Medical history in San Antonio

by Anne Elise Urrutia ©2021-2023

I studied the case; consulted my books: and for a long time, consulted my own book; I opened my heart as the father of many children, and as one entrusted with solving the problem….

~in translation

Estudié el caso; consulté mis libros: y por mucho tiempo, consulté mi propio libro; abrí mi corazon de padre de muchos hijos, y a él le encomendé la solución del problema….

~Dr. Aureliano Urrutia

Dr. Aureliano Urrutia was an innovator and often took on surgeries that no other doctor would accept. The case of the twins, Josefina and Guadalupe H, was certainly an endeavor of that kind.

The girls were born in the fall of 1912 to Diego and Maria de Jesus in a remote village of central Tamaulipas, a sprawling Mexican state that envelopes the vast gulf coast halfway to Veracruz, from Matamoros to Tampico, like a long billowy skirt. The skinny untied belt of the skirt flutters in the breeze westward along the Rio Grande all the way to Laredo. Originally home to the Olmecas, Chichimecas, and Huastecos, the Spanish colonized the rugged landscape of rolling hills for sheep and cattle ranching. Since then, the Apache, norteamericanos, French, and more recently, modern drug cartels and maquiladoras, have occupied the region.

But early in the twentieth century, among perhaps sixty or so households within the municipality of Jiménez, the seventeen-year-old Maria miraculously survived the difficult birth of her first children. The couple had another child late in 1913 before leaving México for the United States.

Urrutia tells that the family traveled to the United States in search of a doctor, but in reality, their journey began in order to join the Foley & Burke carnival based in Los Angeles. You see, the girls were not only twins, but also were conjoined at the sternum.

Maria and Diego found that they could earn a better living traveling with the sideshow than Diego could earn as a rural animal breeder in Jiménez. In the circus, Diego became a showman, as carnival workers are called. Josefina and Guadalupe were presented in the sideshow, and the young parents were able to see to the care of the twins, their young son, and another daughter born in Los Angeles in early 1916. One observer remarked that though the two girls clearly suffered from their extremely challenging situation, they also found happiness and laughter together much like other children.

However, as their daughters grew, the parents noticed that one had grown quite depressed. Though the other remained healthy, they deduced that the illness of one might eventually compromise the other; and if one should die, she would take the other with her. To surgically separate conjoined twins was not a common idea, but perhaps the lively discussions of carnival life inspired them to seriously consider it. They sought out knowledgeable physicians, all of whom rejected the idea, which eventually led them to the San Antonio doctor.

When he met them in the fall of 1917, Guadalupe and Josefina were nearly five years old. Upon examination, the eminent doctor, once the chair of surgery at la Escuela Nacional de Medicina de México prior to his 1914 exile, began to weigh the situation. X-rays, some brought to him by the parents, showed a broad connection across the abdominal cavity, with their sternums joined tightly together. And there was a growing dense shadow in the films that concerned him. Further, the urine of one was high in sugar, while the other was normal. In considering the potential disastrous scenario feared by the parents, Dr. Urrutia began to discern a light in this darkness—the urine test results indicated a certain independence between the two joined bodies. It was this idea that propelled him forward in his thinking about a surgery to free the girls from their peril.

He knew well the formidable yet familiar obstacles—of shock from such a large surgery, or of hemorrhage, not to mention unknown factors sure to arise. He felt that intuition and divine intervention would play a significant part in the outcome, as it had in the past.

He proposed to the parents a two-phased surgery—the first would explore only how the two patients were anatomically and physiologically connected. Then he would pause to decide whether to carry out the separation, and, if so, to contemplate the second procedure. Or, he might learn that the situation was not feasible and discontinue the surgery.

Nowadays, with modern technology, exploratory surgery is rarely needed thanks to many new diagnostic tools and methods, but in the twentieth century it became a standard approach. In 1917, surgical practice was still in its infancy, with exploratory operations having come into use just decades before.

The parents agreed to his plan. Urrutia engaged two anesthesiologists, Dr. Ortega, a fellow exile from México, and Dr. Adams of San Antonio, with the surgery to be performed at the Santa Rosa Hospital.

During the first phase, which began with an incision from the navel to the fourth rib, Urrutia discovered one large liver shared between the two patients. The organ, on Josefina’s side, had a healthy, normal gallbladder, but on Guadalupe’s was only rudimentary. He wondered to himself: “Would these girls survive by dividing this huge organelle into two equal parts?” He temporarily closed the operation to consult with the parents, telling them that the surgery was complicated by the presence of only one liver. He would divide the large organ, giving half to each. Sadly, he acknowledged that one of the two girls might not survive, but he was near certain that at least one would. The parents decided to move forward with the surgery.

The doctor had designed a special tool that could be used for the separation of the liver—pincers that were thirty centimeters in length. Through an incision twelve inches long, Urrutia divided the sternum to reveal two hearts connected by a passage two fingers wide and encased in one pericardial membrane. He stitched the opening closed and divided the pericardia, sewing to give each heart its own sac. Then, as he later wrote in his case notes (translated from the Spanish):

Unconsciously and as if someone forced me to take a break, I started a hemostasis of the whole wound...achieving a completely dry operative field…. I went to the belly and removed the false points…. I protected all the viscera with warm compresses, surrounding the liver by its upper face and its lower face. I then put ad hoc clamps on the enormous red bridge, the only unifying element that tied those two little beings, and prepared myself for the most solemn moment of the operation.

Dr. Ortega, at the moment when he handed me the scalpel to section the liver, said happily in a sweet Spanish, "Todo tiene la blancura de la hostia" [Everything has the whiteness of the host]. I cut the gland firmly, grasped the thick vein mouths that open on the liver tissue from both sides, closed them with a needle and fine silk, and with round needles and number one chromatic catgut sutured the gland resting on the Glisson’s capsule. I did the same with the other child, who despite the efforts of the assistant had lost some blood. I closed the abdominal cavities routinely, faced the tissues of the chest, placed a penrose drain in each mediastinum cavity, and another in each abdominal cavity; and sent each child to her room with the rigorous care received in all high surgeries.

One recovered without even a minor disorder—the operation caused no reaction; neither in temperature, nor in pulse, nor in respiration. The other, Guadalupe, was fine during the first hours, but slowly gave out, unable to take food and without enough resources to survive. Josefina convalesced without incident, for two weeks, after which she left the hospital with her wound completely healed.

Guadalupe passed away within days and was buried at San Antonio’s San Fernando Cemetery. The family returned to their village in the skirt of Tamaulipas, and Diego returned to his work as an animal breeder. Diego and Maria added four more girls and two more boys to the family, all born in Jiménez.

Fifteen years later, Josefina asked Urrutia’s permission to marry. Her parents reported that she had not suffered from anything related to the surgery during the time that had passed. Josefina lived out the rest of her days in that small village and the nearby town of Ciudad Victoria, to the age of eighty-nine.

Dr. Urrutia considered this operation, done in the prime of his life, at age forty-five, to be his greatest accomplishment. It is recorded by some in medical history as the first separation of conjoined twins where one of the patients survived. It may also be a first in the area of pediatric liver surgery, and was certainly an early successful surgery in the area of liver resection.

Professor Dr. Anton Eiselsberg, a Viennese pioneer of surgery and one of the greatest surgeons of the early twentieth century, introduced Dr. Urrutia’s work to his students, stating that the doctor had “performed the most beautiful and daring of operations on record worldwide.” The procedure was discussed and recognized at the Sixth Pan American Medical Congress in 1935 in Brazil, where Urrutia gave presentations on a number of his surgeries.

Dr. Aureliano Urrutia spent more than forty years as a career surgeon and teacher at the Santa Rosa Hospital in San Antonio, retiring from medical practice in 1959 at the age of eighty-seven.

Posted on August 6, 2023.

©2021-2023 All rights reserved. Article, archival materials, translation, and photographs from the collection of Anne Elise Urrutia. Author’s Note: The last name of the patients have been withheld in the interest of privacy for the family. All translations are mine. Photo source unknown.