Though admiring Aston Key’s skill, a Lancet editorial was highly critical of the time he took to perform the operation, and the “obnoxious atmosphere” caused by the presence of more than six hundred spectators in the room. But that was as nothing to the response of a surgeon who wrote to the journal the following week. “Modern surgery is a vampire which feasts upon human blood,”* wrote Mr. Simpson, launching into a ferocious attack upon his colleagues:
I trust that nature was more merciful than man, and from the extremity of his sufferings formed a veil of oblivion, which rendered this unfortunate being at least partially insensible to his agonies. I think that this operation could neither advance the science of surgery, nor be otherwise beneficial to the human race; that it was neither sanctioned by reason, nor warranted by experience.
As Simpson pointed out, the patient’s life had not been in imminent danger; the decision to operate may have had more to do with surgical hubris than clinical need. The death of Hoo Loo prompted a period of soul-searching among the English medical profession—and hastened the end of the “heroic” era of surgery, when interventions were sometimes valued more highly for their dramatic impact than for their effect on the patient. Too late, alas, for the unfortunate Chinese peasant who had traveled thousands of miles in the forlorn hope of a cure.
ALL AT SEA
When I first came across this stirring tale of improvised surgery at sea, I wasn’t at all sure that it could be true. It appeared in 1853 in a minor journal called The Scalpel, which was published in New York between 1849 and 1864. The magazine was edited, and mostly written, by the indefatigable Dr. Edward H. Dixon, a highly regarded expert on sexually transmitted diseases and an outspoken opponent of masturbation—a practice that, according to many doctors of the era, led to illness and even death.
The Scalpel was unlike other medical journals in that it was aimed at lay readers as well as professionals. Its articles were conversational, avoided unnecessary jargon and were often satirical in intent. At first glance, this story looks like one of Dixon’s humorous jeux d’esprit, but much of the detail is corroborated by contemporary newspaper reports and even shipping records.
Edward T. Hinckley, of Wareham, Mass., then mate of the bark Andrews, commanded by James L. Nye, of Sandwich, Mass., sailed some two years and a half since (we find the date omitted in our minutes) from New Bedford, Mass., on a whaling voyage.
New Bedford was probably the busiest whaling port in the world at the time, with eighty-seven ships setting off on expeditions in 1850 alone. One of them, the Ann Alexander, would become famous the following year when she was rammed and sunk by a sperm whale—a real-life Moby Dick!* Very few ships are known to have been sunk by whales, but on its voyage, the Andrews—which weighed anchor just two days after the Ann Alexander—would also have an unfortunate encounter with one. During an eventful voyage, it was the crew, however, who provided the early excitement:
When off the Galapagos Islands, one of the hands, who had shown a mutinous disposition, attacked Captain Nye with some violence, in consequence of a reproof given him for disobedience. In the scuffle which ensued, a wound was inflicted with a knife, commencing at the angle of the jaw, and dividing the skin and superficial tissues of the left side of the neck, down to the middle of the clavicle, under which the point of the knife went.
An ugly-sounding wound. The knife opened up a gash down the side of the captain’s neck, from the hinge of his jaw to the collarbone.
It was done in broad day, in presence of the greater part of the crew; and Mr. Hinckley, the mate, being so near that he was at that moment rushing to the captain’s assistance. Instantly seizing the villain, and handing him over to the crew, the knife either fell or was drawn by someone present, and a frightful gush of dark blood welled up from the wound, as the captain fell upon the deck.
The “dark blood” was a sign that a vein, rather than an artery, had been injured—still serious, but less immediately life-threatening.
Mr. Hinckley immediately thrust his fingers into the wound, and endeavored to catch the bleeding vessel; with the thumb against the clavicle, as a point of action, and gripping, as he expressed it to me, “all between,” he found the bleeding nearly cease. Such had been the violence of the haemorrhage, a space on the deck fully as large as a barrel head being covered with blood in a few seconds, that it was evident from that and the consequent faintness that the captain would instantly die, should he remove his fingers from the bleeding vessel.
An alarming position to be in. His finger was now holding back a crimson tide, like a bloodier version of the little Dutch boy and the dyke. He paused for a moment to work out what to do.
The bleeding had stopped for now, but he needed to find a way of removing his digits without the hemorrhage recurring:
“I found my fingers passed under something running in the same course with the bone; this I slowly endeavored to draw up out of the wound, so as to see if it was not the blood vessel. Finding it give a little, I slowly pulled it up with one finger; when I was pulling it up, the captain groaned terribly, but I went on, because I knew I could do nothing else. As soon as I could see it, I washed away the blood, and was astonished and very glad to see there were two vessels, as I supposed them to be, one behind the other: the cut was in the front one.”
This clear description makes it possible to identify the blood vessels as the subclavian vein and its associated artery. Both lie just underneath the clavicle, the vein in front of the artery. The subclavian artery is one of the major branches of the aorta: If it, rather than the vein, had been punctured, the captain would probably have bled to death within a few minutes. What would you do in such desperate circumstances? I’d probably yell for help, loudly. But Mr. Hinckley was made of sterner stuff.
“As I had often sewed up cuts in the flesh, and knew nothing about tying blood vessels, and supposed that was only done when they were cut in two, as in amputated limbs, I concluded to try my hand at sewing it up; so I took five little stitches; they were very near together, for the wound was certainly not half an inch wide, if so much.”
Mr. Hinckley was evidently skillful with a needle and thread, because this sounds ferociously difficult. Remember, he was standing on the deck of a moving ship, having only just averted a mutiny—hardly the easiest circumstances for fine suture work.
On inquiry of Mr. Hinckley, if he cut off the thread each time and threaded the needle again, he said Yes; but “I only cut off one end, and left the other hanging out.” This he had learned from a little book, prepared for the use of sea captains and others, when no surgeon was on board.
It sounds as if Mr. Hinckley was a quick learner. He used an “interrupted” suture technique: Each stitch was separate from its neighbor. It was standard practice at the time to leave the threads dangling out through the wound—this allowed the surgeon to remove or tighten them as necessary.
Mr. H. continued: “I twisted the ends together loosely, so as to make one large one, and let it hang out of the wound over the bone; then I closed all up with stitches and plasters. On the fourteenth day I found the strings loose in the wound, from which matter had freely come: it healed up like any other cut.”
And that was that: a complete recovery. But having cheated death once, the captain was less fortunate the next time.
Poor Captain Nye finally met a sad fate; he was drowned on the destruction of his boat by an enraged whale.
It’s difficult to establish precisely what happened. Captain Nye and two of his men were indeed killed by a whale on December 29, 1852, but the vessel returned to port on May 3 the following year, minus a captain but carrying 909 barrels of sperm oil. The Andrews then apparently went back to sea and was “lost on the Galapagos” sometime later that year. Of Mr. Hinckley’s subsequent fate nothing is known, although I suspect he left the ship in May 1853, since his account of the operation in The Scalpel appeared some months later.
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The article concludes in grandiose manner:
We may be mistaken in our views of its importance, but we think that in the estimation of our professional readers we have placed upon record one of the most extraordinary circumstances in the whole history of Surgery.
Dr. Dixon has a point. Suturing veins and arteries was a notoriously difficult thing to do, and it was not until the beginning of the twentieth century that a surgeon succeeded in joining the two ends of a completely severed vessel. A specialist at any of the great hospitals of London, New York or Paris would have been proud of the result achieved by this untutored seaman on a mutinous whaling ship in the Pacific.
AN EXTRAORDINARY SURGICAL OPERATION
The San Francisco surgeon Elias Samuel Cooper had a Latin motto written over his bed: Nulla dies sine linea—“No day without a line,” a phrase used by the ancient Greek painter Apelles to describe his utter dedication to his art. Cooper, too, believed in letting no day go to waste. An insatiable autodidact, he slept for only four hours a night and packed more into his forty years than many who live for twice as long. Not all of it was good: He was regularly embroiled in court cases, alienated many of his colleagues and was widely suspected of grave robbing in order to obtain cadavers for his anatomy classes. But he also founded the first medical school on the west coast of America, pioneered the use of chloroform and the caesarean section, and performed numerous operations of breathtaking audacity.
Of all his achievements, however, there was one that Cooper regarded with particular satisfaction, an operation so fraught that he described it unhesitatingly as the most difficult he ever performed. It was reported in an 1858 edition of The Medical and Surgical Reporter under a headline that was, if anything, an understatement:
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!
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 only as 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. 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* 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 frolicsome 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 frolicsome 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 major blood vessels or the heart itself. And goodness only knows how he managed to survive for two months afterward.
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 his condition that he decided to operate first thing the following day. Dr. Cooper was not a superstitious man, but as he prepared for surgery, he had a strange experience that he would later liken to a premonition. While selecting and laying out his instruments, he found himself drawn to an “awkward and ungainly” pair of forceps, an item designed for removing bladder stones and ill suited to the procedure he was about to perform. Without much thought, he slipped them into his pocket and went to the operating room to get on with the job.
Operation.—The patient being placed on the right side, an incision through the soft parts three inches long was made.
When the surgeon cut through the patient’s muscles, 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 that had started to bleed.
The wound was now fully absterged,* 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. Anesthesia 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,* 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 liters.
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 t
o the patient who appeared to be rapidly sinking.
Given the experience the poor man was going through, this is hardly surprising. Brandy was here being administered as a stimulant, though in his situation, I suspect I’d be asking for something even stronger.
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 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 anesthesia 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 anesthesia. 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.
The Mystery of the Exploding Teeth and Other Curiosities From the History of Medicine Page 15
