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 intraabdominal 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.
1
Ephraim McDowell was born November 11, 1771 in
Augusta County Virginia, to Samuel and Mary McClung
McDowell (tomorrow would be his 238th birthday). This
area is now known as Rockbridge County, and contains
Virginia’s famous Natural Bridge. 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 Lincoln County, 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 (Liberty
Hall Academy), 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
2
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.
3
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 Commonwealth 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.
4
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.
5
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
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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
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Appalachians heading 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 Danville
Kentucky. 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:
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“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 Oregon Territory 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
9
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
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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
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4. Riches, Eric. The History of Lithotomy and
Lithotrity. Annals of the Royal College of Surgery
(England) 1968; 43: 185-199
5. Taul, Glen. Dr. Ephraim McDowell in Edinburgh:
An Enlightenment Education. Lecture at Danville,
Kentucky July 13, 2009
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