Doctor Henry Collier
(Tonight we have a discussion entitled “Theodor Billroth, Father of Abdominal Surgery, 1829-1894,”)
I’d like to send around a few exhibits before I get started here, some are translations of Billroth’s textbooks, and here is a book on Brahms and Billroth, and in the JMA Journal there is a painting of Billroth in his amphitheater. I suppose that Billroth, sometime in the past has been presented before this organization. Gene tells me he thinks Rudy Noer, seven or eight years ago gave a paper on him, but I don’t recall in my time anyone presenting this topic.
Christian Albert Theodor Billroth, that’s his full name, who was also to be called scholar, statesman, musician, medical authority, bacteriologist, pathologist, master surgeon, and father of abdominal surgery, was born of Swedish stock. He was born in Bergan on the island of Rugen, in the Baltic Sea, which was a Prussian possession, on April 26, 1829. His father was a Lutheran minister who had been sent to this island. His mother came from a background of musical talent. Theodor, as he was to be called throughout his life, was five years old when his father died of tuberculosis. Theodor was the eldest of five children and was five years old when his father died. His mother, subsequent to this, moved the family to Griefswald, in Germany, to be close to her relatives.
During the school years of Billroth, he was not to show any of the brilliance in his schoolwork that he later showed in medicine and surgery. Some say the reason for this was that he was too interested in music. He was a pianist, he was an accomplished pianist, and it was stated that he spent more time at the piano than he did at his studies. When he was graduated from high school, he had thoughts of making music his career. But his mother apparently was a more practical woman and she influenced him together with a member of the medical profession that was a friend of the family, to enter into the study of medicine. So he enrolled in the University of Griefswald in the medical school, and even during the first semester of this school, why he still paid little attention to his studies and a great deal of attention to his piano. On one occasion, he was the accompanist for Jenny Lind, while he was a freshman medical student. But sometime during this first year of medical school, this friend of the family, Professor Baum, who was a surgeon, somehow influenced Billroth into putting his energy into his studies, and from that time on, he became very studious and very enthusiastic, and he did well and excelled in whatever he undertook, although throughout his life, he never lost his love or his interest in music. When this friend of the family, Professor Baum, transferred from the University of Griefswald to the University of Goettingen, also in Germany, Billroth was so taken with this man that he followed him to this school. While he was a student there, his mother also died of pulmonary tuberculosis.
I guess it’s hard for us to understand today what a terrible scourge this was during these days. He was in some jeopardy about finishing his medical school because of the loss of his mother, but his maternal grandmother was generous enough to give him the financial aid to continue in school. He transferred to the University of Berlin, and while he was a student there, he came under such authorities as Von Langenbeck, Schoenlein, Romberg, and Traube.
Apparently under Traube’s influence, he became interested in experimental pathology and probably this was responsible for the subject that he chose for his graduation thesis which was, “The Nature and Cause of Pulmonary Afflictions Due to the Section of Vagus Nerves.” He graduated from the University of Berlin in 1852 at the age of twenty-three. Following his graduation, he did out his military duties which were required at that time. He passed his state board examinations, and for a while he worked in a private clinic of Albrecht Von Graefe. Then he took most of the year off and took a study tour. He visited clinics in Vienna, Paris, and London, observing things that were going on in the clinics. He returned to Berlin in 1853 and set up his office in general practice. For two months he sat in his office and did not see a patient. By chance, an acquaintance of a friend of his came to visit with him. This man had been an assistant in Von Langenbeck’s clinic at the University of Berlin, and he informed Billroth that there was a vacancy there, and suggested to him that he apply for this position. He did, and he was accepted in this position.
Billroth was by nature throughout his life an individual who had tremendous energy. When this clinic gave him an opportunity and stimulated his interest and enthusiasm, he became acquainted with some famous men of his time in the clinic: Meckel, Von Graefe, and Wilms. At first he...about the first three years he was there, in addition to working as an assistant in surgery under Langenbeck who was the chief of surgery, he also turned his attention to pathological histology, which was an eccentricity at that time. Here again, there was a large amount of clinical material available to him, combined with the energy that he put into it, and his innate ability to learn, he was to establish such a foundation in this field, that later he was able to speak with authority on it, on pathology.
Three years after he had started in this position, he was offered a position in what was called at that time a private docent, which was a lecturer to the medical students. This was a position that was unsalaried, but he did receive renumerations from fees directly from the students there. He gave courses first in pathological anatomy, and in general and specialty surgery, and in operating techniques and later we’ll get to the texts he wrote, and these are a collection of his lectures.
Von Langenbeck was very fond of Billroth and he apparently held him in high esteem, and he granted him many extra privileges that some of the other assistants in the clinic were not granted. For instance, when Billroth married in 1858, he was allowed to live outside the clinic, which was not the custom in that time. But Billroth being the type of individual he was, even with the patronage that Von Langenbeck showed him, he became rather dissatisfied with this lot, and Billroth was pretty much his own man. So he began looking around for other positions.
During this period of time he was offered a position as professor of pathology at his old first university, by the University of Griefswald, but he’d made up his mind by this time that surgery was the field he wished to spend his life in, and he turned this down. Then in 1860, seven years after he had worked as a surgical assistant, he was offered the position of...Chair of Surgery at the University of Zurich. He accepted this eagerly. Von Langenbeck apparently tried to dissuade him from leaving him, because I think he was trying to have him step into his footsteps when he retired. But Billroth wished to get off and be a chief of a service. So he accepted this position. He was thirty-one years old when he became head of the department, and he may well have been the youngest head of a surgical department in Europe at that time.
That was not the day when the young men had the opportunity as we see today. From Berlin, he went to a more relaxed atmosphere, and he was associated with younger men, closer to his own age. He also had more time to write and carry out his own ideas.
It was during the first three years there that he compiled this textbook, which was called Textbook of General Surgical Pathology and Therapeutics. As I said, this was a collection of the lectures that he had given when he was a private docent. This book became a classic in its day. It even went through sixteen editions, eleven during his lifetime, and subsequent to that, one of his assistants did translations of it, or re-editions of it. It was translated into at least ten languages, including English, French, Italian, Russian, and even Japanese. It is thought that maybe the fame that he gained through the popularity of this textbook had to do a great deal with his later being offered the position of Chief of the Surgical Division at the University of Vienna in 1867.
In all, Billroth spent seven years in Zurich, and during those seven years he was offered, on at least three occasions, chair of the Surgery at other institutions, and his medical students prevailed upon him to stay there. He was a great favorite with students. During this time as I said he was under less pressure than he had been before, even though he was chief of a service, he was in a more relaxed atmosphere, and he again rekindled his interest in music, the musical field. He took up the study of the viola, became a member of a string quartet, attended many concerts, and even was a guest conductor of a couple of concerts there, and was also on numerous occasions a guest...a music critic of a local newspaper.
During this period of time, Johannes Brahms came to Zurich, to present a concert, and Billroth attended this. He enjoyed Brahms’s music very much, and he had an opportunity to meet Brahms, and invited him the next evening to repeat the concert as a guest in his home. These two men, although they were of different background, different temperaments, different personalities, established a fondness for each other, and throughout the rest of their lives they were close friends. They corresponded frequently, and Brahms had a great deal of respect for Billroth’s ability to appreciate music, musical selections. He used to send compositions to him for his critical review before he published it, and he also on numerous occasions later, when Billroth was living in Vienna, performed the selections in Billroth’s home before he gave a public hearing of them.
When Brahms went to Vienna about two years before Billroth accepted the position there, it is thought that this had a good deal of influence in the decision of Billroth’s move to Vienna when he was asked to come there in 1867. At the time Billroth went to Vienna there were basically three large medical centers in Europe, Paris, Vienna, and Berlin. And Vienna, if not the first-ranking center, was at least the second-ranking center at that time. The time that Billroth accepted this chair with the position in the University of Vienna, he was 38 years old.
It was during the next 25 years of his life, when he was a professor at the University of Vienna, that he did his most important work, in two fields: the 2 fields for which he best known: that is the field of development of gastro-intestinal surgery, and in the field of training and developing outstanding surgeons of his day.
To say that Billroth was welcomed to Vienna with open arms would be a misrepresentation. In fact, there was considerable opposition to him at first. There were a number of older men that were firm in their positions and they had certain reservations in accepting this very enthusiastic, energetic extroverted upstart who had some ideas how he wanted to change the University affairs. But being the type of personality that Billroth was, and through his friendliness and his warmth, he overcame this opposition by his integrity, his honesty, and his sincerity! Here he was able to develop fully his methods of experimental studies, and he was one of the first surgeons of his time to present honest statistical reporting, not only of his successes, but also of his failures and the complications from his procedures. He was a man who was able to stimulate his medical students, and he had a large gathering whenever he operated, not only of students, but also of visiting surgeons of the time and he was particularly effective in stimulating his assistants, or what we would probably call residents comparable at this time. He chose his assistants with great care. He expected a great deal from them and they had to show to him that they were really interested in working hard and applying themselves before they were taken on. But he also gave them due credits for any of their accomplishments, and he made extra effort when they completed their time with him to see that they received good positions.
Now, there were at least nine men that he trained at that time who became either professors or heads of departments, or became heads of large clinics in Europe. Three of the better-known men who were his assistants were Czerney, Mikulicz, and Von Eiselberg.
Three years after he had arrived in Vienna, in the year 1870, the Franco-Prussian war began, and Billroth was 41 years old at this time, and he was nearing the peak of his career, but he had one strong yearning. He longed for first-hand military experience. In fact when he was assistant in Dr. Langenbeck’s clinic, he did a study on war injuries dating back in history, and their treatment, dating back to the fifteenth century up to that time. By then he had become an American citizen, so he was really not subject to being called into this conflict, but he still felt of himself as a loyal, and native-born German. So he and Czerney joined the Austrian Patriotic Relief Society of Vienna, and their services were accepted, and they were sent to Weissenburg in Alsace. They left Vienna only 10 days after the declaration of war of Germany on France and traveled to Weissenburg, arriving there in the first part of August.
On the day that they arrived in Weissenburg there had been a large ...major battle close by...in the area, and the field hospital had moved forward with advancing troops, and suddenly on this little town of Weissenburg there were descended about 300 severely injured soldiers. They were too severely injured to move all the way to the rear to general hospital. So Billroth found himself faced with a situation of 300 wounded men to care for and a community that was not prepared to accept this sort of catastrophe. There were inadequate or no supplies, and the only available facility that there was, was a military installation there that had 40 available beds. To help him in caring for these 300 men, there was Czerney, and there were four physicians in the community, only one of whom Billroth considered as competent, and about 24 medical students, a number of orderlies from Berlin, and a group of stretcher bearers.
Well, it remains for Billroth, with his organizing ability and his energy to bring order out of chaos, and he proceeded to do this with his usual decisiveness. He set up several hospitals in the community. He gave Czerney responsibility of caring for about a hundred of the injured, and he himself operated in two of the hospitals he had set up, and supervised all the personnel and the facilities. They also set up care of the patients in private homes. Six days after his arrival there, under these chaotic conditions, he wrote to his wife saying, “My activity here in association with Czerney is extraordinarily successful and thriving. In a few days I hope to have my hospital in a condition almost comparable to that of my clinic,” and he said, “I am achieving what I wanted: to help and to learn, and so this campaign fills a great gap in my experience.”
Well, Billroth had expected to stay in Weissenburg till about the middle of September. Now he arrived the 1st of August and he expected to stay there about six weeks, and then his intentions were to return to Vienna and turn over the hospital care and the remaining patients to Czerney who was to phase out or transfer the injured and close down the hospital in the early part of October. But by the end of August, a group of representatives from the Mannheim Relief Society called upon Billroth and asked him if he would become the Director in Chief of all the hospitals in that community. Billroth later was to say that there was an adequate number of physicians in this community to care for the injured but they lacked any energetic authority nor was there anyone there of the ability to make decisions concerning operative procedures. He accepted this position at Mannheim, on the condition that he would be allowed to transfer to Mannheim from Weissenburg 100 of the injured that he was caring for.
Well they accepted this, and so he, as of the 1st of September, took over the duties of Director in Chief of all the hospitals in Mannheim. Now, this was a more complex situation; there were about 12 hospitals there. I don’t recall the exact bed number but it was something like 1400 or so, and 7 of these hospitals...private hospitals were designated for care of the wounded and 7 were designated for care of dysentery and other medical ailments. He was there only about 2 weeks, when there became a change in his mood, and he wrote to his wife, at that time saying, “I have promised to remain here only through September and will not stay any longer. The wounded do not attract me any more. Unfortunately, I have already seen a terribly excessive number of them. There is probably not a square inch on the human body that I have not seen a gunshot wound. Even though the number of those whom I have personally treated is naturally limited, yet I have seen so many thousands of gunshot wounds that I am sick and tired of them. As a surgical science, military surgery is extremely monotonous.”
By October of that year, 1870, he was back in Vienna, doing what he enjoyed doing, teaching, operating, lecturing, while he was operating, he was said to be an extremely accomplished surgeon, he lectured while he operated...nothing troubled him. On one occasion, a can of ether apparently turned over and was ignited, and his assistant’s clothes caught on fire, and everybody rushed for the doors. Billroth calmly goes over and got a pail of water, pours it on and goes back to surgery.
Being a man of statistics also that he was, 2 years after he returned from the war, he published a book that was an account of his military experiences and the problems he encountered, the way he handled them, and the conclusions he drew from them, and a year later, there was a Worlds Fair in Vienna, and he was responsible for organizing an international conference to improve the care of the wounded and sick in the field, and he also helped to prepare a number of exhibits on military medicine. Even later, he was to also publish some studies and ideas of his own transportation of the sick and wounded by rail.
Billroth went to war with zeal to gain first hand experience and military experience. He learned of the horrors of war, but he also developed a great compassion for the injured soldier. Some say that this experience made him in later life a pacifist. Now to his surgical achievements. Of course he’s best known to be the first surgeon to have done a successful gastric resection. This he accomplished in 1881. His other first, for which he’s not so well known for is that he was the first man to resect a carcinoma of the esophagus in 1872. He did the first total laryngectomy in 1873, and he was among one of the first to resect cancer of the rectum. The dawn of gastric surgery is said to have begun January 19, 1881 when he did the first successful gastric resection. However, this followed previous experimental studies by a number of his assistants.
Czerney and Gussenbauer and Winiwater, in 1874 had published a paper...work that they had done on the development of the technique of gastric resection in dogs. He was also not the first man to attempt gastric resection in the human. Two years prior to the time that he accomplished this, Jules Pean, a French surgeon, who had not had any previous experimental study, had attempted a resection for cancer, with a fatal outcome. A year before, in 1880, Von Rydygier, who was a Polish surgeon, who had had some experimental background behind him, attempted a resection also with a fatal outcome.
The first patient was Theresa Heller. She was a 43 year old, female, she gave a 3 month history of indigestion followed soon by vomiting after meals, weight loss, and weakness. Her positive physical findings were, that there was a palpable mass just above the right of the umbilicus. This was described as the size of a small pit. You have to think back on the conditions of these times. They did have anesthesia, but it certainly wasn’t too well developed. I doubt that there were any true specialists in the field at that time. The methods were crude. There was no blood available, there was no intravenous fluids, from a diagnostic standpoint, there were no x-rays available. So these were the conditions that he was working under at the time that he did this procedure. He describes the procedure as having made his approach through a transverse incision over the palpable mass of about 8 centimeters in length, I wouldn’t even try to take an appendix out through that. He divided the attachments of the greater omentum and the lesser omentum and for a distance of 14 centimeters, along the greater curvature side of the stomach, and 10 centimeters on the lesser curvature side of the stomach and then he resected the tumor with only a margin of approximately 1 centimeter on each side of it and following removal, he closed the open gastric pouch along the greater curvature part of the opening, leaving an opening along the lesser curvature side of the stomach. His mobility was such that he was able to anastomose end to end along the lesser curvature side of the stomach and the open end of the duodenum also using silk sutures and did a satisfactory anastomosis, closed the patient, he completed the procedure in 1 ½ hours, saying that this was slowed down due to a slowly administered anesthesia. The tumor microscopically was classified at that time as an alyeolar colloid carcinoma, and there were positive nodes present. The patient took nourishment on her first post-operative day, and gradually improved, left the hospital, she lived for a period of four months and died of what was called exhaustion. A post-mortem examination was done on her, and it showed that she had peritoneal implants. She also had a considerable large number of retroperitoneal nodes, but it was said from the post that the form of the stomach resembled that of the normal organ.
Four years later, Billroth had done a number of these procedures, and by this time he was doing his anasomosis along the greater curvature side of the stomach of the duodenum. He was operating on a patient in which, after resecting the tumor, he was unable to bring the duodenum of the stomach together. So he proceeded to close the duodenum in, he closed the gastric pouch and he brought up a ( ) and did a gastrojejunostomy. This technique had been previously developed by one of his assistants, Wolfler, and thus was born the Billroth 11 procedure.
Billroth himself, the best I can determine, preferred the first procedure, the Billroth 1 procedure. But to this day, general surgeons still argue which is the preferable hook-up in this operation. Billroth was a giant in his time, and he was also a giant in the history of medicine and surgery. He was a multi-faceted, talented individual. His personality was that of a genial extrovert, who loved life, and who was a great contributor in whatever he became involved in. He undoubtedly was an ambitious man, but he obtained his eminence by his own energy and his own efforts. He never was one to gain his goals by using the work of others. He apparently was a self-assured man, but he was also a humble individual. He was a great teacher with a tremendous wealth of knowledge not only in his own profession, but in the arts of music and literature as well. He was a fluent, eloquent speaker. His mind apparently was not cluttered with pre-conceived ideas. He was a gifted organizer and administrator. He had the ability to rapidly shift his mind from one endeavor to another without any loss of continuity. He truly was an artist, and he was one of the great men of medical history. Thank you.