An extraordinary surgical operation

Last week I came across an article which took my breath away. It was published in 1858, in an American journal, the Medical and Surgical Reporter, and it describes an operation of such audacity and skill that I can’t believe it isn’t better known. This is how it was reported:

At the request of a committee of the San Francisco County Medico-Chirurgical Association, Dr. E. S. Cooper of that city has furnished them with a detailed account of an operation performed by him for the removal of a foreign body from beneath the heart!

Some historical context: in 1857 the idea of operating inside the chest was so terrifying as to be almost unthinkable. It was occasionally necessary when projectiles such as musket balls had penetrated the lungs, but it was a measure of last resort. It was inherently risky, since opening the chest would let air into the thoracic cavity, causing the lungs to collapse – a condition called pneumothorax. This could quickly bring about respiratory failure, killing the patient by suffocation. And the location of this foreign object – underneath the heart – added another layer of difficulty to the operation. Many surgeons believed that even touching the heart could cause it to stop beating. The first procedure to treat a cardiac wound did not take place until 1896, partly because so many experts thought that manipulating the organ was virtually impossible.

Dr. Cooper does not tell us what length of time was consumed in performing his extraordinary operation, though he mentions that “at least three-quarters of an hour” were consumed in an exploration of the thoracic cavity by means of a sound [probe] for the purpose of discovering the location of the foreign body. This may give the reader some idea of the entire length of time occupied in the operation.

At a conservative estimate, it must have taken more than two hours. This is not exceptional by modern standards, but you haven’t heard the half of it yet…

Mr. B. T. Beal, aged twenty-five, of Springfield, Tuolumne County, California, with some other young men, in a frolicksome mood, resolved to burst an old gun, and accordingly loaded it with about eighteen inches of powder, to which they connected a slow match and then endeavored to seek security by flight.

“Guys, I’m in a frolicksome mood. Shall we blow up an old cannon?”

Unfortunately, a brisk wind blew up the powder with great rapidity, and the gun exploded before they had retreated far. A slug of iron had been driven into the gun as a temporary breech-pin, which, bursting out in the explosion, struck Mr. Beal in the left side below the armpit, fracturing the sixth rib, entering the chest and lodging, as was afterwards found, beneath the heart upon the vertebral column, just to the right of the descending aorta, where it had evidently remained from the period of the injury, January 25, 1857, until it was removed April 9, seventy-four days after.

This is a pretty extraordinary set of circumstances. The fact that the ‘slug of iron’ had entered the man’s chest without killing him outright is surprising – it might easily have destroyed any number of important structures, including blood vessels or the heart itself. But I’m also amazed that more than two months elapsed between the injury and surgery without him dying.

In a state of extreme prostration he was brought to the city, having had frequent discharges of several ounces of purulent matter at a time from the chest through the original wound. The left lung had lost its function, probably less on account of the violence done the lung at the time than from the subsequent accumulation of pus in the chest, though he had bloody expectoration for a few days. He came to my Infirmary on Mission Street 8th of April, and during the night following had alarming symptoms of suffocation, so much so that I entertained most serious apprehensions that he would not live till morning.

The surgeon would have preferred to let his patient ‘obtain rest from the fatigues of his journey’, but became so alarmed by these symptoms that he decided to operate first thing the following morning.

Operation.—The patient being placed on the right side, an incision through the soft parts three inches long was made.

When the surgeon cut into the man’s side he found that one rib was broken and already in a state of decay – no doubt caused by infection. He enlarged the incision so that it encompassed the original wound, and then had to pause to tie shut two or three arteries which had started to bleed.

The wound was now fully absterged [wiped clean], after which an effort was made to find the breech-pin by using the probe. This failing, the incisions were lengthened and the ribs further exposed.

What has been described so far would not necessarily be out of place in a modern surgical case report. But here’s the thing: this patient was fully conscious.  Anaesthesia was widely available by 1857, but the surgeon decided to do without. This may have been because of the danger of asphyxiation: both chloroform and ether depress respiratory function, increasing the risk of sudden death.

A portion of the sixth rib, which was carious [decayed], was now removed, and was followed by the discharge of about ten ounces of fluid resembling venous blood, contained in a cyst which was broken by the removal of the portion of the rib. A most extensive but careful examination with the probe was now made in order to detect, if possible, the foreign body, yet to no purpose; but air having already been admitted into the chest I unhesitatingly removed portions of the fifth and seventh ribs, together with such an additional piece of the sixth as was necessary to make ample room to afford every facility for the further prosecution of the search.

Just put yourself in the patient’s place for a moment. Wide awake, with a surgeon carving large chunks out of your ribs and having a good rummage inside your thorax.

Some very firm adventitious attachments were now broken up with the fingers, which gave exit to an immense amount of purulent matter—two quarts at least—which had been entirely disconnected with the fluid first discharged from the chest.

A quite horrifying amount of pus: well over two litres.

The pleura had several large holes through it and was thickened to four or six times its natural state in some parts. The pulsations of the heart in the pericardium could be distinctly seen through these holes. Brandy was now administered freely to the patient who appeared to be rapidly sinking.

In the circumstances this is hardly surprising. Though in that state I’d want something considerably stronger than brandy.

The left lung was found completely collapsed after the discharge of purulent matter. By giving brandy freely the patient soon began to revive, when the search for the foreign body was resumed. At this time the fingers could be placed upon different portions of the heart and feel its pulsations distinctly, but could obtain no clue to the location of the foreign body.

While not actually painful (the cardiac muscle contains no pain receptors), the sensation of having your heart touched by a surgeon’s fingers cannot be a pleasant one.

The patient now appeared almost completely exhausted. Brandy was given freely.

Only now (!) was anaesthesia contemplated.

Chloroform was not administered at first, owing to the expected collapse of the left lung on the admission of air into the chest, but a considerable reaction taking place a limited quantity was now used, and the manipulations continued. A sound was introduced and the thoracic cavity explored for at least three-quarters of an hour before anything like a metallic touch could be recognized, and then it was so indistinct as to leave the matter doubtful.

From the description it sounds as if the dose of chloroform was only enough to produce light sedation rather than full anaesthesia. The surgeon now continued his epic search for the rogue piece of metal.

The space immediately above the diaphragm was considered the region in which the metal was most likely to be found; since the immense amount of suppuration which had taken place, it was thought might have dislodged, and gravitation carried it down to the bottom of the chest. The metal not being found here there was no longer any probable opinion to be formed as to its whereabouts, and to describe the difficulties of the search that followed would be difficult if not impossible.

I’ve read hundreds if not thousands of nineteenth-century surgical reports, and this is possibly the most harrowing and complicated operation I’ve come across. In an age before X-rays, finding a small foreign body which might be virtually anywhere in the chest cavity without killing the patient was a truly herculean task.

No one can have any just conception of the degree of patience required to do what was done, save the one who did it. This is not spoken boastingly, but it is simply the truth. It is sufficient to say that a general exploration of that side of the chest was made, and then it was taken by sections, occasionally passing through holes in the pleura, which latter appeared to have scarcely no normal relations to the surrounding structures, touching by lines the entire surface of the parts, and at last the sound appeared to encounter something of a metallic nature beneath the heart, but the pulsations of that organ were so strong against the instrument as to render it difficult to settle the matter definitely.

This is phenomenal stuff. Dr Cooper was performing delicate manipulations that would not become a normal part of surgical practice for many decades.

At last, however, it became evident that the location of the iron was found, and I endeavored to move it out of its position with the point of the sound, in order to get it into a place more eligible for extraction by the forceps. I failed in this, and in manoeuvring the instrument finally lost the track by which the sound had first passed back of the heart to the metal, and it was during my efforts to recover this, and which was accomplished with the more difficulty owing to some membranes falling in the way, that I discovered the sound had in the first instance reached the metal by passing between the descending aorta and the apex of the heart.

Terrifying! Unknown to the surgeon, he had stuck his probe between the largest blood vessel in the body and the heart itself. One slip and it was curtains for the patient.

The metal being again found, the sound was steadily and strongly held in contact with it until a pair of long lithotomy forceps was thereby conducted to the spot and the breech-pin seized and extracted, which, however, was the work of several minutes, owing to the great difficulty in grasping it even after the forceps was made to touch it.

Dr Cooper was alarmed to find that when he opened the forceps their expansion caused the heart to move out of its natural position. Eventually, however, he managed to grab the metal block and remove it.

After the metal was extracted, the patient was turned on the wounded side, and a tent placed in the track of the original sinus, after which the wound was dressed and the sufferer permitted to rest in bed with his body still inclined towards the injured side.

A ‘tent’ is a conical plug of material used to keep a sinus (passage) open, allowing the bottom of the wound to heal first and thus prevent infection.

The patient’s recovery was long and arduous, but in early August his condition was reported as follows:

The external wound has entirely cicatrized [healed]. No cough nor pain in the left side—good appetite and all the functions of the system well performed. The left breast is somewhat sunken, but the upper lobe of that lung has recovered in a great degree its former action.

The left lung was almost destroyed by the injury and subsequent infection, so this represents an impressive recovery. Dr Cooper ends his report with such an enthusiastic endorsement of the Californian climate that the San Francisco tourist board might have used it on their advertisements:

His subsequent astonishing recovery is attributed to his great cheerfulness, good constitution, and to the effects of our unparalleled climate, in which it appears nearly impossible for a patient to die with almost any ordinary degree of injury, provided a reasonable share of attention is afterwards given him. San Francisco has the advantage of every other city on the globe, in regard to climate, for surgical operations, since, if owing to any peculiarity of the case, our coast breezes are not equally well adapted to all the stages of convalescence after an operation, it is an easy matter to obtain almost any desirable change by half a day’s easy travel, which I think can be said of no other city.