Christmas Day in 1809 changed the path of surgery forever. Abdominal surgeon Ephraim McDowell performed an operation that universally was considered to be fatal, but the “experiment” was actually not foolhardy; McDowell’s background and education provided him with the knowledge to proceed.
At 19 years old, McDowell entered a 2-year preceptorship with Alexander Humphreys, MD, in Staunton, Virginia. At that time, Dr. Humphreys was known as an excellent surgeon and the premier lithotomist in the country.
After completing the preceptorship, McDowell entered The University of Edinburgh in Scotland for 2 years but left without obtaining a medical degree. He decided to take private classes with John Bell, the historic Scottish surgeon and anatomist. Upon identifying an ovarian cyst during postmortem examination, Bell speculated that premortem removal would be possible.
A hundred years earlier, John Hunter said, “I cannot see any reason why, when the disease can be ascertained in an early stage, we should not make an opening into the abdomen and extract the cyst itself,” and “Why should not a woman suffer spaying without danger as well as animals do?”1
McDowell returned to his home on the frontier in Danville, Kentucky, in 1795. He opened his practice without the benefit of a medical degree but was soon recognized as one of the best surgeons west of Philadelphia. His repertoire included amputations, strangulated hernias, lithotomy, drainage of abscesses, resection of parotid tumors, and tracheotomy.
In 1809, two Danville physicians consulted McDowell about 45-year-old patient Jane Todd Crawford, who thought she had been “pregnant” for more than a year. She could stand and walk only with great difficulty, experiencing abdominal pain much of the time.
Upon examination, McDowell found her uterus to be of normal size, but he discovered a large abdominal mass that was easily movable from one side to the other. In other words, she had an ovarian cyst—a diagnosis that, at the time, resulted in progressive debilitation and death within 2 years.
McDowell discussed in detail the theoretical possibility of removing her tumor, explaining that abdominal surgery had never been performed successfully. She understood the risks and agreed to the “experimental” surgery.
Crawford traveled 60 miles over 3 days on horseback to Danville because the roads were too bad for a cart.2 Surgery was performed on Sunday, December 25. McDowell preferred to operate on Sundays because his schedule was less hectic, and he drew inspiration from the hymns being sung in the church next door.
On this day, a group of approximately 100 people were gathered outside and could be easily heard and seen. The crowd was very critical of the planned operation, suggesting that McDowell’s life was at risk should the patient die.
Psalms, Moonshine, and Surgery
Major elements of modern surgery were not available to McDowell. William T. G. Morton’s development of anesthesia and Joseph Lister’s sterile techniques were unknown at the time; however, he addressed both to some degree.3 Crawford was reported to calm herself by singing hymns and quoting Psalms during the surgery. She also was given a mixture of cherry bounce moonshine and laudanum, followed by a few sips of barley water whiskey.
In lieu of sterile techniques, several factors came into play. McDowell’s surgeries were known to be much like his personal life with an emphasis on cleanliness, neatness, and precision. His habit of aggressive cleanliness was present in his own attire, as well as his home. There were no bloody frock coats used in one operation after another. His pristine home provided the advantage of avoiding the large bacterial load of hospitals during that time.
The operation was straightforward and probably done in the morning to coincide with church services and daylight. A 9-inch incision was made lateral to the left rectus muscle. The cyst was so large that it could not be removed through this incision. All the intestines were displaced on to the operating table. A ligature was placed around the fallopian tube and ovarian ligament. The cyst was incised, and 15 pounds of gelatinous material were removed. The fallopian tube and ligament were divided, and a 7.5-pound cyst sack was removed.
At the end of the procedure, the patient was turned onto her left side to evacuate blood from the abdomen. The abdominal cavity and intestine were irrigated with warm water.4 Since surgery was in December, the only way the irrigation could have been warm would be for the water to be heated on a stove. If it were heated enough, it might have been sterile. The abdomen was closed with interrupted sutures, probably of silk.5
The suture on the fallopian tube was left long and brought out through the incision as a drain. Adhesive plaster strips were used between the sutures to approximate the skin edges. The operation lasted only 25 minutes; therefore, exposure of the peritoneal cavity was limited. Less than a month post-op, Crawford got back on her horse and rode home. She lived for 32 more years, outliving McDowell.
