The Modern Era of Surgery 1800 to 1900

It is difficult to define the start of modernity in surgery. We truly built upon the past, but so many of those “older procedures” are still being done in pretty much the same way, even if we use more modern instruments to do them. A hernia is the  done using Cooper’s and Poupart’s ligaments, even if the needle is held by a robotic arm using, not only the same anatomy, but the same principles. I chose the beginning of the modern era to be when Madam Sklodowska Curie introduced a new form of energy to us. Not only did she discover two elements that emit radiation, Radium, and Polonium, but she coined the word “radioactivity.” Polonium was named by her, in honor of her country of origin, Poland.

Above she is at the table with most of the physicists that contributed to our current knowledge of the atom. Rutherford, the tall man right behind her on the right, is the man that gave us the standard model of the atomic structure, with a central nucleus, and orbiting cloud of electrons. The second from the right is Albert Einstein. Albert said of her that she is the

only human he knew that was not corrupted by money, fame, or glory. She is the first woman to win, not one, but two Nobel prizes, one for physics and one for chemistry. She gave most of the prize money (not an inconsequential amount) away to associates for research. She even returned the scholarship money to Poland, which she received as a young girl to go study in Paris. The remainder went to the founding of the Curie Institute. During World War I she developed a fleet of mobile X-ray trucks that she, and fellow Red Cross volunteers, had to drive into the battlefield,

risking her own life, picking up injured soldiers, and X-ray the injuries, before delivering the soldiers to the surgery tent to have the shrapnel fragments removed by the surgeon. She was the first to suggest that radiation should be used to treat malignancies, and for the sterilization of instruments. Even though she was not a physician, her contributions to medicine and surgery were monumental, which included the ultimate sacrifice. From the constant radiation exposure which she received from the strong radioactive emitting materials, her bone marrow was destroyed, and she died at age 67 from the ravages of aplastic anemia.

Theodor Emil Kocher

He was a Langenbeck, Virchow, and Billroth protégé, a Swiss surgeon who brought many innovations to surgery. Through personal correspondence with Lister, Kocher became a disciple of asepsis. Every infection that occurred, he meticulously looked for the reason, and his assistants were called to task. He gave us sterile catgut, and a method for relocating shoulders, but he is most remembered for his work in thyroid surgery. Even his mentor, Billroth, gave up thyroid surgery because of the very high mortality of 75%. Kocher reduced this to 0.5%, which he achieved in his 5,000 thyroidectomies (one of whom was Lenin’s wife). He still had a high incidence of hypothyroidism, but on Virchow’s suggestion, he started to leave the posterior capsule with a little bit of thyroid tissue in place, along with at least one parathyroid gland, and had outstanding results with no cretinism, and no hypocalcemia. Kocher is given credit for many eponyms:

• Kocher Clamp- used in practically all open cases
• Kocher Maneuver- to reduce a dislocated shoulder
• Kocher Incision (neck )- exposure of the thyroid
• Kocher Incision (subcostal)- exposure for open cholecystectomy
• Kocher Sign- the exophthalmos of hyperthyroidism
• Kocher Reflex- the contracting of abdominal musculature upon squeezing the testicle
• Kocherizaton- the mobilization of the duodenum
• Kocher’s Vein- the middle thyroid vein

Among his most famous students were Harvey Cushing, father of modern neurosurgery, William Halsted, father of surgical training in the USA, and Fritz de Quervain of tenosynovitis fame. Kocher received the 1909 Nobel prize for his work on the thyroid, and his discovery of the replacement of lack of thyroid hormone, with oral preparations derived from animal thyroid tissue.

Kocher is doing a thyroidectomy with Halsted assisting (Hallsted is marked with the black arrow opposite Kocher).

 

 

 

 ERNST von BERGMANN 1836-1907

The first surgeon to introduce heat sterilization was the successor of Langenbeck at Charité (Hospital) in Berlin. He invented a steam sterilizer that was under pressure to increase the temperature. One of his senior residents, Curt Schimmelbusch, developed a drum that fits in the sterilizer and could be packed with linens, operating room gowns, assorted dressing material, and instruments. After allowing the sterilizer to cool down the drum could be removed, and placed directly on the back table.

The painting commissioned by Bergmann demonstrates the Schimmelbusch drum on the back table. This painting was stolen by Herman Göring during World War II and has not been seen again.

 

 

We owe the use of the surgical mask to Paul Berger, a French surgeon, who introduced the forequarter amputation. In 1899 he wrote: “For several years I have been worried as to the part that drops of liquid projected from the mouth of the operator, or his assistants, may exercise on the outbreaks of infection…” He put on the mask, which was ridiculed at first, but when the eminent Professor Jan Mikulicz-Radecki had a very similar publication with the same recommendation, it caught on and has been with us ever since, now even protecting the general public from giving and getting virus infections.

Edoardo Bassini was severely wounded in the battle for Rome, in 1867,  under  King  Victor Emanuel.

He took the opportunity to become a surgeon during his recovery. He studied with Langenbeck, Lister, and Billroth, eventually becoming Chair of Surgery at the University of Padua. The Bassini operation for groin hernia is the prototype for all inguinal hernia operations. After the hernia sack is amputated, the conjoined tendon (known by other names: the conjoined aponeurosis of the internal oblique and transversus muscle or the falx inguinalis) is sutured to the inguinal ligament, closing the weak inguinal floor through which the hernia protruded. The cord is replaced in its anatomic position, and the external oblique muscle is closed over it.

Chester Mc Vay, an anatomy professor at the University of South Dakota in Yankton, South Dakota (my best friend’s anatomy professor), developed the Mc Vay repair using the conjoined tendon to Cooper’s ligament, converting to Poupart’s ligament at the neurovascular bundle.

This would be the appropriate place to discuss the other classic hernia repairs, even though it is out of order historically.

Shouldice from Canada developed the multiple layer imbrication with the continuous “silver thread,” and avoidance of mesh that has a worldwide reputation for a less than 1% recurrence rate. Lichtenstein developed the tension-free repair, which is basically a Bassini with mesh, connecting the inguinal ligament to the conjoined tendon.

Having done them all, and a few more (Stoppa, Kugel, darn, plug, etc.), I prefer the robotic retroperitoneal repair of closing the defect in the transversalis fascia, a structure I didn’t believe existed before seeing it from the peritoneal side, and reinforcing the repair with mesh.

 

 

Frederick Treves was a noted English surgeon, known for his ability to remove the appendix, for which he was well rewarded. His book on Intestinal Obstruction is a noted classic. Ironically his daughter succumbed to the disease, as well as he when he was age 70. Edward VII, the eldest son of Queen Victoria, got appendicitis before he was to be crowned king. He would not permit the operation, became steadily worse, and finally, the appendix ruptured. The abscess was palpable on the exam. Treves told the “King to Be” that if he continued to refuse the operation, there   would  a funeral instead of a coronation. Edward relented, and the reception salon at Buckingham Palace was readied for surgery. Treves, wisely, asked Lord Lister to consult, which he did, bringing one of his phenol atomizers from Edinburgh.

Treves did just drainage of the abscess that, by now, was pointing on the abdomen. As soon as the pus was released, Edward felt better. The next day he was sitting up in bed, smoking his favorite cigar. The coronation took place with only a minor delay, and Treves was made a Baron.

Treves befriended the so-called “Elephant Man,” Joseph Mereck. Joseph, whom he happened upon, displayed and exploited in a freak-show when Treves rescued him, and brought Mereck to his hospital in London.

It is now known as the Royal London Hospital, where Mereck spent the rest of his life. He was mistakenly thought to have an illness designated as von Recklinghausen’s disease, multiple neurofibromatosis, but in fact, it was a disease called Proteus Syndrome, an even rarer genetic disorder of uncontrolled growth of all three embryonic germ layers.

 

William Stewart Halsted Father of American Surgery

Halsted went to Yale, and Columbia, but had a lackluster performance until his internship at Bellevue, when he started to excel. He recognized that critical data needs to be readily available at the bedside. As an intern, he created the bedside chart for vital signs and fluid balance.

In  1878  Halsted traveled  to the hollowed surgical halls of excellence in Vienna, Padua, Berlin, and Basel, to study, and learn from the icons of surgery, that included a list of surgical giants: Billroth, Esmarch, Mikulicz, Bassini, Bergmann, Chiari, Kocher, Zuckerkandl, Volkmann, and Wölfler. He came back to the US about two years later and duplicated the European method of teaching surgeons to operate.

In 1882 he performed one of the first cholecystectomies in the US on his own mother, reportedly on the kitchen table at 2 AM, and he also did the first transfusion of blood to his own sister, which saved her life. He taught many department heads, and surgeons, who became professors of surgery, such as Harvey Cushing, founder of neurosurgery, and Hugh Young, founder of urology. He was amongst the originators of Johns Hopkins Hospital, and subsequent world-class residency programs, along with William Osler.

An Austrian ophthalmologist published the use of cocaine for anesthesia in eye surgery, which Halsted emulated, and used on his patients. Unfortunately, he experimented with it on himself and his students. This led to a fierce addiction to the drug! His friends saw this disaster unfolding in front of them, and had several interventions that eventually got him off the cocaine, by using morphine, touted to cure a variety of addictions. Neither cocaine nor morphine was illegal at the time. He never got off the morphine, using up to 200 mg a day, until he died at age 70 after complications from gall bladder surgery. Despite his addiction, he continued to function as a surgeon, teacher, and innovator of surgical techniques. His principles of surgery are still applicable today:

• Handle tissue gently
• Maintain meticulous hemostasis
• Observe strict asepsis
• Minimized tissue tension
• Appose tissue accurately
• Preserve blood supply
• Eliminate dead space

Halsted introduced the radical mastectomy, which was the standard treatment for breast cancer for 100 years. When his scrub nurse developed a terrible rash on her hands, secondary to the carbolic acid they all used, he came up with the thin rubber gloves we now all use. She eventually became Mrs. Halsted.

Richard Hall was a friend, and colleague, of William Halsted. Richard came to the US from Ireland, with his family, when he was 12 years old. Hall went to school at Princeton and got his medical degree from the New York College of Physicians and Surgeons. He married into a very prominent Bostonian family, and he and his wife went to Europe for a year, where he studied at the major European medical centers.

Returning to the US in 1880, he and Halsted, became acquainted with the new drug used for local anesthesia, Cocaine. Unfortunately, both he, and Halsted, could not resist trying it out on themselves to determine the proper dosage for local, and regional, anesthesia, and both developed serious addiction problems. In 1886, Hall performed the first successful appendectomy in the US despite his drug problem, three years before Charles McBurney presented his report on operative management of appendicitis to the New York Surgical Society. Halsted continued to become a highly distinguished surgeon, and teacher, but never was able to escape his addiction problems. Hall moved to California in an attempt to rid himself of the drug’s clutches, a feat he finally accomplished. In 1889 he came to Santa Barbara, which did not have a hospital until 1891. Hall became the chief surgeon at the new hospital. In 1896 he introduced the X-ray machine at Cottage Hospital, but in 1897, by a cruel twist of fate, the man that had done the first appendectomy in the US died of a ruptured appendix.