The year after this celebrated failure, medics across Europe thrilled to news of another heroic surgical intervention. Accounts were printed in all the major journals, headlined “Richerand’s Operation.” The hero this time was Baron Anthelme Balthasar Richerand, a prominent Parisian surgeon ennobled by Louis XVIII for his tireless work treating casualties during the Napoleonic Wars. Richerand was an admirer of Sir Astley Cooper, even to a fault: He later fell out of favor in France after daring to suggest that the surgeons of his own country were inferior to those of England. His eponymous operation was every bit as astonishing as Sir Astley’s—not to mention the fact that his patient actually survived. This is how The Medico-Chirurgical Journal described his triumph:
M. Michelleau, a health officer of Nemours, was affected during three years with a cancerous tumour over the region of the heart, which was extirpated in the month of January, 1818; but a bleeding fungus was frequently reproduced, notwithstanding the application of cauteries and caustics.
Not a fungus as we’d understand it today, but in the old medical sense of an unwanted growth. The measures applied in the first attempts to eliminate the recurrence of the tumor were cautery (searing with a hot implement) and caustics (corrosive chemicals used to burn away the affected flesh).
He now came to Paris and M. Richerand found an enormous fungus rising from the wound, and discharging a reddish and horribly foetid sanies.* Yet the patient did not suffer much pain.
M. Michelleau had a chronic cough but was otherwise in fairly robust health. An operation would be a daunting challenge, but the patient seemed strong enough to withstand it.
It was therefore determined to remove a portion of rib or ribs, if necessary, as the seat of disease was considered to be there. Professor Dupuytren, and other surgeons of distinction, were present, and assisted at this formidable operation.
Baron Guillaume Dupuytren was the leading surgeon in Paris, and celebrated throughout Europe. He is principally remembered today for having given his name to Dupuytren’s contracture, a condition in which the proliferation of benign tumors in the connective tissues of the hand make the fingers contract toward the palm, giving them a clawlike appearance. A few years later, the two baron-surgeons, Dupuytren and Richerand, would fall out spectacularly over Richerand’s insult to the French surgical profession; but for now, at least, they were friendly collaborators. The patient was secured to the table to ensure that his movements would not disturb the operators. There was, after all, no anesthesia in 1818.
I commenced (says M. Richerand) by enlarging the wound through the medium of a crucial* incision, and discovered the sixth rib enlarged and red for four inches in length. With a bistoury I separated the attachments of the intercostal muscles, above and below, through this space, and then with a small Hey’s saw I cut through the rib in two places and removed the diseased portion, carefully detaching, by means of a spatula, the costal pleura from the internal face of the rib.
This was difficult and sophisticated surgery. Richerand realized that he needed to remove a section of cancerous rib, which entailed dissecting away the muscles and other structures attached to it, such as the pleura, the protective membrane covering the lungs. The instrument he used to saw through the bone, invented a few years earlier by the English surgeon William Hey, had a long handle and a blade only a few inches long. It was designed for opening the skull, but its small cutting edge made it ideal for this particular task.
The seventh rib was now found to be diseased, to an equal extent, and was removed in a similar manner, but with much more difficulty, and not without penetrating the cavity of the chest by a slight rent in the pleura. This membrane itself was now discovered to be in a thickened, diseased state; and, in short, to be the tissue whence the fungous vegetation sprang. It was diseased eight square inches in extent! To leave this behind was to leave the operation unfinished, and therefore the whole of it was removed by the scissors.
The operation now entered a still more dangerous phase. Puncturing the pleura allows air into the cavity around the lungs; this increase in pressure can cause one or both lungs to collapse, a condition known as pneumothorax. This is less of a threat in the modern operating room because chest surgery is undertaken with mechanical ventilation: The lungs are inflated and deflated automatically via a tube passed down the windpipe. M. Richerand had no such modern luxuries: If both his patient’s lungs collapsed, there was little chance he would survive.
Not a drop of blood was lost. At this moment the air rushed in, the left lung collapsed, and, with the heart enveloped in its pericardium, pressed and presented itself at the wound.
A dramatic spectacle. The (conscious) patient’s beating heart was now visible through the operative incision, while a collapsed lung posed an immediate threat to his life.
The wound was instantly covered with adhesive plaster to prevent suffocation. The anxiety and difficulty of breathing were now extreme, and continued so for twelve hours after the operation. The patient passed the night erect, and without sleep.
This is hardly surprising. Even if he had been comfortable enough to sleep, sheer terror would surely have prevented him from doing so.
Towards the morning sinapisms* were applied to the soles of the feet, and insides of the thighs, rendering the breathing easier. From this moment the pulse rose and the strength increased. The patient was kept on liquids. Three days passed thus. The fever was moderate, but the oppression of the breath was sufficient to prevent sleep. Ninety-six hours after the operation, we removed the dressings. The pericardium and lung had contracted adhesions round the circumference of the wound, which now formed a kind of window, through which we distinctly saw the action of the heart through its transparent covering.
That would be a great icebreaker at parties, wouldn’t it? Imagine being introduced to a fellow guest whose heart was visible through his chest.
Fortunately, the adhesion of the heart to the lung was not complete, and left a sufficient passage for a copious serous discharge which issued from the wound for ten or twelve days, in the quantity of half a pint a day. On the 13th day this discharge ceased; and by the 18th day, the adhesion between the pericardium and lung was complete, and no air entered from without after that period. The patient could now lie down and sleep; his appetite and strength returned; the wound healed, and he perfectly recovered.
Adhesion is being used here in a technical sense: After surgery, the formation of scar tissue can cause adjacent structures to stick together. In this case, it had a beneficial effect, the adhesion between the lung and the sac around the heart forming an airtight seal that allowed the patient to breathe normally once again.
This was an astonishing outcome, but it’s not quite the end of the story. In a more detailed account of the operation and its aftermath, subsequently translated in The Edinburgh Medical and Surgical Journal, M. Richerand gives this sequel:
The patient, who for some days had been making trial of his strength in a garden belonging to the house in which he lived, could not resist the desire of traversing in a carriage the streets of the capital. Not being fatigued by an excursion of five hours, during which he visited l’Ecole de Medicine, and caused to be shown him the portions of the ribs and pleura, which are deposited in the Museum of that establishment . . .
If a large portion of my rib cage had been cut out without anesthetic, and was now on display at a medical museum, I’m fairly sure I’d go and have a look at it.
. . . there was nothing to prevent his returning home, where he arrived safely on the twenty-seventh day after the operation, having provided himself with a piece of boiled leather to cover the cicatrix* when healed.
An understandable precaution. One final detail of this case intrigued M. Richerand. By the early nineteenth century, it was generally accepted that the surface of the heart had no pain receptors—that one could, therefore, touch the organ without discomfort. Chances to have a feel o
f a living human heart being few and far between, Richerand made sure to satisfy himself on this point.
I did not let slip the opportunity here offered of again proving the perfect insensibility of the heart and pericardium.
An oddity that should not be allowed to overshadow a titanic surgical achievement. As the anonymous correspondent in The Edinburgh Medical and Surgical Journal points out, the entire operation was fraught with difficulty. Richerand’s account of sawing through and removing the patient’s ribs makes no mention of the fact that there are many important blood vessels in the area—some of them actually running along grooves in the underside of the bones. To remove sections of rib, he had to dissect these free and tie them to prevent catastrophic blood loss. And he achieved this miracle with a patient who was fully conscious. Though this report doesn’t mention it, the patient was himself a surgeon; I’d like to think this helped him get through his ordeal, but somehow I doubt it.
THE SAD CASE OF HOO LOO
One of the most striking recent developments in health care has been the rapid expansion of medical tourism. It’s estimated that every year as many as 15 million people now travel abroad in order to seek treatment. Those who live in countries where private health care is the norm may be looking for a cheaper option; others go in search of drugs or surgery not available closer to home. You might assume that the possibility of traveling halfway across the world for a lifesaving operation only arose in the era of the jet airliner, but as long ago as 1831, a young man from China did exactly that.
His name was Hoo Loo, and his case caused a sensation. Some months earlier, he had walked from his village to the Macao Ophthalmic Hospital, the first Western hospital built in China for the benefit of the Chinese. He must have presented quite a sight, because his scrotum had swollen to grotesque proportions, apparently the result of a condition known as elephantiasis.* The hospital’s founder and surgeon, Dr. Thomas Richardson Colledge, believed that the unnatural growth could be removed, but it was not a job that he was prepared to undertake. So he paid for Hoo Loo’s passage to London, and gave him a letter of introduction to his old mentor at Guy’s Hospital, Sir Astley Cooper.
Contemporary engraving of Hoo Loo shortly before operation
His arrival prompted newspaper headlines, and the Chinese patient with the hideous deformity even inspired a political cartoon laboriously satirizing the attempts of the prime minister, Lord Grey, to pass his Reform Act. But the medics wasted no time in getting him treated, as The Lancet reported 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.
Hoo Loo’s tumor was simply enormous. It had started to appear ten years earlier, when he was twenty-two, as a small growth on the foreskin. By the time of the operation, it was four feet in circumference, hanging from the abdomen between the navel and the anus—almost entirely engulfing his genitals. The tumor was later found to weigh fifty-six pounds, and so disturbed his balance that Hoo Loo had to throw his shoulders backward while walking 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.
Poignantly, Hoo Loo told one well-wisher that he intended to have the operation so that “he might prove a comfort to his aged mother, instead of being a burden to her.” The procedure was scheduled for a Tuesday, but when the hospital authorities realized 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—hundreds of people, all exhaling their germs in close proximity to an open wound. It was not until the 1860s that surgeons would pay any attention to maintaining sterile conditions in the operating theater. Hoo Loo entered the room and was secured on the 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.
Charles Aston Key, the surgeon who took the lead on this occasion, was a former pupil of Sir Astley Cooper and was married to his niece. A tall man with an aristocratic air, he was also known for his short temper. This operation would try his patience to the limit. In brief, the plan was to excise the tumor while liberating the penis and testicles from their fleshy prison. Key began the procedure by making three large incisions, forming flaps of muscle and skin that would eventually be used to cover the gaping hole left when the growth had been removed. This must have been agonizing, since there was no anesthetic.
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. Their patient was enduring unimaginable pain, and if they took too long, he could die from hemorrhage or shock. Taking this grim shortcut allowed them to get on with the main business of dissecting out the tumor, a painstaking process that 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. In an age when surgeons prided themselves on being able to amputate a limb in a couple of minutes, an operation lasting an hour and three-quarters was something quite out of the ordinary. Hoo Loo fainted several times, and in the latter stages, he was almost entirely unconscious. He had lost a fair amount of blood
, although those present estimated that it was barely more than a pint.
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,* 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.
This really was a last throw of the dice. Blood transfusion had been employed successfully in humans only a few times before; the physician responsible for these attempts, James Blundell, was also on the staff at Guy’s. The operation often failed because the blood of donor and recipient were incompatible.
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 tragic 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.
The Mystery of the Exploding Teeth and Other Curiosities From the History of Medicine Page 14