Great Surgeon Research Articles

Dominique-Jean Larrey: The effects of therapeutic hypothermia and the first ambulance

The fields of emergency medicine and resuscitation are indebted to the Baron Dominique-Jean Larrey (1766–1842) for significant advances in patient care. Larrey was a great surgeon who served in the French army during Napoleon's rule. He developed one of the first ambulance services, utilized positive pressure ventilation, and introduced hypothermia as a form of therapy. He dedicated his professional life to improving the care of wounded soldiers on the battlefield. Larrey coined the term “Triage” to allocate resources to those most in need of emergent care. Today, many of his techniques still prevail in modern medicine.

Breast cancer surgery: an historical narrative. Part I. From prehistoric times to Renaissance

Cancer was known as a disease since prehistoric times. Management of breast cancer evolved slowly through centuries in the ancient world up to the Renaissance. This period is marked by the absence of any scientifically verifiable understanding of the true nature of cancer and its natural history and consequently by a lack of effective treatment. Breast has been considered as a symbol of femininity, fertility and beauty. Hippocrates proposed that breast cancer, among other neoplasms, was a 'systemic disease' caused by an excess of black bile. The humoral theory was further supported by Galen and dominated for centuries in medicine. Fulguration and breast amputation by using various instruments to achieve a rapid operation were widely used up to the 18th century. The Renaissance was a revolutionary period, since it stimulated medical practice; at that time physicians started to scientifically study medicine. Vesalius greatly contributed in the advancement of surgery, and he vigorously opposed Galen's doctrines. Many great surgeons of that time (including Paré, Cabrol, Servetto, Scultetus, Tulp, Fabry von Hilded, etc.) advanced the science of surgery. Interestingly, Bartoleny Gabrol (1590) in Montpellier advocated radical mastectomy, which was popularised by Halsted, 300 years later. However, the lack of anaesthesia and the problem of wound infections (due to the lack of the aseptic techniques) generated significance and often problems for the surgeons of that time. Surgery was often 'heroic' but primitive and even inhumane by current standards. Therapeutic nihilism was the prevailing altitude regarding breast cancer, at least among the vast majority of surgeons.

Arpad Gerster and Max Thorek Contributions to American Surgery

The legacy and the influence on American surgery is discussed of two Hungarian born surgeons: Arpad Gerster (1848–1923) and Max Thorek (1880–1960). Both of them were born in Northern Hungary, then part of the Austro-Hungarian Monarchy, today Slovakia. Gerster got his medical education in Vienna The influence of Theodor Billroth left everlasting impressions in him. In 1874 he arrived in New York and became the first doctor in town who practiced exclusively surgery. He became an attending surgeon in The German Hospital and later at Mount Sinai Hospital. Gerster modernized the hospital's functions and services, introducing the rotation system, and also made the original observation that dissemination of cancer may be caused by surgery. His aseptic methods were revolutionary at the time.Max Thorek arrived in Chicago in 1897. With a fantastic endurance he overwhelmed all barriers and became a doctor. He started his practice in one of Chicago's poor immigrant neighborhoods, but stepwise he could excel and in 1911 he co-founded The American Hospital. His ideas of modernizing surgery became reality. Thorek is one of the first who practiced plastic surgery, and his contribution by writing about surgical errors and safeguards became a great success. He founded the International College of Surgeons, a result of his widespread relations among surgeons all over the world.The parallels in the lives of these great surgeons: solid education, knowledge of languages, talent for music, literature, and arts, creative thinking combined with hard work, good humor, as well as a social conscience led them to make groundbreaking contributions to American and international surgery.

Would Dr. Ogura approve of endoscopic resection of esthesioneuroblastomas? An analysis of endoscopic resection data versus that of craniofacial resection

President Pillsbury, Triologic members, and guests. It is a great honor to present the Ogura Lecture and provide for you a perspective on the treatment of esthesioneuroblastomas. I would like to begin by sharing with you some of the significant accomplishments of Dr. Ogura. I hope to convey in the brief time allotted, to those unaware of his place in our specialty’s history, the significant impact that he had upon the field of head and neck surgery, in particular the evolution of partial laryngeal surgery for laryngeal cancer. Some of our more senior members have trained with him; others like myself, have had a brief encounter with him. All otolaryngologist-head and neck surgeons have been impacted by his contributions that changed the surgical approach to cancer of the larynx. This great surgeon and educator, though small in stature, was very intimidating as he peered over his half glasses that consistently were perched at the end of his nose with his unlit pipe expertly balanced from his right oral commissure (Fig. 1). This was especially true when he was an oral American Board of Otolaryngology examiner. My introduction to him was by my chairman, Dr. John Kirchner, at this meeting held in Bermuda in 1977. Dr. Ogura was a clinical innovator and prolific author regarding the treatment of head and neck cancer (Fig. 2). He developed many of the principles of conservation surgery of the larynx, and his vast experience was recognized internationally as the head and neck surgeon to seek if you were afflicted with squamous cell carcinoma of the laryngopharynx. During the sixteen years he was the chairman of Otolaryngology at Washington University in St. Louis, he authored over 300 publications and trained many outstanding otolaryngologists who went on to have stellar careers of their own. The reverence and esteem shown by his trainees for him reflected the commitment and endless energy that he always exhibited in his pursuit of academic and clinical excellence. His personal commitment to his patients was legendary, with many tales still being shared 25 years following his death. He, to this day, remains one of the very few in our specialty who were granted all three American Laryngological Awards, The Casselberry Award, The James Newcombe Award, and The De Roaldes Gold Medal Award. His list of additional accolades is far too great to share at this time. His greatest legacy was his indefatigable zeal to learn the truth and provide the best possible patient care based upon expert, exhaustive clinical science. He demanded this level of excellence from himself and from all with whom he interacted and trained. Sixty years ago, it was almost considered heresy to suggest doing anything less than a total laryngectomy for advanced carcinoma of the larynx. Dr. Ogura, using acquired information on the growth patterns of cancer within the larynx, persisted and proved that one could obtain cure rates equal to or better than those following total laryngectomy by using conservation surgical techniques. That stated, he would always consider performing a total laryngectomy when mandated by the clinical circumstances. What he did was to perform a procedure, document the course of the patient through careful observations, and collect the data. In this sense, he was the pure clinical scientist allowing the data to speak for itself. It is with this brief background that I wish to share with you some From the Department of Otolaryngology–Head and Neck Surgery, University of Virginia Health System, Charlottesville, VA, U.S.A. Editor’s Note: This Manuscript was accepted for publication August 8, 2008. Paper presented at The Triological Society 111 Annual Meeting, Orlando, Florida, USA, Thursday, May 1, 2008. Send correspondence to Paul A. Levine, MD, University of Virginia Health System, Department of Otolaryngology–Head and Neck Surgery, P.O. Box 800713, Charlottesville, VA 22908. E-mail: pal@virginia.edu

John Benjamin Murphy — Pioneer of gastrointestinal anastomosis

Surgery as a speciality has reached an advanced refinement today both in terms of teaching and technique. With knowledge gained from years of research, teaching is now evidence-based. With the illuminating, pioneering work of a few great former surgeons, the technique of even complex surgical procedures has been well elucidated now. John Benjamin Murphy is one such surgeon to whom the speciality of surgery would remain perpetually indebted. His landmark achievements not only in gastroenterology but also in urology, orthopaedics, oncoplastic and vascular surgery would leave even a hard-core critic marvelling at his genius. Above all, Murphy was a dedicated teacher who spent 4 days a week demonstrating procedures and lecturing interested surgeons. Herein lies the greatness of the man and a tribute highlighting his achievements are in order.

Ludwik Rydygier — contributor to modern surgery

Modern surgery is usually considered to have begun in nineteenth century Europe. One of the most famous contributors to gastric cancer surgery was the Polish surgeon Ludwik Rydygier, born in 1850. He initiated new methods in several fields, such as gastrointestinal surgery, orthopedics, gynecology, and urology. He was the second surgeon in the world to perform an antral resection, which he carried out on November 16, 1880. The patient, a 64-year-old man, suffered from pyloric cancer and died 12 hours after the procedure as a result of postoperative shock. The next pyloric resection was performed by Billroth in Vienna in 1881. In the nineteenth century few gastric resections were performed for peptic ulcer. The first successful antral resection for gastric ulcer penetrating to the pancreas was also performed by Ludwik Rydygier, in 1881. For many years Rydygier advocated resection in the treatment of gastric ulcers, although it was considered too dangerous for benign disease. He eventually proposed four indications for gastric resection: antral cancer, gastric ulcer, perforated gastric ulcer, and bleeding ulcers. Another operation performed for the first time by Ludwik Rydygier was gastroenterostomy, in a patient with a duodenal ulcer. In the following years other types of partial gastric resection and total gastrectomy were introduced. In 1992 the Ludwik Rydygier Association was founded in Krakow to commemorate the achievements of and pay tribute to this great surgeon. The Eighth International Gastric Cancer Congress will take place in 2009 in Krakow, where Ludwik Rydygier built a new surgical clinic in 1889.

Paul Louis Tessier

Paul Louis Tessier

Surgical instruments and endoscopes of Susruta, the sage surgeon of ancient India

Susruta, the great sage surgeon, philosopher and teacher of ancient India, practiced around 600 bc. He is renowned all over the world for his contribution to surgery in general and plastic surgery in particular especially rhinoplasty. But his contribution to endoscopes is not well known to the medical world. His contribution to surgical instruments including endoscopes is reviewed here. Literature survery was the basis of this study. Susruta samhita [1], the treatise compiled by Susruta, various commentaries on it by different authors [2, 3] and other related literature are used as primary sources. Susruta belonged to a period between 600 and 800 bc. His conception of surgical instruments, the description of their quality, methods of manufacture and their usage are very unique, as there were no earlier comprehensive descriptions of similar surgical instruments by any surgeon, not only in India but also the whole world. Susruta was perhaps the first surgeon in the world to describe different types of surgical instruments including endoscopes. This is far beyond the imagination of any other surgeon at that period of time and obviously he was far ahead of his time in this field.

Surgical education: Eschewing the doing

Surgical education: Eschewing the doing

Paul Louis Tessier

Paul Louis Tessier

The Classic: Maggots in Treatment of Osteomyelitis: A Simple Inexpensive Method

Figure: Dr. Duncan C. McKeever is shown. Figure is ©1960 by the Journal of Bone and Joint Surgery, Inc. and is reprinted with permission from Duncan Clark McKeever 1905-1959. J Bone Joint Surg Am. 1960;42:189-190.Duncan Clark McKeever was born in rural Kansas in 1905 [5, 8, 9]. He attended local schools and having financed his own education (partly through the Naval Reserve) graduated from the University of Kansas Medical School in 1929. He interned at the Naval Hospital in Brooklyn, then was assigned to the Great Lakes Training Station in Chicago for three years. He returned to Kansas City to begin a residency in pathology, where he was inspired by the work of Drs. Frank Dickson and Rex Diveley (both of whom were early Presidents of the American Academy of Orthopaedic Surgeons [3, 4]) and subsequently studied orthopaedic surgery with them. He moved to Houston in 1939 to enter into private practice, but his practice was interrupted by the war, where he served at the Long Beach Naval Hospital and Area Hospital in Honolulu. He returned to private practice in 1945 and continued to be very active until the time of his death. His premature death occurred by a traffic accident: on a rainy day in October 1959, he had borrowed a car which ran out of gas and, as he was filling it, he was struck by another car and killed. He was a man of great energy by all reports. In addition to his many publications and innovations, he served in leadership positions in a variety of professional organizations. He was a founding member of the Association of Bone and Joint Surgeons in 1947. His innovations include a patellar prosthesis first reported in 1955 [8] and a tibial plateau prosthesis reported in 1960 [9]. These sorts of innovations were forerunners of our contemporary joint implants. The paper we reproduce here, however, describes the use of maggots to treat infection. McKeever [7] credits Baer [2] with the development of the approach in osteomyelitis based on observations Baer made in France during WWI. (Editor's note: The error in the referencing in this Classic between References 4 and 5 is in the original manuscript.) However, Baer noted previous writers (including the great French war surgeon and surgeon-in-chief to Napoleon's armies, Dominique Jean Larrey) had mentioned the beneficial effects of maggots in soft tissue wounds throughout the 1800s. Thus, the concept was well-known, if not widely used, and not specifically applied to chronic osteomyelitis. McKeever [7] describes in great detail the production of nonsterile maggots and how to apply them in chronic osteomyelitis. While the beneficial effects of maggots in wounds and in osteomyelitis in particular have been documented over the years, they have never gained widespread use. Nonetheless, the United States Food and Drug Administration approved the use of sterile maggots in 2004 [1]. As noted by McKeever, the method remains simple and inexpensive, and appears effective [6, 7, 10]. The approach is one which could readily be used worldwide, particularly when antibiotics are not available or effective and when surgery is impractical.

A tribute to a great academic pelvic surgeon: Professor Ahmed Shafik (1933–2007)

A tribute to a great academic pelvic surgeon: Professor Ahmed Shafik (1933–2007)

Illustrations of neurosurgical techniques in early period of Ottoman Empire by Şerefeddin Sabuncuoğlu

Serefeddin Sabuncuoğlu (A.D. 1385-1468) was the author of the first illustrated surgery atlas Cerrahiyyetü'l Haniyye (Imperial Surgery), which was written in Turkish in 1465. The purpose of this report is to present his unique contribution to modern neurological surgery. Cerrahiyyetü'l Haniyye consists of 412 pages in three chapters, in which there are a total of 191 sections dealing with a variety of surgical specialties, including neurosurgery. In each section of the book, a sentence written in rhyme and meter gives the diagnosis, classification and surgical technique in detail. Serefeddin Sabuncuoğlu describes medical and surgical management of neurological diseases such as spinal trauma, epilepsy, migraine, facial palsy, hemiplegia, low back pain, cranial fracture, hydrocephalus and abscesses of the head in his textbook. Serefeddin Sabuncuoğlu was a great surgeon in Turkish medical history and the sections on neurological diseases in Cerrahiyyetü'l Haniyye are of great importance in neurosurgery. Today, he is justified as a pioneer of surgery, an investigator and a medical illustrator in the early period of Ottoman Empire. His atlas is a modification of original contributions from earlier treatises.

24. The controversial conquering of pain

Before the extensive use of anaesthesia, great surgeons were measured by how little pain could be caused to patients in the shortest possible time. Simple operations, such as the extraction of rotting teeth, were terrible nightmares to patients. Some people compared surgery to the Spanish inquisition and there are many accounts in the literature of yells, screams, panicking, and resistance in the operating room. Because of this, before anaesthesia, surgery was mainly restricted to amputations and external growth removals and little advancements could be made over hundreds of years. 
 Five men make the claim to have conquered the horror of surgery in the operating room by discovering ether as an anaesthetic agent: William T.G. Morton, Charles T. Jackson, Crawford W. Long, Horace Wells, and William Clarke. However, only William T.G. Morton is credited with discovering ether as an anaesthetic agent. Mr. Morton publicly used ether during the excision of a tumour from a patient’s neck on October 16, 1846 at the Massachusetts General Hospital in Boston. 
 But William T.G. Morton was not the saint that he portrayed himself to be. There is no doubt that he made the first public discovery of anaesthesia but there is doubt as to whether it was because of his great knowledge and research in the field, or because he took advantage of an opportunity to display this borrowed method to the public.
 Keys TE. The History of Surgical Anaesthesia. New York: Dover Publications, 1963. 
 Smith HM, Bacon DR. The History of Anesthesia. Clinical Anaesthesia. (PG Barash, B. Cullen, RK Stoeling, eds.) Philadelphia: Lippincott, Williams and Wilkins, 2006.
 Wolffe RJ. Tarnished Idol. California: Norman Publishing Company, 2001.

SH08 AL‐ZAHRAWI – THE FATHER OF SURGERY

A pioneer in all fields of surgery, Al‐Zahrawi developed numerous original techniques as well as instruments. He published the first ever surgical encyclopaedia entitled “At‐Tashrif”. His way of thinking and practice of surgery inspired many subsequent great surgeons. As a result of his imperious work and contribution to surgery, he has been given the title of ‘Father of Surgery’, and provided yet another beacon of light in the dark ages. In his many papers and manuals, he describes various operations and procedures which had never been recorded before. Some have described him as the first ever plastic surgeon, notably for his attention to and methods of incision, use of silk thread suture to achieve good cosmesis. He describes what is thought to be the first attempt at reduction mammaplasty for the management of gynaecomastia. He gives detailed descriptions of other basic surgical techniques such as cautery and wound management. The aim of this paper is to highlight and remind us of the invaluable contributions made by this remarkable pioneer in the field of surgery, which have acted a preamble for many techniques and procedures used in the field of plastic surgery.

Good-Bye to a Great Plastic Surgeon, Ulrich T. Hinderer, M.D. (1924–2007)

Good-Bye to a Great Plastic Surgeon, Ulrich T. Hinderer, M.D. (1924–2007)

THE CLASSIC: Responsibility and Research in Orthopaedic Surgery*

Orthopaedic surgery of today has been left a great heritage by our forebears. It is our duty not only to preserve and to cherish but to enhance this proud inheritance. On south portico of Archives Building in Washington, there is a statue of a beautiful woman holding an infant against a background of stalks of ripened grain, under which appears inscription, heritage of past is that brings forth harvest of The great orthopaedic surgeons of nineteenth century and of early part of twentieth century were our forefathers who not only created this heritage but also planted this seed. The which was sown has borne fruit and has created the harvest of future, orthopaedic surgery of 1954. We of this generation should be doing as our forefathers did for us; we should be sowing seed to bring forth the harvest of for oncoming generations. This should be done, as Willard has expressed it, . . in such a way that we may pass on to our successors a still more perfect inheritance of which both we and they may be very proud. This is perhaps our first and greatest responsibility. How we meet this responsibility will be determined by our vision. We must always remember proverb, Where there is no vision, people perish. Upon our vision rests future of orthopaedic surgery. We can only hope that our Creator may grant to all of us and to our line strength, wisdom, and courage to carry steadfastly torch of our proud heritage, and at all times to maintain a clear, bright, and unobstructed vision for future.

Zum 150. Geburtstag von César Roux (1857–1918)

César Roux was one of the few universal surgeons at the end of the 19th century who dominated all fields of surgery and influenced current surgery with his innovative spirit. Pioneering spirit and the story of the success of modern surgery are linked with his name. On the occasion of his 150th birthday, we recall the memory of this great surgeon. The personality and the history of Professor César Roux form a part of our medical and surgical heritage.

Kocher's Gland Dissector, Thyroid Retractor and Artery Forceps

Theodor Kocher (1841–1917) was Switzerland's greatest surgeon. Indeed, his name ranks high in the surgical world's hall of fame. In the latest of his ongoing series of articles, Harold Ellis explores Kocher's contribution to the field.

Special issue—Collagen

Hernia is the most frequent surgical disease with an overall incidence of more than 10% of the total population and at least the same percentage of the average surgeon’s workload. Since its Wrst description more than 4,000 years ago by Babylonians and Egyptians, hernia has always been understood as a mechanical defect of the abdominal wall caused by trauma, heavy weight lifting, or maximum intraabdominal pressure. Because the etiology of hernia was suspected to be a mechanical problem, traditional surgery consisted of mechanical repair by suture, i.e. direct closure of the hernia defect by suturing. Although this repair usually succeeds, hernias recur at a rate of 10–15%, despite the best mechanical suture repair. At the beginning of the 20th century, understanding of hernia as a simple mechanical defect was questioned by some anatomists, who asked about the connective tissue and its role in hernia development. The Wrst systematic discussion of hernia as a disease of the connective tissue was that of Raymond Read in the 1960s, with many studies and papers on hernia as a result of weak collagen. Since these pioneering publications much evidence has accumulated suggesting hernia disease can no longer be regarded as a simple mechanical defect but must be understood as a connective tissue problem. The demographic development of our population furnishes evidence of an inverse correlation between mechanical activity and hernia incidence—the older the patients the higher is the incidence of hernia and the less the strength of the connective tissue. Surgeons from all over the world therefore agree that we must understand hernia as a connective tissue disorder that can be treated only in very few young patients by simple suture and must be handled in most patients by mesh augmentation. This understanding of collagen disease is the reason for the increased use of mesh in hernia surgery today; it will continue as long as we have no pharmaceutical method available to increase the strength of the weak collagen. It was Raymond Reads proposal to arrange a special supplement on collagen disease in the “Hernia” journal. Authors from diVerent groups worldwide have participated in this collection and present diVerent aspects of the collagen problem in hernia disease. One can see that since the Wrst discussions of hernia as a collagen disorder much evidence and knowledge has been accumulated, enabling slightly better understanding and treatment of this misunderstood “mechanical” problem. Because Raymond Read was the pioneer of this new understanding of hernia as a collagen disease, this volume is dedicated to this great researcher and surgeon, the nestor of modern hernia surgery.