FRUITFUL COOPERATION
PART V
period 1810-1860
Nikolay Ivanovich Pirogov –
Great Innovator and Reformer
Great Innovator and Reformer
It was not a Tsar or Tsarina but Nikolay Ivanovich Pirogov (1810-1881), a well-educated Russian physician who further reorganised medical education in the nineteenth century. He extended surgery from a craft to a science and contributed beyond the boundaries of surgery. He raised the medical skills in Russia to a level equal to the advanced countries of Europe.
Nikolay Pirogov (18810-1881) was born 13 (25) November 1810 in Moscow. The Napoleonic Wars were still raging across Europe and Russia. Caricatures of the French were published as cards in alphabetical order and distributed to all houses in the city. Nicolay Ivanovich learned to read Russian by these cartoons at the age of 6 years. He was about seven years old when he received as a Christmas gift from his father what he considered the best gift of his life: ‘The children's Reader’ by Nicolay M. Karamzin, containing dialogues, plays and fairy tales. He also read ‘The spectacle of the Universe, Children's Museum’ and ‘Journeys through Russia’ by Peter Simon Pallas. Pallas studied medicine at the University of Halle and Göttingen, but obtained his doctorate at the University of Leiden.
Portrait of young Nikolay Ivanovich
about 18 years old, artist A.D. Khripkov.
© From the collection of the Military Medical Museum, St. Petersburg
© From the collection of the Military Medical Museum, St. Petersburg
One of the older brothers of Pirogov went bedridden with rheumatic fever. Several doctors looked after his brother, but nothing helped. Then the family called in Professor Efrem Osipovich Mukhin, one of the family friends. He was dean of the Medical Faculty of the Imperial University of Moscow, and his specialities were anatomy, surgery, trauma and physiology. His brother started to recover after just a few days. Mukhin left the most excellent impression on the young Nikolay. The approach of the four-horse carriage, the liveried manservant and the tall, grey-haired physician with his majestic appearance impressed him very much. He started to imitate Mukhin. The young Nikolay watched and observed the handlings accurately and closely. The people at home and even his cat, dressed as a woman, were his patients. He asked them to lie down on a cot or sit in a chair. Pretending to be the doctor himself, he approached his imaginary patients with an air of importance, felt the pulse, looked at the tongue, wrote prescriptions behind a desk, gave advice on how to prepare the medicines. Feeling important, he prepared to leave, and then left the room.
Portrait Efrim Osipovich Mukhin
pen-ink-drawing, 1830, artist Alksander Florov.
In public domain
In public domain
Pirogov was 13 years as he entered 1814 Moscow University as a medical student. During the Christmas season in his first year of university, he saw a lithotomy performed in the clinic. Being at a friend's house, he decided to amuse the young guests by demonstrating this operation. He somewhere got an ox bladder, placed a piece of chalk inside, tied the bladder between the legs in the perineum of a meek guest, asked him to lie down on the table and part his thighs. Armed with a knife and some other domestic instruments, he dissected the chalk piece and said the words: "...safe, quick and pleasant..."
Handwritten letter by Nikolay I. Pirogov
dated 11 September 1824.
© From the collection of the Military Medical Museum, St. Petersburg
© From the collection of the Military Medical Museum, St. Petersburg
Pirogov graduated at the age of seventeen from Moscow University but was very unsatisfied. He did not consider himself a physician because he did not carry out a single operation, a bloodletting, pulling any teeth, dissecting a dead body, or sectioning a single muscle. Pirogov stated that "…it was a rather theoretical education based on textbooks from the 1750s…". Was he referring to the textbooks of Nicholaas Bidloo, Herman Boerhaave, and the atlases of Andreas Vesalius and Govert Bidloo?
At the age of seventeen, he continued his studies at the German-Baltic University of Dorpat (now the University of Tartu in the Republic of Estonia) with a scholarship from Emperor Nicholas I. The aim was to obtain a medical doctorate in Dorpat so that after his doctorate he could go for a postdoc traineeship of two more years at foreign universities in Europe. In his first year at Dorpat, he wrote an essay based on an assigned, contemporary topic. Pirogov researched the topic What is observed when a large artery is ligated? The ligation of an artery in a patient with an aneurysm was a very new and potentially dangerous procedure at that time. Pirogov's essay won him the Gold Medal. The essay was the beginning of his doctoral thesis: "the feasibility of treating aneurysms of the inguinal artery by ligation of the abdominal aorta".
In his zeal and youthful passion, he operated on both dead and living animals to learn as much as possible about their anatomy and how they reacted to ligation of the aorta. Pirogov had considerable reservations about the safety of this procedure in humans. Pirogov successfully defended his thesis 'Num vinctura aortae abdominalis in aneurysmate inguinali adhibitu facile ac tutum sit remedium' and was awarded his doctorate in April 1832. Pirogov emphasised his core belief that nothing should be taken for granted in science and stated that "…Science is not built from what people think, but from what people have discovered …"
Cover of the dissertation defended by Nikolay I. Pirogov in 1832 at the Baltic-German University in Dorpat
© From the collection of the Military Medical Museum, St. Petersburg
Two-years post-doctoral study in Germany
After gaining his doctorate, Pirogov travelled to Germany to complete a further two years post-doctoral study of anatomy and surgery at the Charité Hospital in Berlin in 1833.
In the summer of 1834, he visited the University of Göttingen. He attended lectures by professor Konrad Langenbeck, famous for his speed and precision as a surgeon. He taught Pirogov how to achieve the most efficient movements during surgery and how to use a scalpel "...do not pressure the scalpel but move it slowly, playing it as a bow over the violin..." Pirogov understood that a fast and skilled surgeon was critical to spare the patient for pain and trauma.
In the summer of 1834, he visited the University of Göttingen. He attended lectures by professor Konrad Langenbeck, famous for his speed and precision as a surgeon. He taught Pirogov how to achieve the most efficient movements during surgery and how to use a scalpel "...do not pressure the scalpel but move it slowly, playing it as a bow over the violin..." Pirogov understood that a fast and skilled surgeon was critical to spare the patient for pain and trauma.
Return to Dorpat
Drawings of Nikolay I. Pirogov of his plastic surgery operations.
© From the collection of the Military Medical Museum, St. Petersburg
After his return in May 1835 to Dorpat in May was Pirogov appointed as an extraordinary professor. While waiting for the confirmation in Saint Petersburg gave Pirogov over six weeks many anatomy demonstrations in the mortuary of the Obukhov Hospital. He also gave a lecture to the Imperial Academy of Sciences 'About plastic surgery in general, and about rhinoplasty in particular'. During his career Pirogov carried out forty rhinoplasties.
An extensively illustrated atlas of arterial trunks and fasciae, published in 1837 by Pirogov and republished by Julius Szymanovski 1860.
© From the collection of the Military Medical Museum, St. Petersburg
Pirogov spent eight hours each day carrying out and analysing anatomical experiments in addition to his clinical duties. During these experiments, he made at least two or three drawings of his dissections as he believed that these would be useful to surgeons in helping them during operations in patients. The result of these experiments was published, in black and white, in an extensively illustrated atlas of arterial trunks and fascia in 1837. In it, he wrote: "...A real anatomical-surgical image must be for the surgeon what a map is for the traveller..." The atlas was re-published in 1860, including an extra page of a drawing of the total body, and with coloured arteries in red and veins in blue.
Orthopaedic treatment: the transection
of the Achilles tendon.
of the Achilles tendon.
Nikolay Pirogov's first encounter with orthopaedic surgery was with a 14-year-old female patient with a clubfoot. Until then, he was only aware of the speciality through publications. Pirogov considered the operation of tenotomy as one possible treatment for his patient, although he thought it somewhat risky. Nonetheless, he decided to proceed and cut the tendon. Pirogov believed in impartial research and considered surgery to be successful only if experiments and anatomical-physiological and pathological studies firmly confirmed the theory. He published his research results in 1840.
It shows both sheaths of the Achilles tendon, detached from the skin, after the subcutaneous tenotomy. Drawing made by Nikolay I. Pirogov.
© From the collection of the Military Medical Museum, St. Petersburg
Professional career
at the Imperial Medical-Surgical Academy
at the Imperial Medical-Surgical Academy
In 1838 the Imperial Medical-Surgical Academy in Saint Petersburgoffered Pirogov a newly created chair of surgery. It took some time, but in March 1841, Pirogov was appointed as Professor of Applied Anatomy and Hospital Surgery and chief surgeon of the Second Military Landforce Hospital with 1000 beds. He accepted the offer, because he was allowed to combine the didactic teaching of surgery with practical, hands-on experience at the bedside of the sick.. Thus he could expose young students to scientific principles. Pirogov's approach to medical education was very much in keeping with the teaching of the Dutch physician Herman Boerhaave, who had re-introduced bedside teaching in Leiden in the Netherlands in the early 18th century. Pirogov admired Herman Boerhaave and had access to his scientific legacy. Nikolay became secretary for the Academy of Science and technical director of the St. Petersburg medical tool factory. He also worked as a consultant-surgeon in three other hospitals and ran a busy private practice. His aim was: "...To assist in raising the medical skills in Russia to a level equal to that of the advanced countries of Europe..."
Medical instruments and cases design by Nikolay I. Piogov as director of the St.Petersburg factory for medical tools and used by him.
© From the collection of the Military Medical Museum, St. Petersburg
A plan for teaching microscopy at the Imperial Medico-Surgical Academy
Field microscopes by the firm Plössel and Brunner designed and made in the 1840’s
https://web.archive.org/web/20080723195555/http://musoptin.com/ploessl_mikroskop.html
http://www.antique-microscopes.com/photos/Brunner_Pocket_microscope.htm. In public domain
In 1825, while still studying in Berlin, practical and theoretical courses in microscopy were introduced in the leading medical institutes of this city. In a book published in 1839,Pirogov described the importance of the microscope for research into the influence of altered blood corpuscles on the capillary system. In his first series of monographs on clinical surgery,published in 1854, Pirogov argued that microscopic examination is indispensable in distinguishing lip carcinoma from trivial injuries like a burn from a cigarette or a neglected lip tear.He wrote that "…The microscope is much more indispensable than the stethoscope, which in most cases can be replaced by a practiced ear. Pirogov always carried a portable field microscope with him and recommended the Brunner pocket microscope to his readers as it magnifies up to 400X.
The "Pirogov amputation"
Drawing by Pirogov of the forefoot amputations bearing his name and a portrait/photograph of Dr. Theodor Billroth.
© From the collection of the Military Medical Museum, St. Petersburg
During his trip through Europe in 1846, Pirogov observed two patients who had undergone a foot amputation following the Syme method and could walk without discomfort. He was so impressed that he determined to use this operation on his return to Russia. As always, Pirogov did not immediately use the method on his patients. Because experiments on cadavers revealed several problems with the Syme method, he devised a new approach to amputation of the foot, now known as the Pirogov amputation, and the world's first osteoplastic surgery. But Pirogov's surgical method was so innovative that it met with criticism. However, in Pirogov's support Theodor Billroth confirmed that he had applied Pirogov's method to the satisfaction of his patients: "...(They) go admirably on their stumps..." Pirogov's approach is still used today. Pirogov described his method in the first volume of his textbooks on Clinical Surgery.
The Anatomical Institute
In 1844 Pirogov wanted to add an Anatomical Institute to the Academy. It took two years before permission was granted. During his travels abroad in 1846, he met Wencheslav Leopoldovich (Wenzel) Gruber. Pirogov invited him in 1847 to become his first prosector. The combined skill of Pirogov and Gruber worked out as a marriage closed in heaven. Pirogov instructed medical students and doctors in pathological and surgical anatomy, surgical procedures on cadavers, and combining practical work in the Anatomical Institute. The institute also functioned as a postgraduate education centre. Other Russian medical institutes later followed the path taken by the Imperial Medico-Surgical Academy.
Portrait of Wencheslav Leopoldovich (Wenzel) Gruber
engraving, artist Ignatiy I. Chelmitsky. In the art and literary journal World illustration, 1883, vol. 27, issue 697 p. 409. In public domain
The implementation of anaesthesia in surgery
When Nikolay Pirogov learned about Morton's demonstration of ether anaesthesia and the interest of the Russian government in this new development, he began experimenting with ether in January 1847. Pirogov hesitated to use ether because he was worried about the safety of the technique and the effects during the recovery from anaesthesia. He investigated the clinical course of ether anaesthesia on himself and his assistants before using it on his patients.He carried out his first two operations under ether anaesthesia on 14 February 1847 using a simple green bottle with a rubber tube inserted into the patient's nose to inhale ether vapor. He was convinced that ether anaesthesia was '....a remedy, that in a sense can transform the whole of surgery. He published his first monograph on the subject on 17 May 1847. He wrote a book where he described his experience of administering ether to 40 animals and 50 patients. The purpose of the manual was to provide physicians with information about the effects of ether anaesthesia. Although he was convinced that the discovery of ether anaesthesia was one of science's greatest achievements, he was also very much aware of its limitations and dangers.Pirogov wrote: "…a slow operation even using anaesthetics could be harmful to the patient, because of the prolonged anaesthesia and the trauma…".
Pen-ink-drawing of anaesthesia equipment designed and used by Nikolay I. Pirogov. pen-ink- drawing of the administration of anaesthesia by Pirogov and assistant on the battlefield.
© From the collection of the Military Medical Museum, St. Petersburg
Emperor Nicholas I, being aware of Pirogov's research and results, insisted that ether should be used in surgical operations during the Caucasian campaign in 1847, not only for humanitarian but also for tactical reasons. En route, Pirogov visited several towns and cities where he introduced ether anaesthesia to the local physicians. He widely used it in the summer of 1847 during the Caucasian War. He described and summarised his views about anaesthesia and its importance for surgery in his book Medical Report from a Trip to the Caucasus.
After returning from the Caucasian War, Pirogovadministered his first anaesthesia with chloroform on 21 December 1847 in Moscow; the subject was a large dog. Chloroform had apparent advantages over ether also for use on the battlefield. The quantity needed for adequate anaesthesia was small, and chloroform was not flammable. It did not require complicated equipment since anaesthesia could easily be induced using a simple rag-and-bottle technique.
From personal experience, Pirogov warned against the administration of anaesthesia by untrained assistants. Pirogov became convinced that the effectiveness of anaesthesia increased when doctors focused on administering anaesthesia with the help of trained assistants. Pirogov's opinion was the first step towards safety in anaesthesia and for the patient. The widespread use of anaesthesia by Pirogov in times of war was of significant influence. The whole population was given more and more access to anaesthesia during surgery in Russia.
After returning from the Caucasian War, Pirogovadministered his first anaesthesia with chloroform on 21 December 1847 in Moscow; the subject was a large dog. Chloroform had apparent advantages over ether also for use on the battlefield. The quantity needed for adequate anaesthesia was small, and chloroform was not flammable. It did not require complicated equipment since anaesthesia could easily be induced using a simple rag-and-bottle technique.
From personal experience, Pirogov warned against the administration of anaesthesia by untrained assistants. Pirogov became convinced that the effectiveness of anaesthesia increased when doctors focused on administering anaesthesia with the help of trained assistants. Pirogov's opinion was the first step towards safety in anaesthesia and for the patient. The widespread use of anaesthesia by Pirogov in times of war was of significant influence. The whole population was given more and more access to anaesthesia during surgery in Russia.
The cholera epidemic of 1847
Plates from the atlas on Pathological Anatomy of the Asian Cholera by Nikolay I. Pirogov in 1849.
© From the collection of the Military Medical Museum, St. Petersburg
In 1847 when the Caucasian War had ended and travelling home, Pirogov was confronted with a raging epidemic of Asian cholera. Pirogov observed the disease at the various stages of the epidemic and was able to study the progress, symptoms and treatment of the disease. He developed an atlas of the pathological anatomy of the illness based on the approximately 500 autopsies that he had carried out or supervised. The atlas of the Asian cholera was extensively reviewed by Rudolf Virchow in 1852. He praised the quality of the atlas.
Teaching Applied Anatomy
Between 1843 and 1848, Pirogov worked on a book with drawings of the human body, intended to teach physicians about applied anatomy. The fascial and synovial sheaths and inter-fascial spaces in the lower limbs were illustrated in detail. The illustrations in the book were layered so readers could obtain a three-dimensional image of the structures. He published the book on the upper and lower limbs, including the foot and the hand. In an accompanying textbook, a detailed one-and-a-half-page explanation was given of each illustration.
Anatomy as a value to forensic pathology, disarticulation and resection
Nikolay Pirogov was interested in anatomy and its application to surgery and its value to forensic pathology. After the Caucasian conflict, Pirogov put the experience he had gained to good use. He experimented and analysed the relationship between the velocity of the bullets of various firearms, ammunition and the characteristics of the entry and exit wounds on animal cadavers, based on his observations and knowledge of anatomy. Pirogov introduced the disarticulation of joints and resection of bones to save limbs instead of amputations. Then, the only method of surgical treatment for gunshot fractures. Pirogov was so able to save a limb with fractured bones.
In 1862 Pirogov was asked for a consultation by colleague surgeons, who treated the Italian freedom fighter Giuseppe Garibaldi. This one had been shot in the foot during the Italian unification conflict. Pirogov, having travelled to Italy, was able to locate the bullet. He advised a conservative treatment, i.e. no immediate surgical intervention to remove the bullet. His advice was followed and six weeks later, the bullet had spontaneously migrated to just under the skin and was easily removed. The patient made a full recovery. Garibaldi warmly thanked Pirogov in a letter.
In 1862 Pirogov was asked for a consultation by colleague surgeons, who treated the Italian freedom fighter Giuseppe Garibaldi. This one had been shot in the foot during the Italian unification conflict. Pirogov, having travelled to Italy, was able to locate the bullet. He advised a conservative treatment, i.e. no immediate surgical intervention to remove the bullet. His advice was followed and six weeks later, the bullet had spontaneously migrated to just under the skin and was easily removed. The patient made a full recovery. Garibaldi warmly thanked Pirogov in a letter.
Letter of thanks from the freedom fighter Giuseppe Garibaldi to Pirogov.
© The Military Medical Academy named SM Kirov, St. Petersburg
Forerunner of the plaster of Paris cast
Pirogov was dissatisfied with the starched cast based on the method of Louis Seutin. The two layers of bandages pre-impregnated with dry plaster powder by Antonius Mathijssen could also not please him. Pirogov continued to develop the starched cast and its implementation because he was no longer willing to amputate unless absolutely necessary. He observed that sculptors used strips of linen soaked in liquid plaster of Paris to make models. Based on this observation, in 1851/1852, he developed his own method for immobilising fractures, using canvas soaked in a plaster of Paris mixture immediately before application to the limbs, which were protected by either stockings or cotton pads. The preparation of plaster cast did not require boiling water, and it immediately hardened. The cast was so hard that splints were not needed, even when large drainage windows were created. Pirogov, as a good manager, was well aware of the treatment costs involved and stated "...The simpler, faster and cheaper the creation of such a bandage is as a replacement for the manual action, so suitable and advantageous it is for the hospital practice. Even old rags would not be lost, they could be washed clean..."
Three-dimensional Topographic Anatomy
of the human body
of the human body
During his first years in Saint Petersburg, Pirogov started to work on a textbook on Applied Anatomy. When visiting the local meat market during the freezing winter of 1846, Pirogov noticed in a butcher shop that the frozen carcasses of pigs on display had been sliced open, giving a clear view of the positions of the animal's internal organs. He realised that he could also use the cold Russian winters to freeze corpses "to the density of the thickest wood" and then cut them into thin slices. This method would allow him to describe the topographical anatomy of the human body in detail never before attempted. It would allow him to overcome one of the problems associated with the standard approach to determining the exact location of organs within the living body.
Plate of a compilation of anatomical drawings published by various anatomists among
others Berangario de Capri, Andreas Vesalius, Ambr. Parré and Julius Placentius.
made by Nikolay Pirogov in one of his An Illustrated Topographic Anatomy of Saw Cuts Made in Three Dimensions across the Frozen Human Body in four volumes between 1852 and 1859.
© From the collection of the SM Kirov Military Medical Academy, St. Petersburg
Pirogov and his team studied carcasses that had been frozen to at least minus 15 degrees Celsius. As director of the Medical Instruments Factory in St. Petersburg, he was able to use its facilities to make a particular mechanical saw, constructed along the lines of those used by furniture makers, allowing him to make cuts of 1; ½; or ¼ centimetre thickness. Pirogov was of course, aware that thin cuts in only one direction would not allow the exact location of organs to be determined. What was needed was to make cuts in several directions, and when the images were finally studied in the correct order, the result would be a three-dimensional effect.Pirogov made, in different cadavers, a series of transverse, longitudinal and anteroposterior cuts. On a cut frozen slice, a glass plate was placed, and on this glass plate a sheet of paper with drawn rectangular grids was laid. An accurate drawing was then made of the frozen cut. This allowed the precise position and appearance of the different parts of the body to be recorded in their natural position on marble.
Portrait of Nikolay Ivanovich, 1852
image, photographer unknown
© From the collection of the Military Medical Museum, St. Petersburg
© From the collection of the Military Medical Museum, St. Petersburg
The first drawings were published in St. Petersburg in 1852. Two years later, he submitted the first pages of the manuscript to the Imperial Academy of Sciences of France in Paris for their acknowledgement. In a letter dated 10 August 1862, the French surgeon Félix Hippolyte Larrey (1808-1895), member of the Paris Academy, praised the quality of the atlas. The topographical atlas was Pirogov's last work on medicine before taking part in the Crimean War from 1854-1856. After the Crimean War, he resigned his position at the Imperial Medico-Surgical Academy and focused more on humanitarian activities and education.
