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Professor Emil Theodor Kocher By
Most great men are known by their works and very little is told of their intimate personal life. Theodor Kocher was born August 25th, 1841 in Berne, Switzerland. An early account of his life is not recorded. He was raised in an atmosphere of culture. His appreciation of the best in life began early. From youth he demonstrated his studious tendencies, being a rather quiet, unassuming boy, but quite mischievous. His early training was in the grade schools, and he graduated from the university of Berne in 1865. Following his graduation he spent some time in study, in Berlin, London, Paris, and Vienna during which time he was a pupil of Langenbeck, Billroth and Luche. His associations with Billroth are said to have influenced him most of all. From 1886 to 1872, during his study in foreign clinics, he was Associate Professor of Surgery to professor Luche in Berne, and following Luche’s death in 1874, Kocher was unanimously elected to the chair of surgery at the age of 31. This chair he occupied with supreme distinction until his death in 1917. To be selected by his own people at such an age was indeed an outstanding honor. But why he remained in Berne has always been a question to some. The proverbial love to the Swiss for his country explain in part this apparent anamolu of why in such an age of intensive progression he positively refused to accept most flattering calls to extensive and remunerative fields of activity. For he found at home the most favorable and congenial surroundings to work. Nowhere in the world were so many natural advantages combined for the free promotion of this abnormal activity than in Switzerland geographically. Not restricted by politics and unhampered by social or financial prejudice, these and many other equally conductive conditions kept him in his most loved hometown. From his earliest medical training he was a born anatomist. His first contribution to surgery that attracted attention was as a student under Billroth. He worked out a method, now known by his name, for the reduction of dislocated shoulders. A case of old subcoracoid dislocation of the shoulder was brought into the clinic and every method to reduce the dislocation had been tried and failed. Billroth, turning to the spectators, asked if there was anyone who wished to give a suggestion. Kocher, having just perfected his method in such cases, stepped forward eagerly and asked to be allowed to try the procedure; the shoulder was replaced at once. When asked what method and process he used he said humbly, “the Kocher method.” He then described the usual position of the rent in the joint capsule, direction of movements of the head of humerus as it escaped from the joint, and the final position in which it must lie, and demonstrated why his method would succeed if duly carried out. By this (procedure) Kocher first attracted attention in surgery, and he kept before the profession from that time. Quite early in his career he realized the truths and the vast scope of listeners teaching, and was the first to pay strict attention to aseptic principles in open operations for carcinoma of the tongue. As a man Kocher was small in stature, thin, quiet, with a slow but keen appreciation of wit, an unceasing worker inhumanly patient and kind, with an indomitable will and unconquerable tenacity, and endowed with the typical old world courtesy. In his home he was always pleasant and affectionate, accepting only the truth, square and honest in all of his dealings, respected by all classes and beloved by his family. Because of his overwhelming generosity in the care of his patients he was prone to overtax his seemingly strength, and it was for this reason that Mrs. Kocher directed his social and many of his professional activities. Some of the stories of his so-called “henpecked” life are in striking contrast to the domination personality he presented in his profession. As a teacher he was diligent and earnest, tireless in his painstaking details. Working form 8:00 A.M to 10:00 he taught in the theater, where the cases were brought in, examined with great care and discussed at length. He was aided in teaching by some artistic ability. Never impatient with an honest if stupid effort on the part of the student, his voice grew high pitched and querulous when students would try to deceive him by asking thoughtless questions. It was said that at times, under such conditions, his small statue would fairly vibrate with frenzy in anger with the students for jesting over some point he had taken as serious. He was a man who was never precipitate in his diagnosis of a case; he knew the value of careful and repeated observations and insisted upon absolute certainty in each individual case. Rarely was there a case that he could not explain. He implanted into his students that sense of duty, which sacrifices all to the cause of the patient. He refused to distinguish between important and unimportant matters, for every detail held some importance for him and he never failed to impress this on his students. He did not train any great men in his own school, as did Billroth, but there are surgeons all over the earth who can say that in large or small part it is with pride they claim some humble share of his great inheritance. His pupils were attracted to his clinic, not so much by the brilliancy of his teaching, as by the amount of sound knowledge they knew was to be gained form him, and the excellent training in conservative and logical reasoning which they received. As a surgeon his life was one unceasing activity, he began teaching and operating at an early age, and throughout his career his freedom from prejudice for his own intellectual progeny was shown. His broad mindedness was shown in his early acceptance of Lister’s theory, use of aseptic surgery and in his use of Bassini’s operation when indicated, giving full credit for its merits, when Kocher’s hernia operation had already been accepted by many. He was consecrated to his profession as his very life, and his holidays were invariably devoted to theoretical work. There were few days in the summer or winter seasons of school when he did not visit the post mortem rooms to demonstrate an old operation or try out a new one. Throughout his whole long life his devotion to anatomy and his operative work on the cadaver were unceasing. As a result of this, every operation he did was a supreme exhibition of his perfect knowledge: combined with a flawless, aseptic conscience, technical efficiency, and unfaltering courage with sound unruffled judgment and the most exquisite gentleness that man could accomplish. He was unsurpassed in his observance of details in technique; no one seeing his operations could ever forget his tender care, exquisite gentle touch, and deft movements of every finger. Even the minutest detail was so arranged that was no hastening, no untidiness, no shedding of one drop of blood that could be spared, no loss of time. With infinite accuracy, care, and patience he obtained results as near absolute perfection as is possible in surgery, and by such work he was able to obtain apparently impossible results in his work. There were surgeons on the continent or abroad that could operate with much more speed but never was there one whose judgment was so sound in the performance of a daring operation where the risk of life arose. The so-called “Kocher speed” was uniform whether he performed the simplest or the most complex operation, and there is hardly a branch of modern surgery in which he has not left valuable and permanent impressions. Professor Kocher remained active until the very last, at the age of 76, shortly before he died, he lectured and operated with youthful vigor, and those who knew him had to admit that he displayed the same abounding energy at the close of his career as he did when he started his work in the Swiss Capitol. Professor Kocher not only kept a pace with the progress of science and time, he was ahead. Monihan states that Kocher lived a long life of unceasing industry and covered a wider range of subjects than any loving surgeon. His work in almost any one department of surgery alone would have made him a reputation as a surgeon of great gifts. In his resourcefulness he constantly devised methods, some entirely new, others wise, sound true modifications of old methods. His literary work was amazing both I quantity and in high value. He published numerous works on bones, stomach, gall bladder, hernia, cranial nerves, osteomyolitis and goiter, and as his chief distinction rests in his development of operating methods for thyroid disorders. I whish to speak of his extraordinary work in that branch of surgery. We find from 1866 to 1872, Theodor Kocher was assistant to professor Luche in Berne. During that time Luche performed ten goiter operations; of these patients, nine died. Two years after having been elected Luche’s successor, Kocher, in 1874, published his first paper on the thyroid gland-on the pathology and treatment of goiter. In this paper he published his first thirteen goiter operation, with only two deaths. He said that there were three forms of operation for goiter; total thyroidectomy, partial thyroidctomy, and enucleating. The total thyroidectomy is easier procedure “Than practical thyroidctomy, but it is a question whether there is any connection between the total extirpation of the thyroid gland and the altered mental condition I have noticed in one of my cases of total thyroidectomy.” His goiter operations were done on a preconceived plan-even at that time he sought in each case to legate the arteries first. A few years later (1887) he published his first operations for malignant goiter, describing a method of “evident” of soft malignant tumors, especially intrathoracic ones. In 1883 he published the results of his first 101 goiter operations. He gave at the same time a list of all the goiter operations performed to date. He found that with his own 101 cases, 240 goiter operations had been performed. In this same paper he detailed his exact method of operating, and then described the consequence of total thyroidectomy. He had reviewed all the cases he had operated on and in the eighteen cases where total throidectomy had been done he found the typical picture of myxoedema. In April 1883, he read a paper on the consequence of total throidectomy at the German Surgical congress, calling the disease “cachexia thyreopriva.” From that moment he began to treat these cases of total thyroid glad or goiter in many different parts of the human body, skin, muscle, arteries, peritoneum, intestine, etc., but the effect was only temporary. Later on he reviewed these cases as often as possible; he found that those cases in which a real total thyroidectomy had been performed, died with seven years after the operation (no thyroid tissue could be found at the postmortem examination), while those who lived longer had developed a new but small goiter, proving that total thyroidectomy had been done. In the years form 1880 to 1890 he studied the question of the etiology of goiter, examining thousands of school children all over the canton of Berne, and examining especially the water at the different places. In 1889 he published a map showing a close connection between geological formation and the distribution of goiter. At that time, in a public lecture, he urged the Government to boil the drinking water in the public schools, or to add iodine to it, in order to prevent goiter. In 1889 he published the results of another 250 goiter operations. In this paper he described his exact procedure in the operation he named “inucloatin resection,” including the collar incision of the skin. This method of operation for goiter was that used by him in his entire goiter operations without any modification; it became and remains to day the classical method operation for nodular goiters all over the world. This method not only included the collar incision of the skin now universally used, but also gave the exact method of leaving all healthy thyroid tissue behind, so assuring a sufficient function of the recurrent nerve and of the parathyroid glands, which became known only later on. Hotz calls it the Kocher operation. In 1887, when showing a case of Grave’s disease to his students to illustrate a clinical lecture, he demonstrated the hypervascularization of the thyroid gland, and suggested that the symptoms of the disease were due to hyperthyroidism. He was the first to perform a successful operation for goiter in a typical case of Grave’s disease. In 1897 he published sixty-nine cases of Grave’s disease operated upon, with only four deaths. In 1892 Theodor Kocher published his paper on the origin and prevention of cretinism, in which he described a case of congenital goiter with cretinism, and showed that cretinism was due to lack of thyroid function, and can be prevented. This point of view for long met with much opposition, but has nowadays been generally accepted. In 1895 Theodor Kocher had done 1,000 goiter operations; in 1901, 2,000; and in 1905, 3,000. at the time of his death in 1917 he had personally performed 6,000 goiter operations. In 1897 he read a paper on the action of iodine on goiters. In that paper he suggested that the normal thyroid gland must contain iodine, as the action of desiccated thyroid glad on goiters was the same as that of iodine. Unfortunately, the professor of chemistry at the University of Berne, who made the investigation, could not find any iodine in the thyroid glands he examined. A year later Bauman in Freiburg published his article on the normal iodine content of the thyroid gland. In 1907 he read the opening paper at the German Congress of Internist at Munich, on the pathology of the thyroid gland, and in 1906 gave the annual oration (on the same subject) before the Medical Society of London (British Medical Journal, 1905, vol. I, P. 1261. This work was the starting point f modern endocrinology, nothing important on malignant goiter, describing the different forms in conjunction with Langhaus. In 1908 he described his methods of gland grafting, publishing seventy-nine cases of transplantation in myxoedema, mongolisn, and hypothyroidism. He especially recommended taking the transplant from a gland of a case of Exophthalmic goiter, thus proving by his successful cases that the gland in Grave’s disease is hyperactive and not toxic. In the same year he published the exact analysis of the blood in 260 cases of Grave’s disease, showing that the leukocyte formula displayed a typical change, and a few years later he also showed a typical blood change in myxoedema, pointing out that the number of the lymphocytes in the blood was connected with the functional change of the thyroid gland. Williamson has recently established this close connection of the lymphocytes and lymphoid tissue to the secretion of the thyroid gland histologically. In 1910 Theodor Kocher gave the classical picture of Iodbasedov, showing that the use of iodine can produce Grave’s disease in certain forms of goiters, and drawing attention to the harm that can be done in consequence by the use of iodine in goiters. Thought at the present the Mayo school has shown that Lugol’s solution can, in certain cases of Grave’s disease, bring about an improvement and make the operation less dangerous; Kocher’s observations and statements remain quite true. The exact role of iodine in the disease is, however, far from being explained. In 1909 he was awarded the Nobel Prize for his research work and especially for his discovery of the function of the thyroid gland. He hen gave before the Academy of Medicine of Stockholm as address in which he drew a classical picture of the minor functional troubles of the thyroid gland, hypo-and hyper-thyroidism. In 1911 Kocher published the results of 1200 operations on the thyroid gland in grave’s disease, with 80% complete cures. In that paper the showed how the disease can be diagnosed in an early stage, and advocated early contraction of the levitator palpabrae superioris when the patient is made to look up and down quickly. At the meeting of the Swiss Surgical Congress in 1917, a few months before his sudden death, Theodor Kocher reviewed all his goiter operations from which it appeared that he had had, at that time, a mortality of 2 per mile in operation of ordinary goiter , and of 2%, in Grave’s disease. At the time he gave a summary of our knowledge of the etiology of goiter, commending the prophylactic treatment. It is worthwhile to recall all that has been done for the advance of our knowledge about the thyroid gland by Kocher, and under his guidance by his people. It is noteworthy that Kocher never made any fantastic statements, but only drew the conclusions he could really prove, giving entire credit to all tat others have contributed to the question. Since his death comparatively little work has been done of the subject, but very many theories have been advanced. Following in the advancement of the thyroid operations to what they are today are Halsted, Crile, Mayo, Lyhe, Crotti, all of whom have made valuable contribution in management and operative technique of operation for goiter patients. But Kocher’s work was the foreword of them all. When we try to measure the greatness of a man we are confronted with the selection of standards of comparison to determine the chief legacy a surgeon bears. Personal reputation, however exalted is soon forgotten, and the name of a distinguished surgeon may not long remembered in his own country. Books and writings, which at the time of their appearance are striking in the new thought or in the fresh presentation of old ideas, cease soon o be real, new publications bring changes in thought. Likewise, spoken words easily slip the memory and characteristic sayings soon loose their authorship. So we believe that the chief legacy a surgeon can bequeath is a gift of the spirit. To inspire his many survivors with a firm belief in the high destiny of our calling and with a confident and unwavering intention both to search out the results of medicine in her innermost recesses and to practice the knowledge so acquired with sincere purpose, height ideals and generous heart, for the benefit of humanity, that is the best that a man can convey. I believe that those who were fortunate enough to know Kocher will agree that he uplifted in every way the spirit of his profession. We can truly ay that in the death of Kocher, on July 27th, 1917; one of the outstanding modern masters of surgery has been removed. It is pleasant to note tat in his own native town, so dear to him, his genius was so early and long recognized.
Some of His Pioneer Accomplishments
1) Appointed to professor of surgery at 31, while still a young man, he had a splendid opportunity of gaining wide surgical experience, and of developing his intellectual gifts in all directions. 2) As professor of surgery for 45 years, he acquired a wealth and variety of materials for observations and research, such as falls to the lot of few surgeons. 3) In a period in which introduction of antiseptics led to hereto under treatment of advances in surgery. His work was neither interrupted nor retarded by any great international disturbances. 4) Complete absorption in his subject.
Bibliography History of Medicine. Garrison, 3rd edition. Obituary: British Medical Journal, Vol. 2, Jan. to Dec., 1917. 168. Obituary: Boston Medical Surgical Jour. Vol.178, Jan. 29 to July 1918. Correspondence: Albany Medical Annals. Oct 17 p. 471. Obituary: Atlantic Monthly. Howard A. Kelly, July 17. Army Medical Library. Personal correspondence.
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