Kentucky’s Early Lithotomists

M.J. Henry, M.D.
Professor of Urology
University of Louisville School of Medicine 1928
Presented to the Innominate Society

It is with no little hesitancy that I undertake to address this society upon a subject, which because of its interest to each one of us, is no doubt familiar to all.

I am deeply conscious of the fact that everything I have to say has recently been told by a member of the Kentucky profession in a manner not to be improved upon.

 I have chosen this subject for two reasons- First, I wanted an interesting topic; and secondly, since the writing of any historical paper would require some reading, I preferred directing my reading to channels, which I desired to explore. I realized that any paper on this subject would require some knowledge of the early history of this state, and naturally I wanted to know more about the history of the land that gave me birth.

My knowledge of medical history is scant, and is a result of the custom of many scientific writers of giving a short resume’ of the history of the work done on the subject about which they are writing; and the bits of medical history I have appropriated from the papers read before this society during the past year.

The writing of biography requires special talents, which very few possess. A very brilliant essayist, who happens to be of our profession, has this to say of biography: “Biography is the story of a life, told by a man who lived it, or by a student of it. Biography does not consist solely of a record of events or adventures that constitute the actual and visual side of existence. It is not merely a chronological narrative of happenings from which the reader may divine the inner and hidden qualities of the subject: it is primarily a statement of the subject’s thoughts and strifes, ambitions and realizations- and as thoughts and ambitions condition action, behavior and achievement, that which we call the “live” of a man flows from them. Biography presents a picture of a mind, a soul, a heart; of an environment; of successes and failures that make or seek to make the subject immortal.”

When one prescribes such conditions for biography it need not mew said that there are few which meet all, or even a few of this essayist’s requirements.

Physicians have achieved much in this world, but none have seen fit to write an autobiography, which would portray for us the thoughts, which preceded one’s epoch making discoveries or deeds. Unfortunately the world has had but one Boswell. It is to be regretted that some of our medical pioneers did not have such an alter ego.

The men whose lives I have chosen to remind you of this evening were Kentucky’s first surgeons and they distinguished themselves in that branch of surgery which today is called urological surgery; though ones title to immortality was merited by his labors in another branch of surgery- they are Ephraim McDowell and Benjamin Winslow Dudley.

To have a proper conception of the greatness of their accomplishments it is necessary to have a mental picture of the field in which they were done. Both began their life’s work in the closing years of the eighteenth century, and this was practically simultaneous with the birth of the state of Kentucky.

Probably the first white man to set foot on Kentucky soil was La Salle, the explorer of the Mississippi River. It is thought that in 1669 or 1670 he came through part of Kentucky from the extreme Eastern boundary to the falls of the Ohio. There was a long period between this time and the advent of another white man, for the next one to come was Doctor Thomas Walker, who, in 1750, made exploring expeditions from his home in Virginia to the Eastern section of Kentucky.

In 1769 John Findley piloted Daniel Boone through a gap in the Cumberland Mountains to the Kentucky, which was then a part of Virginia. Findley had gone through the gap several times as he had made trips to trade with the Indians. It was not until 1775 Colonel James Harrod had built a cabin at the place now called Harrodsburg.

McDowell and Dudley were known as lithotomists since their outstanding achievements were the removal of stones from the bladder.

Urologic surgery was perhaps the first surgery known. The sacred writings of the early Hindus attest the fact that surgery of the genito-urinary tract was in common practice centuries before the coming of Christ. The antiquity of circumcision is an example of early surgery of this type.

The Ayurveda which was written between the sixth and third centuries before Christ speaks of treating strictures by gradual dilation done with wooden or quill instruments, practiced every third day. It also speaks of the treatment of urethritis by injections.

The operation for stone in the bladder is thought to have originated in India, as lithiasis was very common in that country. From India the practice of lithotomy spread to Greece, thence to the remainder of Europe. Hippocrates described the formation of stone in the bladder, declaring that it gradually enlarged from a nucleus.

In Italy during the middle ages there were many traveling stone extractors. These men were not physicians, but learned to remove bladder stones as a trade, and like some of our present day tradesmen refused to teach their trade to anyone outside their immediate family. So prevalent must have been the disease of stone in the bladder that some of these wandering lithotomists were salaried by municipalities. The operation done by Kentucky’s early lithotomists was called a lateral lithotomy. A strolling incisor named Jacques de Beaulieu, or Freere Jacques in the year 1697 devised this operation. The operation was modified by William Cheselden (1688-1752) who, on March 27, 1727, performed an operation, which had its inception in the Jacques operation. The Lateral lithotomy has passed from general usage, and one cannot help wondering why, for with this operation, done prior to the era of aseptic surgery almost unbelievable mortality statistics were given. The operation of superapubic cystotomy has replaced Cheselden’s operation, the first suprapubic operation for this condition was probably done by Pierre France in 1556.

A lateral lithotomy is performed in the following manner. A curved urethral sound is passed into the bladder and held there while the patient is put in the lithotomy position, the staff of the sound is then held nearly parallel to the abdomen by an assistant- this causes the membranous urethra to be recognized more easily- Incision made beginning at a point one-third inch to left of median perineal raphe at a point 1 ¼ inch to 1 ½ inch anterior to anus. At the point of starting the incision the knife is thrust deeply until it encounters the urethral sound.  The incision is then carried outward and posteriorly to a point midway between posterior margin of anus and ischial tuberosity. This incision is usually form two to three inches in length. Besides the superficial structures cut in this incision the following deep tissues are severed- membranous and prostatic urethra deep layer of the triangular ligament, compressor ruethra muscle, anterior portion of the levator ani muscle, and left lateral lobe of the prostate gland.  Through such an opening the index finger of the left had is inserted to the bladder, the stone located and forceps for removal are inserted with the right hand, the dexterity of the English surgeons in doing this type of operation becomes evident when one reads that John Bell who was McDowell’s instructor at Edinburgh frequently removed a stone in eight minutes; even with such rapidity he could not attain the record of Cheselden who was known to have removed a stone in this was in three minutes.

The factors which magnify the achievements of McDowell and Dudley are: the state of development of the community in which they were done; the degree of professional ability common to their vicinity; and heights reached by surgery throughout the world at their time, which was the pre-anesthetic period. McDowell and Dudley began their professional careers at a time when the communities in which they practiced were still subject to attack by the Indian savages, mostly from the North of the Ohio River.

Ephraim McDowell’s birth occurred in Virginia four years before a permanent home had been built in Kentucky. He was born on November 11, 1771. Thirteen years later he came with his father to Kentucky and settled at Danville after a trip, which was very hazardous due to the danger of attack by Indians.

His progenitors were Scotch, though they came to America from Ireland where the family had been placed by the British government on confiscated land.

Is father realized the value of an education for he sent his son to the best schools the new country afforded. He received the major portion of his education at the school of Jones and Worley at Lebanon town, now called Georgetown, situated twelve miles north of Lexington. This school was large enough to accommodate fifty or sixty pupils; had courses in Latin and Greek, the sciences usually taught in first class seminaries. The tuition was twenty-five shillings a quarter. The board, washing, and room rent were three pounds or five hundred weight of pork on entrance, and three pounds at the beginning of the third quarter.  Each student had to furnish his own bed, or pay thirty-five shillings a year to have one furnished.

Following his course at Jones and Worley’s, McDowell spent two or three years as an apprentice in the office of Dr. Humphrey at Staunton, Virginia.

At the age of twenty-two years he went to Edinburgh University, but held private classes. It was Bell more than any other who influenced the future of McDowell.

Bell was born in 1763 and died in 1820. He was a great anatomist and artist, his papers on anatomical subjects being beautifully illustrated by himself. He was finished surgeon; and with Desault and Hunter is considered the father of vascular surgery. He was a very forcible speaker. Bell spent much time lecturing on stone in the bladder. He told his pupils that this condition was found most frequently in persons residing in a limestone country. McDowell’s interest was aroused because his section of the country at home was of such sub-structure. He saw bell operate twice for vesical calculus- no doubt- with McDowell, like w2ith many other pupil of some great teacher, the imprint left by the teacher is not the actual knowledge imparted, but the inspiration which quickens a native talent to develop and accomplish, sometimes, even greater things than the generator of that inspiration had ever done.

McDowell returned from Scotland and began the practice of medicine at Danville in 1795. This was just three years after Kentucky was admitted into the union. It is but natural that he soon acquired a large practice. The people were quick to realize that a man who had had two years study abroad was superior to the doctors in the vicinity, many of whom had never attended even the best schools in the country.

He was a student in the sense usually applied to a physician that is he read the books and periodicals then available. He soon became known as the best surgeon west of Philadelphia. He was very strong in his convictions, an enemy of quacks and charlatans, and would refuse to meet in consultation any many whose ethics were open to criticism. His enemies were begotten of jealousy. It is said of him that he had a great memory for names and faces, a fortunate faculty for any physician to possess.

His habits were exemplary. He did not use profane language; did not use tobacco; and used alcoholic beverages only after unusual exposure. He was quiet and unassuming, and had an attractive personality.

At the age of thirty-one he married the daughter of Isaac Shelby, Kentucky’s first governor.

McDowell came from a family of Presbyterians, and strict ones. Though of exemplary habits and religious inclinations he did not join any church until after his marriage, when he embraced the faith of his wife, becoming a very devout and active member of the Episcopal Church. He donated the ground upon which the present Episcopal church of Danville stands.

McDowell is best known as the first man to successfully remove an ovarian tumor, but he was a well-known surgeon before that time. His epoch making operation was done n Dec. 1809, and two years prior to it he received a diploma from the Medical Society of Philadelphia, the most select medical society of the day, but it was not until 1823 that he received the degree of Doctor of Medicine, an honorary one from the university of Maryland.

In 1812 he operated upon James K. Polk, for vesical calculus. Polk was then seventeen years old- even after Polk became a resident of Washington he would write McDowell assuring him of his gratitude for the relief he received from his operation; a tribute to surgeon and patient.

McDowell performed twenty-eight lithotomies without a death. This, in a day when anesthetics were unknown, when a surgeon was left entirely on his own resources, for traveling was a great undertaking and a man of McDowell’s type had no consulter to whom he could appeal for aid, as there was no man within reach who had attained a skill comparable to his own.

The later years of McDowell’s life were spent on a farm near Lexington, and even in those days the Bluegrass Region was noted for its beautiful farms. He died June 20, 1830. His death was due, according to the physicians attending him, to acute inflammation of the stomach. One might conjecture almost endlessly as to what pathological process brought to an end the life to this man who was one of the most outstanding men of medical history of all time. In his death Kentucky, more than the rest of the country, lost an invaluable asset, but his successor was in the making long before he passed behind the curtain of death. A surgeon of Lexington, Dr. Benjamin Winslow Dudley, immediately took his place as a surgeon of Lexington, Dr. Benjamin Winslow Dudley, immediately took the most able surgeon west of the Alleghenies.

Dudley was born in Spotsylvania County, Virginia, April 12, 1785. His parents moved to Kentucky soon after his birth, thus he came to this state a couple of yeas after the arrival of McDowell. His father was a Baptist minister, widely known, esteemed, and the possessor of a reputation as an orator.  Dudley went to the neighboring schools and for a while worked in one of the stores of Lexington. Later he began the study of medicine in the office of Dr. Frederick Ridgley. Ridgley was considered a learned man of his time and was very careful in his efforts to impart his knowledge to young Dudley. Dudley started his medical studies at a very early age, so that his childhood merged into manhood without the intermediate stage of youth.

Dudley was a man of average height, erect, and fair complexion. He possessed a pleasing voice: which is an asset to none more than it is to a physician. He must have been somewhat pompous, as one historian says that he was exceedingly polite and used the broad “a”, and accent which surely must have been foreign to Kentucky in his day. He was distant, making friends slowly, but retaining them once they made. He belonged to no secret societies, and to no church, though he kept a pew at, and attended the Episcopal Church when possible. When thirty-six years old he married a Miss Short, and from this union there were three children.

Dudley’s medical education was ideal. Even at this date it would be considered excellent from a purely clinical aspect. After serving as an apprentice in the office of Dr. Ridgley he entered Transylvania Medical College, which was, then in its infancy having been started in 1799. In 1804 he went to Philadelphia, and was graduated from the University of Pennsylvania in 1806 – just two weeks before he reached his majority. He came immediately to Lexington to begin practice and opened a one-room office for that purpose. Success was not long n reaching him for in 1810 he had completed plans to take a postgraduate course in Europe.

In our day we hear much of one working his way through college, but we need not delude ourselves into believing that this is a result of a modern love of education, or a condition unknown to those of a century ago. Dr. Dudley’s method of financing his post-graduate study was unique and showed the courage with which he was endowed, which courage later proved a valuable asset in the many professional problems, which he encountered. He bought a flat boat, loaded it with produce and floated down the Ohio to the Mississippi river and on to New Orleans. At New Orleans he sold the boat and his cargo, and re-invested in a cargo of flour. He billed this to Gibraltar, and with it reached his destination sometime in 1810. He sold his cargo at Gibraltar and Lisbon at a large profit. With the funds he hurried through Spain and France to Paris. He was now at the fountainhead of surgical wisdom. While in Paris he had the good fortune to hear Baron Larrey tell of his military experiences. Larrey was Surgeon in Chief of the Armies of Napoleon; and was one of the first to amputate the leg at the hip joint; and he is said to have done two hundred amputations in 24 hours.

Dudley had the good fortune to be present in the Chamber of D3eputies when Napoleon came to report his disastrous Russian Campaign, which report he began with those words which are indelibly written on the pages of history: “The Grand Army of the Empire has been annihilated.”

Dudley remained in Paris for three years and then went to England to study the methods employed in the great Hospitals of London. He had the opportunity of hearing Abernethy who was considered the most dramatic teacher of his time, and of seeing Sir Astley Cooper operate frequently. The latter he considered the most dramatic teacher of his time, and of seeing Sir Astley Cooper operate frequently. The latter he considered the most skilled and graceful surgeon of his day. It might be of interest to the surgeons here present to state that cooper was a great believer in the value of knowledge of anatomy. He was a tireless worker and it was his practice to do some dissecting every day. He would arise at 6 A.M. every day and dissect until 8 A.M, when he would have his breakfast. Part of the afternoon was spent in the dissecting room with his students. Even when away from home he had to do his daily dissecting, and this necessitated the payment of fabulous sums to body snatchers. 

Dudley had the advantage of study under these two exponents of the two methods of teaching, Abernethy the champion of the didactic method, and Cooper the teacher who insisted o actual demonstration in the sickroom, operating room, or dissection room.

After four years in France and England, Dudley received an honor rarely coming to American Surgeons, that of becoming a member of the Royal College of Surgeons.

When he finished his post-graduate work he spent six months traveling in Italy and Switzerland. Surely such a trip was an asset to him later for it added to his standing as a cultured gentleman. A position to be striven for by any young professional man.

While in Europe, Dudley had collected some rare books and instruments, together with some rare mineral specimens, and these were in the Custom House at London when that structure was burned. He lost all his treasures.

In 1814 he returned to Lexington, Kentucky, and immediately began the practice of medicine. His success was almost instantaneous, and he soon had a national reputation. He was made the head of the Medical Department of Transylvania University in 1817 and was appointed to fill the chair of anatomy and surgery.

His manners were those of a Frenchman, while his surgical methods were the result of the English influence. He was very dignified and serious at all times; had no gifts as a speaker, but his great earnestness and directness made him an able teacher, and his presence on, and at the head of the faculty of Transylvania brought nation-wide recognition to his school.

The general public held Dudley in the same high regard which his students did. His patients came from far and near; come coming from Europe.

While professor of anatomy and surgery in 1818 he got into a misunderstanding with Dr. Daniel Drake over a postmortem examination done on the body of a man who had been shot. Dudley, tired of carrying on their controversy with pen and ink, finally challenged Drake to a duel. Drake declined, but his friend, Dr. Wm. H. Richardson, accepted in his stead. The duel resulted in Dudley shoot Richardson in the groin. The victim bled profusely and Dudley by thumb pressure controlled the hemorrhage until the vessel could be tied. He saved Richardson’s life and the two were warm friends for the remainder of their lives.

Dudley wrote very little. The first publication of the Transylvania Journal of Medicine, published one hundred years ago this month, contained an article by Dudley on the cause and treatment of epilepsy. He believed this condition resulted from fracture of the skull, and that it should be treated by trephining. He operated upon five successive cases, all resulting in cures. He was very fortunate in not picking the idiopathic type of epilepsy.

Dudley did, as all other physicians of his day, both general practice and surgery, but he let every one know that he preferred surgical cases.

In the day of Kentucky’s first surgeons the most prevalent condition requiring surgical treatment was vesicle calculus. Kentucky is said to have had more cases of stone in the bladder than the rest of the country combined. The limestone foundation of the then settled part of Kentucky was probably the cause of this condition.

Dudley was not only the foremost lithetomist of his time in Kentucky, but in the world. A prominent New York surgeon came to Lexington to see Dudley do some lateral lithotomies. Dudley did three for him and they were done so rapidly that the visiting surgeon said that had he turned his head he would have missed the whole operation.

In his lifetime Dudley operated upon 225 cases of stone in the bladder, with three deaths. Such a record could not be improved upon today. When one considers the fact that in the days when this state was young and its surgeons great in every case of vesical calculus operated upon the diagnosis was made from the history and the passage of the sound, the number of cases operated upon is noteworthy. Had the x-ray been in use in Dudley’s time we would probably be reading of five hundred or more cases instead of two hundred and twenty-five.

In 1850, when 65 years of age, he retired from practice and from his teaching positions at the medical school. He had amassed a fortune from his practice. He was known to be very lenient with the poor, but when working for the wealthy they paid him handsomely. When he retired in 1850 he went to live at Fairlawn, his beautiful farm near Lexington. He lived twenty years after his retirement, and died on January 20, 1870, after an illness of ten hours.

These two outstanding men had lives that were full. McDowell died at a comparatively early age – 59 – yet he had witnessed the opening of a country, which had to be won from a savage race. He not only was a witness to the rapid changes in Kentucky in the first quarter of this country during the years soon after its formation. He had done his part towards bringing renown to his country as a result of his industry and talents.

Dudley’s span of life covered a most interesting period in the science of medicine. He had the same opportunity possessed by McDowell; to see early development of the commonwealth of Kentucky, but he had much more for he died just forty years later than McDowell. He was still a practicing surgeon when ether came into use as an anesthetic, since Crawford W. Long used it the first time in 1842. Lister began the antiseptic era of surgery five years before Dudley died and it is natural to assume that a man of Dudley’s mental attainments was a most interested observer of the infancy of modern surgery, and died knowing those who followed him would have a more roseate path to tread than that which he faced. The final years of his life saw his country go through a terrible civil strife and the trails that this strife caused for years after its settlement.

To my mind the most valuable lesson we might learn form the lives of these two men, and the success they made of their lives, is the value of reparation. They were endowed by mature with foresight and intelligence and they prepared themselves for the opportunities they felt would be theirs were they capable of utilizing them. They both had good training in the profession they were to follow. McDowell whose medical education was purely a practical one, save for the theory he had culled from the books of Doctor Humphrey, soon realized that to be a success he had to seek knowledge from those who were especially fitted to impart it. He probably saw from experience that to be self-taught is to be poorly taught, for the weakest link in the chain of self education is the danger of such a pupil making a mistake and then continuing to make it because it is not recognized as an error. He went to the place he thought had the most to offer him. He was fortunate that the surgical leadership of the world had been wrestled from France by a people who spoke his tongue; this condition being largely due to the eminence attained by John Hunter (1728-1793).

What percentage of the graduates of medicine of this day can boast of a better postgraduate training than that of Dr. Dudley. In his medical education he clearly shows his courage and foresight, two attributes that were largely responsible for the prominent position he reached. He began his medical education in the office of a practitioner in Lexington- later he entered Transylvania medical school. With his growing knowledge of medical education he must have come to the conclusion that an older, more established a school would be a better place to go for a thorough medical education. Consequently he went to the University of Pennsylvania. The University of Pennsylvania was the oldest medical school in the United States, dating from 1765 when it was founded by Doctors Shippen and Morgan. At the time Dudley was a student there, the surgical department was under the guidance of Philip Syng Physick (1768-1837) who has been called the father of American surgery.

Upon the completion of his studies at Pennsylvania Dudley had to do what many a one since his time has been forced to do- he had to get into active practice immediately because of the state of his finances, but this did not thwart his ambition. He kept before his mind the goal for which he was striving, pre-eminence in his profession. As soon as the financial difficulties had been over some he lost no time in resuming his medical education. He spent three years with the master surgeons of France. Dudley’s education had been a more thorough one than McDowell’s and while his biographers do not state it, he must have been able to converse in French, also he would not have spent such a long time in a country the language of which he could not understand. Before coming home he wanted to get some idea of the British School of Medicine. He must have found conditions in England ideal for his needs, as he spent a year in that country. One would have expected him to go to Edinburgh because of the influence the university of that city had upon his Alma Mater. Both Shippen and Morgan, who founded the University of Pennsylvania, were graduates of Edinburgh- as was Physick, the foremost American surgeon of Dudley’s school days.

In the lives of these two Kentucky pioneers we have shining examples of the value of a thorough education and training. Professional and material success was not long in reaching them and it remained with them until the close of their careers. These two well-prepared surgeons did no come home and seek some large city in which to practice their profession – each went to the place in which he was reared. The success that they attained would lead one to believe that they were believers in the thought so impressively expressed by Emerson when he said:

“If a man write a better book, preach a better sermon, or make a better mouse-trap than his neighbor, though he build his house in the woods, ht e world will make a beaten path to his door.”