washed the exposed bowel loops with warm water, draining the peritoneal cavity by turning her on her side. Then he returned the bowel loops to the abdominal cavity, and sewed her up, leaving the ligature externally as a drain. Not until 1845 would this same procedure be attempted in Edinburgh.
As he was not on a tenure track, McDowell did not publish a great deal. In 1817 he reported in the Eclectic Repertory about three cases, one being Crawford. A second article in 1819 added two more cases. A total of ten or eleven abdominal surgeries are thought to have been done by McDowell. One of his successes was witnessed by none other than Andrew Jackson, in Nashville. Many academes rejected his reports, including Dr. Philip Syng Physick, Father of American Surgery. These two famous individuals will fill out later parts of this saga.
Urinary bladder stones were much more common in early America than today. Improvements in sanitation and diet are thought to be the reasons for the marked reduction in their frequency today. Bladder stones were particularly devastating to children, and were associated with severe pain, infections, failure to thrive and ultimately renal failure.
Bladder stones have been known since ancient times. The earliest stone discovered was that in an Egyptian mummy dating to 4900 BC. That early man was plagued by stones is reflected in the Hippocratic Oath (4th-5th century BC) wherein the wise man counsels against cutting for stone. Lithotomy should be left to ‘practitioners’, not physicians. Ammonius of Alexandria apparently first used the term “lithotomy” in 276 BC. Itinerant ‘cutters’ or ‘incisors’ preyed upon the suffering from ancient times to the Modern Era.
The first accurate description of lithotomy is seen in De Re Medicina by Celsus (25BC-50AD). He describes the “Lesser Operation” which was performed up until the 1500s. Usually reserved for children, the technique involved palpating the stone per rectum, pushing it down and laterally onto the perineum, and then cutting directly upon it, pulling out the stone with finger or a hooked tool. This was a deadly operation in adults. Galen(131-200AD) was a lithotomist.
The “Greater Operation”, or Marian operation derived from the Italian Joannes de Romanis of Cremona and his student Marianus Sanctus Barolitanus, dating to approximately 1520. This was a rough procedure that required an array of instruments. The patient was restrained and a metal urethral sound was inserted, grooved on the side. A midline perineal incision was made, and instruments were guided in place with the stem as a reference, tearing through muscles, nerves, prostate, ducts and bladder neck. When the hole was large enough, the stone was crushed with forceps and fragments scooped out.
Hemostasis was obtained by pressure and lint soaked in wine. Complications were worse than with the “lesser operation”, and included incontinence, fistula, ED and death.
The “Lateral Operation” was introduced in the late 17th century by Pierre Franco, and the pseudo-monk Jacques Beaulieu, thought by many to be the “Frere Jacques” of nursery rhyme fame. This procedure was modified by several surgeons through the 18th century and early 19th century, and is undoubtedly the procedure McDowell would have used.The diarist Samuel Pepys underwent lithotomy on March 26, 1658, and celebrated the anniversary of his apparently successful outcome for the rest of his life.
William Cheselden (1688-1752) was a London surgeon who refined the lateral technique. It involved a grooved urethral sound, and a perineal incision on the left between ischial tuberosity and scrotum. A gorget was advanced to dilate the track, and forceps were then used to grasp the stone. The bladder hole was smaller; ligatures were used for hemostasis, and Cheselden could do it all in one minute! Fistulas and death were uncommon, and morbidity was further reduced when antisepsis and anesthesia were introduced in the 19th century. McDowell further modified this technique in opening the bladder by direct dissection, rather than the gorget.
James Knox Polk was born November 2, 1795 in western North Carolina, less than twenty miles from the site of Andrew Jackson’s birth 28 years earlier. These two men, “Old Hickory” and “Young Hickory” would become lifelong friends, and would each have major impact on the emergence of the United States in the first half of the 19th century.
As a young boy James was quite frail, with recurring severe abdominal pains which were attributed to bladder stone. Like McDowell, Polk and his family had crossed the Appalachiansheading west. Samuel Polk, like Samuel McDowell, was a judge. As the McDowells became leading figures in Danville, so did the Polks in Columbia, Tennessee, south of Nashville.
James’ education was spotty, largely due to his chronic, debilitating illness. His father was prosperous, and politically powerful, entertaining the Andrew Jackson party at his home. Polk pere became aware of a physician in Philadelphia, the aforementioned Dr. Philip Syng Physick, who might be of help to his son. Now 17 years of age, James was placed in a bed in a covered wagon for the 800 mile trek to Philadelphia. Such was the discomfort felt by young James that the trip was stopped in DanvilleKentucky. He had been “seized by a paroxysm more painful than any that had preceded it.”
Samuel Polk was aware of and sought out Dr. Ephraim McDowell, who had a wide reputation. The stone was quickly removed, and the surgeon gave it to the young boy to take it home with him. Forty years later, October 20, 1852, the stone was exhibited by Samuel D. Gross, MD, Professor of Surgery in Louisville in his “Report on Kentucky Surgery”. Gross allegedly acquired the stone from McDowell’s son Wallace.
James was grateful for his improved health, and twice wrote to McDowell. His first letter, December 12, 1812, was “badly spelled, and written in the worst style”. The second letter, written in 1826 while Polk was a Congressman is more eloquent:
“My Dear Doctor: I have been enabled to obtain an education, study the profession of law, and embark successfully in the practice; have married a wife and permanently settled in Tennessee, and now occupy the station in which the good wishes of fellow citizens have placed me. When I reflect, the contrast is imposing, indeed, between the boy, the meagre boy, with pallid cheek, oppressed and worn down with disease, when he first presented himself to your kind notice in Danville, nearly fourteen years ago, and the man of today in full enjoyment of perfect health.”
The documentation of these two letters is admittedly spotty, coming from the 1890 biography of McDowell written by his granddaughter.
Polk led a most productive life as Congressman, Speaker of the House, Governor of Tennessee and President of the United States. He was forever tied to his mentor, Andrew Jackson, as a Jacksonian Democrat. When he ran for President he had three goals: westward expansion through Texas and California by confronting Mexico; acquisition of the OregonTerritory from Great Britain (“54-40 or Fight”); and an independent treasury. And that is his legacy.
Our Treasury system continues to change, but the western United States are still part of our country, in large measure due to Polk. When Presidential ratings emerge from time to time, James K. Polk is usual included in the top ten. He was a hands-on President, who rarely left Washington during his term. He disavowed a second term early in his campaign, and was true to his word.
After seeing Zachary Taylor take office in March 1849, Polk and his wife Sarah embarked on a long farewell tour through the South, reaching Nashville in April. The rigors of an eventful Presidency had undoubtedly weakened the constitution of Polk. Cholera was encountered several places along the tour, and Polk was susceptible to gastrointestinal disease. He and his wife were building a new home in Nashville, Polk Place. In June Polk became ill with what may have been cholera, and died June 15, 1849, age 53 years.
Some would say that the stress of the Presidency killed him. He was never a robust specimen, no doubt the residua of his sickly childhood. Photographs (he was only the second President to be photographed) show a dramatic change during his four year term. The operation that saved his life probably rendered him sterile, no doubt a frustration for him and Sarah. Nevertheless, Polk was a tough and determined man who accomplished a great deal in a short life; and we have Ephraim McDowell to thank for that life.
References
Books
1. Borneman, Walter. Polk: The Man who Transformed the Presidency and America. (New York: Random House, 2008)
2. Gray, Laman. The Life and Times of Ephraim McDowell. Edited by Oscar Bryant (Ephraim McDowell House)
3. Schachner, August. Ephraim McDowell, Father of Ovariotomy and Founder of Abdominal Surgery (Philadelphia: J. B. Lippincott and company, 1921)
4. Siegenthaler, John. James K. Polk. (New York: Times Books, 2003)
Articles
1. Gray, Laman. After Office Hours: Ephraim McDowell, 1809. Obstetrics and Gynecology 1960; 16: 503-516
2. Herr, Harry. ‘Cutting for Stone’: The Ancient Art of Lithotomy. British Journal of Urology 2008; 101: 1214-1216
3. Ikard, Robert. Surgical Operation on James K. Polk by Ephraim McDowell.Tennessee Historical Quarterly 1984; 43: 121-131
4. Riches, Eric. The History of Lithotomy and Lithotrity. Annals of the RoyalCollege of Surgery (England) 1968; 43: 185-199
5. Taul, Glen. Dr. Ephraim McDowell in Edinburgh: An Enlightenment Education. Lecture at Danville, KentuckyJuly 13, 2009
1