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Review of 'Doctors on Horseback'

Review of 'Doctors on Horseback'

Doctors on Horseback
James Thomas Flexner
Fordham University Press, $20

The woman in the backwoods Kentucky cabin had been suffering excruciating labor pains, but still the baby wouldn't come. When the ninth and then the tenth month passed with no sign of birth, her doctors summoned the surgeon said to be the best on the frontier, Dr. Ephraim McDowell of Danville, Kentucky. The year was 1809.

From the perspective of today, the medicine practiced in the late 18th and early 19th centuries was medieval. Anesthesia was unknown. The best medical minds considered purging and bleeding to be the most effective remedies for fevers; in extreme cases, as much as four-fifths of a patient's blood was drained off. Surgery was limited to simple operations on the extremities, where vital organs would not be exposed to infection.

Dr. McDowell, examining the poor woman by candlelight, realized quickly that she wasn't pregnant. She had a large ovarian tumor. The prevailing medical wisdom, he explained to her, was that she would inevitably die in a year or maybe two. Some physicians, he added, had contemplated surgery in such cases, but none had tried it. Opening the abdomen, they believed, was certain to result in a fatal infection of the abdominal wall. McDowell, however, thought there was a chance that an operation could result in a complete cure. If she was willing, he told her, he would operate, but it would require a 60-mile trip by horseback to his home. She agreed to do it.

The doctor knew that he could lose his practice and perhaps even be prosecuted if the woman died. His partner at first declined to assist him, and the townfolk talked of forcibly preventing him from operating. McDowell decided to perform the surgery on Christmas Day, when most people were at church. But when the churchgoers emerged and realized that the operation was under way, they gathered outside the doctor's house and screamed threats while the brave patient clenched her fists and tried to sing hymns. The sheriff kept the crowd from rushing the house.

McDowell coolly removed 15 pounds of "a dirty, gelatinous-looking substance" and a 7.5-pound growth in a 25-minute operation, then stitched up the incision. The crowd cheered on hearing the news, but five days elapsed before the doctor knew for certain that the danger of infection was past. The woman recovered fully, and a month later she was back doing chores and taking care of her five children.

McDowell's pioneering surgery, described by James Thomas Flexner in a reissue of his exciting 1937 book Doctors on Horseback, was one of the most important operations in medical history. It stilled the fear of infection that had allowed thousands to die untreated. Appendectomies, kidney surgery and dozens of other operations are "lineal descendants," Flexner writes, of this one bold stroke in the Kentucky wilderness.

Flexner tells several other fine stories in his well-researched, if occasionally overwritten, account of the early years of American medicine. One of the best is the saga of another frontier doctor, William Beaumont, and his lifelong effort to understand the digestive system by studying a patient whose stomach was blown open by a shotgun and never healed over. When Alexis St. Martin recovered from the near-fatal shooting, Beaumont persuaded him to serve as a kind of living laboratory, a cutaway model of the stomach's anatomy and functioning. Watching the man's stomach at work, Beaumont produced the most accurate descriptions of the organ's interior before the use of x-rays, and demonstrated the crucial importance of gastric juice in digestion.

The trouble was that St. Martin, who was healthy enough to work and raise a family, never stopped squirming uncomfortably in the role of guinea pig. He wanted a life of his own. The demanding, self-righteous physician and the unlearned, irresponsible patient came to loathe each other. Despite a contract that obliged him to "obey, suffer and comply with all reasonable or proper orders or experiments" in return for room, board and cash, St. Martin fled, only to be coaxed back and then to flee again. When he died, 28 years after Beaumont's death, his financially strapped family was determined to leave him in peace at last. They turned down doctors' requests to autopsy the body and exhibit the celebrated stomach.

A chapter titled "The Death of Pain" chronicles the long wrangle among four medical men-two dentists, a small-town Southern doctor and a high-profile lecturer-over credit for the discovery, in the 1840s, of the anesthetic properties of ether. The doctors in Flexner's pages were touchy about things like credit. It was a time when physicians competed for the public's attention and trade as diet savants do nowadays. It turned out that the mildest-mannered of the four claimants to the ether laurels, a Georgian named Crawford Long, had the best case. He and his friends were in the habit of getting drunk on ether, which was a common drug before it was an anesthetic, and Long noticed that they felt no pain when under its influence. In 1842 he administered ether to a patient while removing a tumor from the man's neck, and it was thus that pain during surgery was finally conquered. The unseemly squabble for credit ultimately unhinged the other three contenders-one committed suicide, another wound up in an asylum, and the third suffered a series of nervous breakdowns.

When Flexner's pioneering doctors weren't arguing over credit, they were busy refining ways to libel one another. Daniel Drake, founder of one of the first medical schools west of the Alleghenies, in Cincinnati, had a special gift for insulting his rivals. When one confronted him on the street and sneered, "I do not propose to step aside for a fool," Drake deftly stepped to one side and replied, "I will."

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