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Ephraim McDowell, Pioneer Surgeon

Dr. Ephraim McDowell of Danville, Kentucky, became in 1809 the first surgeon world-wide to successfully remove an ovarian tumor. It is difficult for us to understand that performance of an operation, done today routinely with minimum risk, was in 1809 a singular contribution to medical progress, but such was the case. Until then, ovarian tumor was an incurable and frequently fatal disease, and was thought to be unapproachable surgically. Indeed, opening the abdomen for treatment of any internal disorder was not considered feasible by the savants in European medical centers where medicine and surgery were the most advanced. As a result, the report by a backwoods American physician of the first ovariotomy was at first disparaged by disdainful British surgeons. Nevertheless, McDowell is now universally recognized as the first to demonstrate the feasibility of the operation and, being from the neighboring state of Kentucky, would surely have been among the pantheon of eminent surgeons who inspired the efforts of the young Dr. Elias Cooper in Illinois. This is an additional reason why Dr. McDowell deserves our respectful notice here.

Dr. Ephraim McDowell (1771-1830) served an apprenticeship in his native state of Virginia for about two years under Dr. Alexander Humphreys of Staunton who was an MD graduate of Edinburgh University. McDowell then spent two years (1783-85) at Edinburgh, but did not graduate; nor did he hold a medical degree from any institution until he was awarded an unsolicited Honorary MD degree by the University of Maryland in 1825. By 1809, in spite of his lack of medical credentials, he had become one of the most highly regarded surgeons west of the Allegheny Mountains. [86] [87]

The patient from whom Dr. McDowell removed a huge ovarian tumor in 1809 was a courageous Kentucky woman of about 46 named Mrs. Jane Todd Crawford. He described her as a woman of small stature whose abdomen had become so pendulous with the tumor as to reach almost to her knees. During the few days before the operation she rode 60 miles by horseback, resting the tumor on the horn of the saddle, to reach Danville, then a frontier town of possibly a thousand. [88]

The procedure was carried out in Dr. McDowell's house. He was assisted in the operation by one of his nephews, Dr. James McDowell, who had graduated in Philadelphia a few months previously and who, from the time of Mrs. Crawford's arrival in Danville, made frequent attempts to persuade his uncle from operating on her. Several other attendants were present to observe the operation and to help restrain the patient who was operated on without anesthesia. In this pre-anesthesia era, an alcoholic or narcotic potion was commonly administered before an operation, yet the utmost fortitude was still required by the patient. Mrs. Crawford is said to have diverted her thoughts during the procedure by repeating the Psalms. Under such circumstances speed, deftness, self assurance and a precise knowledge of anatomy were essential qualities of a surgeon. Antisepsis and asepsis were unknown, and postoperative infection usually occurred.

In an otherwise bare room in McDowell's home in Danville, the patient was placed on an ordinary table. Equipment consisted of scalpel, scissors, forceps, needle holder, ligature passer, heavy thread and an assortment of household items such as basins, towels and other dry goods, all laid out on a small nearby stand. The following are the important features of the operation.

  1. A long incision was made to the left of the midline, extending from the rib margin above to the pubis below.

  2. The tumor then came into full view. It was freely movable with a pedicle of sufficient length so that a strong ligature could be tied around the fallopian tube and other tissues containing the tumor's blood supply.

  3. The tumor, being so large that it could not be delivered from the abdomen, was then opened and its gelatinous contents were evacuated - whereupon the intestines rushed out of the abdomen and remained exposed until the remaining solid portion of the tumor was cut off from its pedicle and removed.

  4. The patient was turned briefly onto her side to permit escape of accumulated blood from her abdomen.

  5. The operation to this point had taken 25 minutes. Another five minutes were required to replace the intestines and close the abdomen with large interrupted sutures, the long ends of the ligature on the tumor pedicle being brought out through the lower end of the wound for later withdrawal from the abdomen after it had cut through the pedicle. Altogether the procedure took about a half an hour.

  6. The tumor was partly cystic and partly solid, the cystic portion weighing 15 pounds and the solid portion weighing 7 1/2 pounds, a total of 22 1/2 pounds.

  7. Postoperative course was exceptionally smooth. She did not develop either of the two most feared and frequent complications of abdominal operations - peritonitis and wound infection. In five days she was up and making her bed, and in 25 days she returned home. Mrs. Crawford was in apparently good health for the next 33 years until her death in 1842, outliving her surgeon by 12 years. [89] [90]

Dr. McDowell told Mrs. Crawford that the operation he proposed to her would be "an experiment" - as indeed it was at the time. Recognizing that she had no other alternative if she wished to live, she promptly agreed. Before publishing the Crawford case in 1817, McDowell performed his "experimental operation" on two additional patients, both of whom survived the procedure and were included in his original report. [91] However, it was not until mid-century, and after the advent of anesthesia, that ovariotomy gained general acceptance in the higher echelons of British and French surgery. The prolonged delay in the adoption of this life-saving procedure in Europe led Schachner to attribute McDowell's earlier initiative and success to the spirit of independence nurtured by the American frontier, and to his freedom from the constraints of an entrenched professional elite such as existed in Europe. [92]

Ephraim McDowell's unprecedented operation demonstrated for the first time the curative potential of surgery in the previously hopeless condition of ovarian tumor. Equally important, it proved that the abdominal cavity, formerly off-limits to the surgeon, could be safely explored. By these memorable achievements, McDowell became not only "Father of Ovariotomy", but also "Founder of Abdominal Surgery". [93]

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Medical Department of St. Louis University

Just as the Medical College of Ohio fought hard to prevent the opening of a rival school in Cincinnati in 1835 by Daniel Drake, so Joseph McDowell reacted furiously to a similar challenge to his medical college in St. Louis. As early as 1836, three years before McDowell's arrival in the city, St. Louis University, founded by the Jesuit Order of the Catholic Church in 1818, had adopted a plan to establish a Medical Department. For various reasons, steps to put the plan in operation were delayed until after McDowell had established his school. When the University finally enacted a constitution for its Medical Department on 14 October 1841, McDowell assailed the plan in vitriolic anti-Catholic speeches, specifically attacking the Jesuit Order. Nevertheless, a medical faculty was appointed by St. Louis University and lectures were begun a year later on 8 October 1842. The faculty consisted of a Dean and four associates. During the next seven years, in spite of McDowell's fulminations and the vigorous competition of his College, the Medical Department of St. Louis University prospered and capacious new quarters were constructed. [94]

photo of St. Louis Medical School

In addition to Joseph McDowell's move to St. Louis, repercussions from the late Medical Department of Cincinnati College were felt in other ways on medical education in St. Louis. One of Dr. McDowell's able students at Cincinnati Medical College during 1837-38 was a young man from Huntsville, Alabama, by the name of Charles Alexander Pope (1818-1870) who transferred to the University of Pennsylvania Medical School in the following year and there earned his MD degree in 1839. After a Wanderjahr in Europe where he spent most of his time in Paris, but also visited other great medical centers on the continent and in Great Britain and Ireland, Dr. Pope returned to the United States to settle in St. Louis in 1841. He too was interested in starting a medical school in the rapidly growing city which now had a population of about 20,000. He took part in the organization in 1841 and activation in 1842 of the Medical Department of St. Louis University, in spite of the implacable opposition of his former teacher. [95]

In his pursuit of an academic career, Pope had a powerful advocate in Dr. Samuel Gross, Professor of General and Pathological Anatomy in the Medical Department of Cincinnati College where he had been a faculty colleague of Joseph McDowell. Gross considered McDowell to be an incomparable teacher of anatomy, but otherwise something of a crank. For McDowell's Uncle Ephraim, however, Gross had the utmost respect and was chosen to deliver the Memorial Oration at the dedication of a monument to the ovariotomist at Danville, Kentucky, in 1879.

After leaving Cincinnati, Gross rose to national prominence as a surgeon and served for 26 years (1856-1882) as Professor of Surgery at Jefferson Medical College. He well remembered Pope's studious habits and moral and intellectual attributes while a student at Cincinnati Medical College, and ever retained a kindly disposition toward him. It was upon Gross's strong recommendation that St Louis University chose Pope as Professor of Anatomy in 1843. Later, in recognition of his special interest and ability in the field of surgery, the University transferred Pope to the professorship of Surgery in 1847. He was given the additional appointment of Dean of the medical school in 1849, a position he filled with such distinction for the next 15 years that the Medical Department of St. Louis University was commonly referred to as "Pope's College". This was particularly galling to the head of "McDowell's College". Elias later referred gratefully to Dr. Pope as a benefactor during his student days. [96]

As for the controversial McDowell, he lives in memory as the most colorful character in the history of medical education in Saint Louis. He never lost his antipathy for the rival Jesuit school, or overlooked an opportunity to ridicule it. Medical students looked forward with relish to the commencement exercises of McDowell's College when he was sure to have something caustic and irreverent to say about Pope's College. On one such occasion McDowell, who was an avid amateur musician,

. . slowly sauntered down the aisle with violin and bow in his hand. Seeing so many students sitting sideways he commandingly said: "Gentlemen, I pray you, sit straight and face the music." After scraping off a few tunes he very gravely laid aside his violin and bow and said: "Gentlemen, we have now been together for five long months and we have passed many pleasant and delightful moments together, and doubtless some sad and perplexing ones, and now the saddest of all sad words are to be uttered, namely, "Farewell'. . .In after years one of your number will come back to the City of St. Louis, with the snow of many winters upon his hair, walking not on two legs, but on three, as Sphinx has it, and as he wanders here and there upon the thoroughfares of this great city, suddenly, gentlemen, it will occur to him to ask about Dr. McDowell. Then he will hail and ask one of the eager passersby: "Where is Dr. McDowell," he will say: "What Dr. McDowell." "Why, Dr. McDowell, the surgeon." He will tell him, gentlemen, that Dr. McDowell lies buried out at Bellefontaine. Slowly and painfully he will wend his way thither. There he will find amidst rank weeds and seeding grass a simple marble slab inscribed, "J.N. McDowell, Surgeon." As he stands there contemplating the rare virtues and eccentricities of this old man, suddenly, gentlemen, the spirit of Dr. McDowell will arise upon ethereal wings and bless him. Yes, thrice bless him. Then it will take a swoop, and when it passes this building, it will drop a parting tear, but, gentlemen, when it gets to Pope's College, it will expectorate." [97]

To the Medical Students, the sardonic humor of the irrepressible McDowell during commencement services was a welcome alternative to the weighty sermons usually delivered on such occasions.

During his final years this "erratic genius", estranged from his children because of a second marriage of which they disapproved, and in a state of utter bankruptcy, turned in the end to the Roman Catholic religion and received in death the blessing of his spiritual comforter and companion, a Jesuit priest. [98] [99] This brief account of the birth of medical education west of the Mississippi, presaging as it does later San Francisco conflicts in which we have a special interest, lends support to Drakes' postulate that medical schools are a fertile source of discord within the profession.

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Perspective

The historical roots of Stanford Medical School are deeply planted in American medicine of the 1800's. If we are to understand and appropriately evaluate the contributions of the men, women and institutions of these earlier days we must know the conditions under which they labored.

It is for this reason that we have referred in this and preceding Chapters to aspects of American society that affected the careers and achievements of Elias Samuel Cooper and Levi Cooper Lane. We have also attempted an overview of American medical education from its beginning in Philadelphia in 1765, through some pioneer schools west of the Alleghenies, to the advent of the modern era at Johns Hopkins. In the following Chapter we complete our "environmental impact study" by noticing the condition of medical science and practice in the 19th century as experienced by Cooper and Lane.

It is hoped that this approach will lead to broader insight, and a deeper appreciation of the challenges overcome by the Faculties of Stanford's predecessor institutions for, to paraphrase Macauley, Medical Schools that take pride in the achievements of remote antecedents are more likely to be remembered with pride by remote descendents.

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