The sad case of Hoo Loo

Great surgeons are usually remembered for their successes rather than their failures. Sir Astley Cooper, one of the preeminent figures of early 19^th-century medicine, had many notable successes – such as his operation for popliteal aneurysm, in which he saved the leg of a cab driver by tying a ligature around a major blood vessel.  But one of his most famous cases was a failure.  Although the patient died, the operation caused a sensation, with reports in all the major newspapers and journals. And – perhaps uniquely – more than 600 people watched the procedure as it was being performed. This account was published in The Lancet in April 1831

Hoo Loo, a Chinese labourer, was admitted into Luke’s ward, Guy’s Hospital, in the third week of March last, with an extraordinary tumour depending from the lower part of the abdomen, and of a nature and extent hitherto unseen in this country. He had been brought to England from Canton, by his own desire, in an East-Indiaman, for the purpose of having this tumour removed at one of the London hospitals, the native surgeons declining to make the attempt, a general disinclination to the performance of serious operations prevailing in the East, where both the climate and the law offer important objections to surgical proceedings which may lead to the loss of human life.

Hoo Loo’s tumour was simply enormous. It had started to appear ten years earlier, when he was 22, as a growth on his foreskin. By the time of the operation it was a massive growth, four feet in circumference, hanging from the abdomen between the navel and the anus – almost entirely swallowing his genitals. The tumour was later found to weigh 56 pounds, and was so heavy that Hoo Loo had to throw his shoulders backwards while he walked to compensate.

We have heard that on his voyage here the change of air had such an effect on his constitution, as to occasion a material increase in the tumour. Since his arrival his appetite, health, and spirits, were extremely good. While in the hospital there appeared nothing to induce the surgeon to order him any medicine. His diet consisted principally of boiled rice, and no restraint was placed on his appetite, which was very great. He was generally considered to have improved in health while in the hospital, though it was difficult to form a decided estimate on this point. He all along contemplated the operation with satisfaction.

The operation was scheduled for a Tuesday, but when the hospital authorities realised that a large crowd of spectators was likely to attend they moved it to a Saturday in the hope that this would deter them:

Notwithstanding this precaution, however, an assemblage, unprecedented in numbers on such an occasion, presented themselves for admission at the operating theatre, which was instantly filled in every part, although none but pupils, and of those only such as could at the moment present their “hospital tickets,” were admitted. 

‘Hospital tickets’ were issued to medical students and entitled them to watch operations for educational benefit.

Hundreds of gentlemen were consequently excluded, and it became obvious to the officers of the hospital, that some other room must be selected. Accordingly Sir Astley Cooper entered, and, addressing the pupils, said, that in consequence of the crowd, the patient being in a state which would admit of the removal, the operation would take place in the great anatomical theatre. A tremendous rush to that theatre accordingly took place, where accommodation was afforded to 680 persons, and where preparations were immediately made for the patient.

A microbiologist’s nightmare – 700 people, all exhaling their germs all over the patient.  It was not until the 1860s that surgeons would pay any attention to maintaining sterile conditions in the operating theatre.  Hoo Loo entered the room and was secured on the operation table:

A short consultation now took place between Sir Astley Cooper, Mr. Key, and Mr. Callaway, during which it was finally agreed, that if it were found possible, the genital organs should be preserved. The face of the patient was then covered, and Mr. Key, taking his station in front of the tumour, commenced the operation.

In brief, the plan was to remove the tumour, liberate the penis and testicles, and form three flaps of muscle and skin which would meet in the middle to cover the genitals. The operation began with three major incisions to form these flaps.

The operator then proceeded to lay bare the two [spermatic] cords and the penis, a step in the operation which was performed with very great neatness. Sufficient time had now elapsed for the depressing effects of the operation to exhibit themselves, while the penis and testicles had yet to be dissected out. The determination to attempt this arose from, its having been ascertained that the sexual inclinations of the man were unimpaired, seminal emissions being occasionally experienced. The delay, however, which so intricate a portion of the operation would have occasioned, now induced Sir Astley Cooper to propose that the genital organs should be sacrificed, and the suggestion was promptly acceded to.

This may seem a brutal decision, but the procedure was a battle against the clock. They were operating without anaesthetic, and loss of blood was also likely to be a major threat. Having removed Hoo Loo’s genitals they got on with the main business of removing the tumour, a painstaking process which entailed tying off a number of blood vessels.

But a period of time elapsed before the conclusion of the operation which must have far exceeded the anticipations even of the most fearful, and by the time the tumour was entirely separated and the exposed parts were closed over, an hour and forty-four minutes had passed. This tremendous protraction was chiefly occasioned by the intervals which were from time to time allowed the patient for recovery from the fits of exhaustion which supervened.

Understandably. 

Complete syncope occurred twice, and during the whole of the latter steps of the operation he was in a state of fainting. The quantity of blood lost was variously estimated by those who assisted, and though certainly not large, it was the operator’s own impression that the haemorrhage was the immediate cause of death… Immediately after the removal of the tumour, another fit of syncope—if syncope could be said to be at all incomplete for the last half hour—came on, from which the poor fellow did not for a moment rally. No remedies that were directed to overcome this state of collapse had the slightest effect; warmth and friction of the extremities, warmth to the scrobiculis cordis [pit of the stomach], the injection of brandy and water into the stomach, and, ultimately, from the suspicion that the loss of blood had been too great, transfusion to the amount of six ounces, taken from the arm of a student—one amongst several who offered to afford blood were amongst the means resorted to. The heart’s action gradually and perceptibly sunk. The patient did breathe after the operation, but that is as much as can be said. Artificial respiration was subsequently, but vainly attempted. 

The unnamed author of this report adds a tribute to the unfortunate but courageous patient:

The fortitude with which this great operation was approached, and throughout undergone, by Hoo Loo, was, if not unexampled, at all events never exceeded in the annals of surgery. A groan now and then escaped him, and now and then a slight exclamation, and we thought we could trace in his tones a plaintive acknowledgment of the hopelessness of his case. Expressions of regret, too, that he had not rather borne with his affliction than suffered the operation, seemed softly but rapidly to vibrate from his lips as he closed his eyes, firmly set his teeth, and resignedly strung every nerve in obedience to the determination with which he had first submitted to the knife.

Though admiring the skill of the surgeon, a Lancet editorial was highly critical of the circumstances under which the operation took place – in particular, the decision to allow 680 spectators into the room, and the decision to give the patient occasional breaks to recover his strength. 

We hint not in the remotest sense that Mr. Key made a single incision more than was necessary, or that he performed one cut unscientifically, but we think that the pauses were injudicious, and are decidedly of opinion, that the time and place selected for the operation showed an extraordinary, if not a fatal, want of professional discrimination.