&10MED! C784r Report Reraov. Prom Of An Operation For ing A Foreign Body Benep.th The Re-^rt By . • ., Cooper N*^-^ OPERATION Jfor |Umflljtitg II Jfnrtign ^a^ FROM BEMATH THE HEART. «d B"2" E„ S. COOI>BIl, A.. 3VC. 3Vi:. ID. Publislied by the San Francisco County Medico Chirurgical Association as an additional paper to its Transactions for the year 1857. SAN FRANCISCO: WHITTON, TOWNE & CO., PRINTERS AND PUBLISHERS, 151 Clay Street, tliird door below Montgomery. 1857. San Francisco, Sept. 1st., 1857. E. S. CoorF.n, M. D., Deau Sin : At ft mpofinp: of ihn Snn Fninoi.'^ro County Mcd- ro Chiurcioftl Association, held on Friilay Evcninfr, Aw^. 21st, 1S.'>7, the niidorsifjncd were appointed a Committee to publisli the ease of Mr. Bual, hy authority of tlic Asso- ciation. For this object wc liavc the honor to reiiiicst a copy of your Report of said case at your earliest convenience. The Committee undertake the discharge of their duty in the premises witli pleasure, the more so, since the successful result of tlie ex- traordinary operation upon Mr. Bcal must, when fully known, bo alike honorablo to Sur- gery, and consoling to Humanity. Very Respectfully, M. B. ANGLE, M. D., J. ]'. MACAULEY, M. D., V. J. REILLY, M. 1). R. BEVERLEY COLE, M. I). DAVID WOOSTER, M. D. Committee. San Francisco, Sept. 1st, 1857. Gentlemen : Your note of to-day, requesting a Report of the case of Mr. Bcal for publication, is before mo. In reply, I shall not attempt to burthen my compliance with your request with a pompous affectation of modesty, but would say, that should it bo tho means of subserving, in the smallest degree, tlie cause of our noble profession, I shall bo glad. Very Respectfully Yours, E. S. COOPER. M. B. Angle, M. D., J. P. Macaulev, M. D., P. J Rbilly, M. D., R. Beverlkt Cole, M. D., David Wooster, M. D. Committee. R E I^ O R T . to bo -7 «£3 Mr. President and Gentlemen : The operation I am about to describe has been tlic subject of such a variety of comments and so difterently represented by the pubhc prints, as Avell as by parties who were not present, and consequently knew nothing of its real merits, that in giving a true description of the «r> case it appears due to myself to mention this fact, and also to refer to ^ those present at the operation, for confirmation of my report. No one oc who knew anything of Beal's condition at the time, hesitated to say gg that he must die without an operation. He expected to die under the Ij knife and gave dh-ections about his bui'ial before the operation began. 5 His friends expected him to die, and were assured that such would ^probably be the case ; but all wished him to embrace the only remain- "^ ing chance of prolonging life, and guided by a brave spirit, he most cheerfully took all risk and fortune rewarded his courage. It has been known from immemorial time that wounds penetrating the cavity of the chest are not necessarily fatal. This knowledge sug- gested operations upon the thorax in the very infancy of surgery. Accordhigly we find that exsection of the ribs was practised by Galen in his native village, Porgamus, Asia Minor, while he was still a very young man, as early as the first half of the second century, and by numberless other surgeons up to our own time. (^3Iereure de France, April 1758.) Suif excised two ribs of a man named Botaque,in such a manner as to be able to introduce the fist into the chest. ( Velpeaii^s Operative Surgery.') Even the native Fiji Islanders frequently cut through the intercostal spaces by means of a sphnter of shell, and extract barbed arrows from the inside of the chest. ( Williains Tonga Islands.') The operation of Richerand, where a most extensive section was 2911S9 made, is well known. Since 1818, the ribs have twice been cxscctcd successfully, Ijy Cittadini, by Percy, for caries of two ribs, result- inji; frtjm <2;un shot wounds, by ^I. JJlaudin, at Ueaujon, by Ivoux, at la Charite, and by Mott, of New York. But the case of Kiehcrand is the only one that bears any resemblance to the one I am about to report. In Richerand's case " it became nec- essary to remove the middle portion of four ribs, to the extent of several inches. The pleura, which was greatly thiekened, had also to be re- moved, so that the ])ulsations of tlic heart were exposed naked to the si^lit." This operation was for cancer, and the patient died at the cx])iration of a few months, from the regeneration of the disease. ( Vclpian loc. cit.^ Wounds of the heart itself are well known not to l)e necessarily fatal. Dissections have revealed cicatrices on the heart when the subject had died from an entirely different cause long after the womid had been received. Cases might be cited with names and dates if they were not well known to the learned. But the demand for surgical interference in cases of foreign bodies in the chest, depends upon the violence of the attendant symijtoms and upon the nature of the foreign body itself. Lead for instance will generally become encysted and caiise comparatively little incon- venience after it once stops, while a small bit of iron will jjroduce su])pu- ration and is liable to keep changing its location and may therefore produce violent symptoms after mouths or even years. Case. — Mr. B. T. Bcal, ^-Et. twenty-five of tSjn-ingfield, Tuolumne Count V, California, with some other young men, in a frolicksome mood, resolved to burst an old gun, and accordingly loaded it with about ei*T'htccn inches of powder, to which they connected a slow match and then endeavored to seek security by flight. Unfortunately a brisk wind blew up the powder with great rapidity and the gun exjtloded Itefore they had retreated far. A slug of iron an inch long and half an inch in diameter had been driven into the gun as a temporary breech pin, wliich bursting out in the explosion struck Mr. Beul in the left side below the armpit, fracturing the sixth rib, enter- ing the chest and lod^ng, as was afterAvards found, beneath the heart upon the vertebral column, just to the right of the descendhig aorta wliere it had evidently remained from the period of the injury, January ■20th, 1857, until it was removed April 9th, seventy-foiu- days after. In a ^ate of extreme prostration he was brought to the city, having had frequent diseharges of several ounces of pundent 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 Idoody 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 mueli so that I entertained most serious apprehensions that he would not li\e till moniing. So urgent had his symptoms become that after his' arrival he was constantly in absolute danger of dying from suiFocation, so that no time was to be lost, even for him to obtam rest fi-om the fatigues of his journey. Under the greatest disadvantages therefore, the operation had to be performed ; otherwise he must be abandoned to his fate, which a surgeon feels but httle inclined to do in case of such a brave patient who is wilUng to endure any operation however pamful or hazardous to save life. Operation. — The patient being placed on the right side, an incision through the soft parts three inches long was made : commencing opposite the seventh true rib and following the track of the original wound, was carried over the fifth and sixth ribs, which were drawn close to each other by contractions, consequent upon the injury. The sixth true rib Avas found fractured and slightly carious. A transverse incision three inches long, was now made, beginning at the centre of the first when the soft parts were reflected, so as to expose the ribs. Torsion was applied to one intercostal and two or three small arteries which bled rather freely. The wound was now fully absterged after which an efibrt was made to find the breech-pin by using the probe. This failmg the incisions were lengthened and the ribs further exposed. A por- tion of the sixth rib which was carious was novf removed and was fol- lowed by the discharge of about ten ounces of fluid resembling venous blood, contained in a cyst which was broken by the removal of the por- tion 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 ri1is 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. 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. The pleura had several large holes through it and was thickened to four or six times its natm-al state in some parts. The pidsations of the heart in the pericardium could be distuictly seen through these holes. Brandy was now admin- istered freely to the patient who appeared to be rapidly sinldng. The left lung was found completely collapsed after the discharge of puru- lent 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 loca- tion of the foreigTi body. The patient now appeared almost completely exhausted. Brandy was given freely. Chloroform was not admin- istered 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 Avas now used and the manipulations continued. A sound was introduced and the thoracic cavity explored for at least thrce-(iuarters of an hour before anythiiiL:; like a metallic touch could be rccoi^ized, and then it was so indistinct as to leave the matter doul)tful. The space immediately above the diaphraij^n was considered the region in which tlie metal was mostlikely to be I'uund ; since the immense amount of supperatiun which had taken ])lace, 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 proba- ble opinion to be farmed as to its whereabouts, and to describe the dii- ficulties of the search that followed would be difficult if not im]>ossiblc. No one can have any just conception of the degree of jiatience re(|uired 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 ap})cared to have scarcely no normal relations to the surrounding structures, touchnig by lines tlie entire surface of the parts, and at last the sound appeared to encounter something of a me tallic nature beneath the heart, but the jmlsations of that organ were so strong against the instrument as to render it difficult to settle the matter definitely. At last, however, it became evident that the locar tion 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 manoc- vering the instrument finally lost the track by wliicli the soinid had first passed back of the heart to the metal, and it was during my efiorts to recover this, and wliich Avas accomplished with the naore difficulty owing to some membranes falling in the way, that I discovered the somid had in the first instance reached the metal by passuig between the descending aorta and the apex of the heart. The metal being again found, the sound was steadily and strongly held in contact with it until a pair of long lithotomy forceps Avas thereby conducted to the spot and the breech-pin seized aiid extracted, a\ Inch, however, Avasthe Avork of sevei-al minutes, OAving to the great difficulty in grasping it even after the forceps Avas made to touch it. The forceps, however, being heavier, the motion of the heart was not so embarrassing to its manipulations as it had been to that of the sound, but OAving to its size it could not folloAV the sound and be expanded sufficiently to seize the metal Avithout lifting the apex of the heart considerably out of its natural ]>osition. After the metal Avas extracted, the }»atient AYas turned on the Avounded side, and a tent jdaced in the track of the original sinus, after Avhich the Avound Avas dressed and the suflcrer permitted to rest in bed with his body still incUned towards the injured side. ▼ April 10th. — Greatly prostrate ; slight pain in the left breast ; no motion of that lung ; gave morphine. April 11th. — Same as yesterday. April 12th. — Slight cough; gave enema and light nourishment. April loth. — Evacuations from bowels; slight discharge from the wound, being the first since the operation. April 1 4th. — Improving ; considerable appetite. April 15tli. do do do Api'il 16th. do do do April 17th. do do do April 18th. do do do April 19tli. — Considerable cough. April 20th, — Severe cough to-day and pain in the right side, as also in tliat of the wound, though not so great as in the other. Skin dry ; no expectoration ; urine scanty and highly colored. These symptoms were very alarming, the more so from the fact of their impli- cating the hitherto sound lung. The pneumonic symptoms continued without abatement for several days and finally subsided, but left the patient greatly prostrate. On the 26th purulent expectoration began and continued to increase for about a week, when nearly a pint was discharged in the space of twenty-four hours, and during this time but little escaped from the wound. After this period, for nearly two weeks, the discharge was greater or loss from the wound in proportion to the amount of purulent matter expectorated and \ace versa. The matter from both places being of the same quality and occasionally tinged with blood. At the end of two weeks from the time the communication between the trachea and the original suppurating surface appeared to have been established, the purulent expectoration began gradually to subside, and the patient's condition slowly to improve until the end of seven weeks after the operation, when he left the city. There was no perceptible motion of the left lung at this time. He was considerably fatigued by his journey from the city to the country, and appeared worse for several days in consequence, but eventually began to improve rapidly and continued to do so until three weeks since, at which time, as is "well known, he visited this city, and was so improved as not to be recog- nized by medical men present at the operation, who had seen him every day for some weeks after. Aug. 1. — Present condition. — The external wound has entirely cicatrized. 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. This operation was per- formed in presence of the following medical men, some of whom assisted — " I. Rowell, Censor of San Francisco Medical Society. " Wm. Carman, Secretary San Francisco Medical Society. " B. A. Sheldon, Vice President, San Francisco Medical Society. Dr. L. Grover, Member San Francisco Medical Society. " J. M. Williamson, Censor oi' »Stato IMcdical Society. " Wm. Fifer, member State JVIedical Society. " R. Beverly Cole, Pres. S. F. County Medico Chirurgical Association " P. J. lieilly. Secretary do. do. do. do. do. " L. Hubbard, Ex-Pres. S. F. County Medico Chirurgical Association " Wm. Hewer, Censor do. dO. do. do. do. " J. M. Tewksbury, do. do. do. do. do. do. " F. P. Wierzbicki, do. do. do. do. do. do. " J. Lee Webster, do. do. do. do. do. do. " J. P. Macauly, late Surgeon San Francisco City Hospital. " B. F. Hardy, late of Ilonolula, S. I. " J. S. Calef, Member San Francisco Medical Society, and others. Rejiarks. — The carious condition of the sixth rib was probably a fortunate circumstance in this case, since it favored the formation and continuation of a sinous opening through which purulent matter Avaa discharged fi'om time to time, prior to the operation, and which hmited, to some extent, the immense accumulation that, as it was, had nearly terminated the patient's life previous to that period. His subsequent astonishing recovery is attributed to his great cheer- fulness, 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 atten- tion is afterwards given him. San Francisco has the advantage of every other city on the globe, in regard to climate, for surgical opera- tions, since, if owing to any peculiarity of the case, our coast breezes are not equally well adapted to all the stages of convalescence alter 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. In Mr. BeaFs case, while nothing could have been better than our cool bracing atmosphere, for the first few weeks after the operation still, having recovered from the immediate effects of that, the subse- quent lung symptoms were much better controlled by a i-emoval to the Santa Clara Valley,. thu-ty miles distant, than they could possibly have been by medicine, conjoined with the greatest care that could have been bestowed upon him in this city. mTTVERSITY OF CAUFORNIiL AT LOS ANGELES I i